Biology Study Guide Complete review of your notes • Vocabulary + concepts to know • No tables This guide covers the vocabulary, nitrogen cycle, phosphorus cycle, water cycle, energy transfer, food chains, organisms, and ecological processes from all your notes. I combined repeated information and clarified a few definitions to help you prepare for tomorrow’s test. Part 1: Vocabulary 1. Ecology and ecosystem organization Ecology — The study of interactions between organisms and their environment. Biosphere — All parts of Earth where life exists. Population — Members of the same species living in the same area. Community — Different populations living and interacting in the same area. Ecosystem — A community of organisms and the nonliving environment they interact with. Biomass — The total mass of living organisms in a particular area or trophic level. Trophic level — An organism’s feeding position in a food chain. 2. Types of organisms Autotroph — An organism that makes its own food using light energy or chemical energy. * Examples: plants, algae and some bacteria. * Autotrophs are also called producers. Heterotroph — An organism that obtains energy and nutrients by consuming or absorbing organic matter from other organisms. - Examples: animals and fungi. Producer — An organism that makes its own organic food. Consumer — An organism that obtains energy by eating other organisms. Herbivore — An organism that eats plants or other producers. Examples: deer, cows and caterpillars. Carnivore — An organism that eats other animals. Examples: lions, hawks and sharks. Omnivore — An organism that eats both plants and animals. Examples: humans, bears and crows. Scavenger — An organism that feeds on dead animals. Example: a vulture. Detritivore — A heterotroph that obtains nutrients by ingesting detritus. Detritus — Dead and decomposing plant and animal material, including organic waste. Decomposer — An organism that breaks down organic matter externally using enzymes and absorbs the released nutrients. - Examples: fungi, mushrooms and bacteria. Phytoplankton — Tiny photosynthetic organisms, including algae, that drift in aquatic environments and form the base of many aquatic food webs. 3. Food and energy vocabulary Food chain — A single pathway showing how energy passes from one organism to another. Food web — A network of interconnected food chains showing feeding relationships in an ecosystem. Energy transfer — The movement of energy from one organism to another. Photosynthesis — The process that uses light energy to make sugars from carbon dioxide and water. Cellular respiration — The process of breaking down molecules such as glucose to release usable energy. Chemosynthesis — The process of using energy from chemical reactions to make organic molecules. 4. Nitrogen cycle vocabulary Nitrogen fixation — The conversion of atmospheric nitrogen gas into usable nitrogen compounds. Assimilation — The process in which plants absorb nitrogen compounds and use the nitrogen to build organic molecules. Consumption — Animals obtain nitrogen and other nutrients by eating plants or other animals. Ammonification — Decomposers convert nitrogen in organic matter into ammonia or ammonium. Nitrification — Bacteria convert ammonium into nitrite and then nitrate. Denitrification — Bacteria convert nitrate into nitrogen gas, returning nitrogen to the atmosphere. Ammonia — A nitrogen-containing compound with the formula . Ammonium — A positively charged nitrogen ion with the formula . Nitrite — A nitrogen-containing ion with the formula . Nitrate — A nitrogen-containing ion with the formula , which plants can absorb. 5. Water cycle vocabulary Evaporation — Liquid water absorbs energy and changes into water vapor. Condensation — Water vapor cools and changes into liquid droplets. Transpiration — The release of water vapor from plants, mainly through their leaves. Precipitation — Water falling from clouds as rain, snow, sleet or hail. 6. Nutrients and other vocabulary Phosphorus — An essential nutrient used to build DNA, RNA, ATP and cell membranes. It also supports plant growth and root development. Limiting nutrient — A nutrient whose limited availability restricts the growth of organisms. Eutrophication — The process in which excess nutrients enter a body of water, promoting excessive algae growth and potentially reducing dissolved oxygen. Amino acids — The building blocks of proteins. Proteins — Molecules made of amino acids that perform many functions in living organisms. Nucleic acids — Molecules such as DNA and RNA that store and transmit genetic information. External digestion — The breakdown of food outside an organism’s cells or body using enzymes, as fungi do. Decomposition — The breakdown of dead organic matter and waste, returning nutrients to the environment. Part 2: Things You Need to Know 1. The nitrogen cycle The nitrogen cycle describes how nitrogen moves between the atmosphere, soil, water and living organisms. Nitrogen is essential for making proteins, amino acids and nucleic acids such as DNA and RNA. Although the atmosphere contains a lot of nitrogen gas, most plants cannot use atmospheric nitrogen gas directly. The main processes 1. Nitrogen fixation Atmospheric nitrogen gas () is converted into usable nitrogen compounds. * Mainly carried out by nitrogen-fixing bacteria. * Lightning also helps convert atmospheric nitrogen into compounds that enter the soil. 2. Assimilation Plants absorb nitrate () or ammonium () from the soil and use the nitrogen to make proteins and nucleic acids. 3. Consumption Animals obtain nitrogen by eating plants or other animals. 4. Ammonification Decomposers break down nitrogen-containing material in dead organisms and waste, releasing ammonia or ammonium into the environment. 5. Nitrification Bacteria convert ammonium into nitrite and then nitrate. NH_4^+ \rightarrow NO_2^- \rightarrow NO_3^- 6. Denitrification Bacteria convert nitrate into nitrogen gas, returning nitrogen to the atmosphere. Important things to remember * Nitrogen fixation starts with atmospheric nitrogen gas, . * Nitrogen fixation is carried out mainly by bacteria, but lightning also contributes. * Plants need nitrogen to build proteins and nucleic acids. * Animals obtain nitrogen through food. * Decomposers recycle nitrogen from dead organisms and waste. * Nitrification produces nitrite and then nitrate. * Denitrification returns nitrogen to the atmosphere. The nitrogen cycle is a cycle, so nitrogen can enter through several pathways. The processes do not always occur in one simple sequence. 2. Nitrogen formulas to memorize * = nitrogen gas * = ammonia * = ammonium * = nitrite * = nitrate Pay special attention to the difference between ammonia, ammonium, nitrite and nitrate. 3. The phosphorus cycle Phosphorus is an essential nutrient that organisms need to survive. How it moves through the environment * Weathering breaks down rocks and releases phosphorus into soil and water. * Plants absorb phosphorus through their roots. * Animals obtain phosphorus by eating plants or other animals. * Waste and dead organisms are broken down by decomposers. * Phosphorus returns to soil and water, where it can be used again. Why phosphorus matters * It is needed to build DNA and RNA. * It is part of ATP, which cells use to transfer energy. * It is a component of cell membranes. * It helps plants grow and develop strong roots. * It is often a limiting nutrient in soils and aquatic ecosystems. Important difference: Unlike the nitrogen cycle, the phosphorus cycle does not have a major atmospheric gas phase. 4. Eutrophication Eutrophication happens when too many nutrients enter a body of water. This can occur when fertilizers or sewage enter lakes and rivers. Know the steps: * Excess nutrients enter the water. * Algae grow rapidly, creating an algal bloom. * Algae die and decomposers break down the dead material. * Decomposers use dissolved oxygen during decomposition. * Oxygen levels decrease, which can harm or kill fish and other aquatic organisms. Remember that the problem is not simply that algae grow. The decomposition of dead algae can use up the oxygen aquatic organisms need. 5. The water cycle The water cycle describes how water moves between Earth’s surface and the atmosphere. The four main processes * Evaporation: Liquid water absorbs heat and becomes water vapor. * Condensation: Water vapor cools and forms liquid droplets, helping create clouds. * Precipitation: Water falls from clouds as rain, snow, sleet or hail. * Transpiration: Plants release water vapor through their leaves. Water also collects in rivers, lakes and oceans, while some infiltrates the soil and becomes groundwater. Make sure you can explain the difference between evaporation and condensation: * Evaporation: liquid to gas. * Condensation: gas to liquid. 6. Photosynthesis, respiration and chemosynthesis Photosynthesis * Uses light energy to produce sugars. * Takes in carbon dioxide and water. * Releases oxygen in typical plant photosynthesis. * Stores energy in chemical bonds. Cellular respiration * Breaks down glucose and other molecules to release usable energy. * Happens in plants, animals and many other organisms. * Most of the energy organisms obtain is eventually released as heat. Chemosynthesis * Uses energy from chemical reactions instead of sunlight. * Allows certain organisms, such as some bacteria, to produce organic molecules. How they differ Photosynthesis uses light energy, cellular respiration releases usable energy from molecules, and chemosynthesis uses chemical energy to make organic molecules. 7. Carbon and energy in ecosystems Your notes include these important ideas about carbon and energy. * Carbon enters the atmosphere through processes such as respiration, decomposition and the burning of fossil fuels. * Vehicles release carbon dioxide when they burn gasoline or other fossil fuels. * Plants remove carbon dioxide from the atmosphere during photosynthesis. * Energy moves through food chains and food webs. * Most energy obtained by organisms is eventually released as heat. * Unlike nutrients, energy does not continuously recycle through an ecosystem; it flows through the ecosystem. 8. Food chains and food webs A food chain shows one pathway of energy transfer, while a food web shows many connected feeding relationships. For example: Grass — Producer Grasshopper — Primary consumer Frog — Secondary consumer Snake — Tertiary consumer Arrows point from the organism being eaten to the organism receiving the energy. Know these facts * Producers make their own food. * Primary consumers eat producers. * Secondary consumers eat primary consumers. * Tertiary consumers eat secondary consumers. * Food webs connect multiple food chains. * Less energy is available at higher trophic levels because energy is used for life processes and much is released as heat. 9. Autotrophs versus heterotrophs Autotrophs: * Make their own organic food. * Use light energy or chemical energy. * Include plants, algae and certain bacteria. Heterotrophs: * Obtain organic food from other organisms or organic matter. * Include animals and fungi. * Depend directly or indirectly on producers for energy. Remember that not every heterotroph eats another living organism. Decomposers, for example, absorb nutrients from dead organic matter. 10. Detritivores, decomposers and scavengers These three types of organisms are easy to confuse. Scavengers eat dead animals. Examples include vultures and some crabs. Detritivores ingest dead organic matter and waste. Examples include earthworms, woodlice and some aquatic organisms. Decomposers break down organic matter externally by releasing enzymes, then absorb the nutrients. Examples include fungi and bacteria. Where they live * Terrestrial means land-based. Examples of detritivores include earthworms and woodlice. * Aquatic means water-based. Some crabs and other aquatic organisms feed on detritus. Why they matter They help recycle nutrients back into the environment, allowing those nutrients to be used by other organisms. 11. Ecosystem organization Know the difference between these four terms: * Population: One species living in a particular area. * Community: Multiple populations living in an area. * Ecosystem: The community and its nonliving environment. * Biosphere: All parts of Earth where life exists. A community consists of different populations. An ecosystem includes both living and nonliving components. 12. Phosphorus transfer through food webs * Plants absorb phosphorus from soil or water. * Heterotrophs obtain phosphorus by eating plants or other animals. * Phosphorus moves between organisms through feeding. * Decomposition and waste return phosphorus to the environment. Phosphorus is important for plant growth and for building molecules that all living organisms need. Part 3: What to memorize before the test If you’re short on time, make sure you can answer these questions without looking at your notes. Final review checklist 0 of 13 Define ecology, biosphere, population, community and biomass. Explain the differences between autotrophs and heterotrophs. Distinguish herbivores, carnivores, omnivores, scavengers, detritivores and decomposers. Explain the nitrogen cycle processes and put them in context. Memorize N₂, NH₃, NH₄⁺, NO₂⁻ and NO₃⁻. Explain the phosphorus cycle and why phosphorus matters. Explain the steps of eutrophication and why oxygen decreases. Define evaporation, condensation, precipitation and transpiration. Compare photosynthesis, cellular respiration and chemosynthesis. Explain the difference between food chains and food webs. Explain why energy decreases at higher trophic levels. Explain how decomposers recycle nutrients. Describe how carbon enters and leaves the atmosphere. My advice for tonight: Study the vocabulary first, draw the nitrogen cycle from memory, and then explain eutrophication and the water cycle out loud. Finish by testing yourself on the checklist. If you can explain each item without looking, you’re in a good position for your test.

# Neuro Exam Essentials Only what your instructor said to know: lectures, live class, slides, and the assigned book pages (with the "do not read" parts left out). Read in book = a part your instructor told you to read in the textbook. How to use this ## One tab. One chunk. Then flip cards. - Read the colored **60-second box** first. That's the big idea. - Open **one** chunk at a time. Close it when done (it'll say ✓ seen). - Do the **tap-to-flip cards**, then the **quiz**. - Hit **Mark done** at the bottom. Take a break between tabs. **Your instructor's study advice:** the nursing care **overlaps** across all these diseases. Eye problem → protect the eye. Can't swallow → nutrition support (weights, calorie counts, prealbumin). Weak or stiff → mobility and fall prevention. **Don't memorize slide by slide. Understand the idea.** But do notice how brain, spinal cord, and peripheral nerve problems look different. The nervous system map Think of a house. The brain is the electrical panel. The spinal cord is the main cable running down the wall. Peripheral nerves are the wires going out to every room. | Central (CNS) | Peripheral (PNS) | | --- | --- | | Brain + spinal cord | Spinal nerves (from the spine) · **12 cranial nerves** (from the brain) · autonomic system | **Autonomic system** = automatic, not under your control: - **Sympathetic** = "fight or flight." Speeds things up (heart rate, breathing). - **Parasympathetic** = "rest and digest." Slows things down. Word bank (terms that show up everywhere) | Word | Plain meaning | | --- | --- | | **intracranial pressure (ICP)** | Intracranial pressure: pressure inside the skull | | **level of consciousness (LOC)** | Level of consciousness: how awake and aware | | **Glasgow Coma Scale (GCS)** | Glasgow Coma Scale: scores LOC from 3 (no response) to 15 (normal) | | **Aura** | A warning sign right before a migraine or seizure | | **Dysphagia** | Trouble swallowing → aspiration risk | | **Dysarthria** | Trouble speaking clearly (slurred) | | **Diplopia** | Double vision | | **Nystagmus** | Eyes jerk side to side on their own | | **Ptosis** | Drooping eyelid | | **Photophobia** / **phonophobia** | Light hurts / sound hurts | | **Paresthesia** | Numbness or tingling | | **Acetylcholine (ACh)** | The "go" chemical that makes muscles move | | **Dopamine** | The "brake" chemical that smooths movement (also pleasure) | Your instructor's 15 neuro terms have their own tab: **Terms**. Review class: exam breakdown + how to study Review class From the in-class exam review (Joline case study + NCLEX questions). | Exam section | Points | | --- | --- | | Peripheral nervous system (PNS) | 28 | | Trauma: stroke, head injury, intracranial pressure (ICP) | 32 | | Renal: acute and chronic kidney disease (lecture recordings) | 18 | | Michelle's content (use her posted study guide) | 10 | | **Total** | **90** · about 1 hr 35 min. Don't rush. | - You only need what she **did not cross off** in the book + what's in the **lecture recordings** and **PowerPoint**. Some lecture content isn't in the book. That's okay, it still counts. - Use the **outline in the syllabus** as quiz questions. - Studying alone? **Record yourself answering out loud** on your phone, then play it back next to your notes. Saying it out loud moves it to long-term memory. - On her big day-one med chart, write **only the "exception to the rule"** facts. Those are what get tested. - Stuck? **Email her** instead of going down a YouTube rabbit hole. Quick recall · tap to flip The 60-second version ## 15 words. Break them into pieces and they explain themselves. - **a-** = without · **dys-** = hard or bad · **hemi-** = half (one side) - **-plegia** = paralyzed (can't move) · **-paresis** = weak (can move a little) - **-phasia** = speech/language · **-lexia** = reading · **-graphia** = writing - **-opia / -opsia** = vision · **gnosia** = knowing/recognizing · **praxia** = doing From your instructor's "Neurology – Medical Terminology" list Talking, reading & writing (4) ### 1. Aphasia **Word parts:** a- (without) + phasia (speech) **Means:** trouble with **language**. The brain can't make or understand words. The brain's dictionary is broken. The mouth works fine; the words don't come out right, or what you hear makes no sense. **Example:** a stroke patient wants water but says "chair," or can't understand "squeeze my hand." **3 types:** **Expressive (Broca)** = understands, can't speak · **Receptive (Wernicke)** = can't understand · **Global (mixed)** = both. ### 2. Dysarthria **Word parts:** dys- (hard) + arthr (joint/articulate) **Means:** **slurred speech** because the mouth, tongue, or face muscles are weak. The words are right, but the mouth is clumsy, like talking after a dentist numbs you. **Example:** the patient knows exactly what to say, but it sounds mumbled. **Don't mix up:** **Aphasia = a word problem** (brain's language center). **Dysarthria = a muscle problem** (words are right, just slurred). ### 3. Alexia **Word parts:** a- (without) + lexia (reading) **Means:** **can't read**, even though they could before and their eyes work. **Example:** the patient looks at a menu but the letters mean nothing. ### 5. Agraphia **Word parts:** a- (without) + graphia (writing) **Means:** **can't write**, even though the hand can hold the pen. **Example:** asked to sign a consent form, they can't form the letters of their name. Eyes & vision (4) ### 4. Papilledema (choked disc) **Word parts:** papilla (optic disc) + edema (swelling) **Means:** the **optic disc** (where the eye nerve connects, at the back of the eye) is **swollen**. The provider sees it with an ophthalmoscope. Pressure in the skull pushes on the eye nerve and "chokes" it, like a garden hose swelling when the water can't get out. **Key point:** papilledema = **always a sign of ↑intracranial pressure (ICP)**. ### 9. Nystagmus **Means:** the eyes **jerk or bounce side to side** (or up and down) on their own. Like the eyes are watching a fast tennis match that isn't there. **Seen in:** multiple sclerosis (MS), meningitis, stroke, brainstem problems. ### 12. Ptosis **Means:** a **drooping upper eyelid**. Ptosis sounds like "toe-sis": the lid falls down toward your toes. **Seen in:** myasthenia gravis, uncal herniation (CN III), stroke. ### 13. Diplopia **Word parts:** dipl (double) + opia (vision) **Means:** **double vision**. Sees two of everything. **Nursing:** eye patch, switched between eyes every few hours. ### 14. Homonymous hemianopsia **Word parts:** homonymous (same) + hemi (half) + an (without) + opsia (vision) **Means:** blind in the **same half** of the vision field **in both eyes**. For example, they can't see anything to their left. Like someone put tape over the left half of both lenses of their glasses. **Nursing:** teach to **turn the head side to side (scan)**. Put food and items on the side they can see. They may eat only half the plate. Movement & coordination (5) ### 7. Hemiparesis **Word parts:** hemi (half/one side) + paresis (weakness) **Means:** **weakness** on one side of the body. They can still move it, just not strongly. **Example:** weak right hand grip and right leg after a left-brain stroke. ### 15. Hemiplegia **Word parts:** hemi (one side) + plegia (paralysis) **Means:** **paralysis** on one side of the body. Can't move it at all. **Memory trick:** **Paresis = Partial** (weak). **Plegia = Paralyzed** (can't move). Both are on the side **opposite** the brain injury. ### 8. Apraxia **Word parts:** a- (without) + praxia (doing/action) **Means:** can't do **learned, planned movements**, even though the muscles are strong and they understand the request. The muscles work, but the brain lost the "instructions" for the task. **Example:** handed a toothbrush, they don't know the steps to brush their teeth. **Nursing:** simple, short, one-step directions; be patient. ### 10. Ataxia **Word parts:** a- (without) + taxia (order/coordination) **Means:** **poor coordination and balance**. Wobbly, unsteady walking; clumsy movements. Walking like you're on a moving boat. **Nursing:** **fall precautions**. ### 6. Proprioception **Means:** your body's sense of **where its parts are** without looking (body position sense). It's how you can touch your nose with your eyes closed. **If lost:** the patient doesn't know where their arm or foot is → falls, injuries. Watch the affected limb. Recognizing things (1) ### 11. Agnosia **Word parts:** a- (without) + gnosia (knowing) **Means:** can't **recognize** familiar objects, people, or sounds, even though their senses work. The eyes see a fork, but the brain can't name it or tell what it's for. **Nursing:** safety. They might misuse objects. **The "A" trio:** **Apraxia** = can't **do** (action) · **Agnosia** = can't **know** (recognize) · **Ataxia** = can't **coordinate** (wobbly). All 15 at a glance | # | Term | Simple meaning | | --- | --- | --- | | 1 | **Aphasia** | Trouble with language (words) | | 2 | **Dysarthria** | Slurred speech (weak mouth muscles) | | 3 | **Alexia** | Can't read | | 4 | **Papilledema** | Swollen optic disc = ↑intracranial pressure (ICP) | | 5 | **Agraphia** | Can't write | | 6 | **Proprioception** | Sense of where your body is | | 7 | **Hemiparesis** | One-sided weakness | | 8 | **Apraxia** | Can't do learned movements | | 9 | **Nystagmus** | Jerky, bouncing eyes | | 10 | **Ataxia** | Poor coordination/balance | | 11 | **Agnosia** | Can't recognize things | | 12 | **Ptosis** | Droopy eyelid | | 13 | **Diplopia** | Double vision | | 14 | **Homonymous hemianopsia** | Blind in the same half of both eyes | | 15 | **Hemiplegia** | One-sided paralysis | Flashcards · tap to flip Practice A client clearly says "I want my glasses," but the words are mumbled and hard to understand. This is: The right words, but slurred = a muscle problem = dysarthria. Practice A client eats only the food on the right side of the plate. The nurse suspects: They can't see the left half of their field. Teach head scanning; turn the plate. Practice A client holds a comb but can't figure out how to use it, even though the arm is strong. This is: Strong muscles, lost "how-to" for a learned task = apraxia. Practice The provider documents papilledema. The nurse knows this means: A swollen optic disc is always a sign of ↑ICP. Practice A client after a stroke can lift the right arm a little but it's weak. Correct term? Paresis = partial (weak). Plegia = paralyzed. Practice A client walks with a wide, wobbly gait and loses balance. Priority nursing action? Ataxia = poor coordination → fall risk. The 60-second version ## Stroke = a "brain attack." Time is brain. - **transient ischemic attack (TIA)** = mini warning stroke; symptoms gone in 30–60 min. Prevent the real one. - **\~90% are ischemic** (clot). The rest are **hemorrhagic** (bleed). - **computed tomography (CT) head WITHOUT contrast first**, to rule out a bleed. - **tissue plasminogen activator (tPA) (alteplase)** within **3 to 4.5 hrs** of when symptoms started, only for ischemic. - First sign of trouble (↑intracranial pressure (ICP)) = **change in mental status**. A stroke is a heart attack of the brain. Ischemic = a clogged pipe (no blood gets through). Hemorrhagic = a burst pipe (blood leaks where it shouldn't). The treatment for one is dangerous for the other, which is why the computed tomography (CT) comes first. transient ischemic attack (TIA): the warning sign - Brief drop in blood flow to the brain → **temporary** stroke-like symptoms. - Usually gone in **30–60 minutes**, often before reaching the emergency room (ER). Many people never go. - Symptoms are **one-sided**: numbness or weakness of face/arm, blurred or double vision, slurred speech, trouble swallowing. - It's a **red flag**: high risk of an ischemic stroke soon. **Prevention is the key intervention:** - #1 risk factor = **hypertension**. Control blood pressure (BP). - **Diabetes**: keep glucose in range. Exercise, healthy food. - **Antiplatelets**: **aspirin** and **clopidogrel**. Both together = **dual antiplatelet therapy** (same as after a myocardial infarction (MI)). **Don't mix up the classes:** **Antiplatelets** = aspirin, clopidogrel (stop platelets sticking). **Anticoagulants** = heparin, warfarin, direct oral anticoagulants (DOACs) like apixaban, rivaroxaban, dabigatran. Ischemic vs. hemorrhagic Blood flow cut off for more than a few minutes → brain cells starve of oxygen → **brain infarction** (like a myocardial infarction (MI), but in the brain). | Type | Cause | Onset | | --- | --- | --- | | **Thrombotic** (ischemic) | Clot builds slowly from **atherosclerosis**, often where arteries split (carotids, circle of Willis) | **Slow/gradual**: symptoms come and go, or slowly worsen. Body grows **collateral circulation**. | | **Embolic** (ischemic) | Clot travels, usually from the **left side of the heart**. Big risk: **A-fib**, valve disease | **Sudden**; often improves quickly too | | **Hemorrhagic** | Vessel breaks: **severe hypertension (HTN)** (incl. **cocaine**), ruptured **aneurysm**, or an ischemic stroke that turned into a bleed | Sudden or slow (depends on the bleed) | Right-heart clot → lungs (PE). Left-heart clot → brain (stroke). Left vs. right brain stroke The brain controls the **opposite** side of the body. Left brain stroke → **right** side weak. Right brain stroke → **left** side weak. | Left hemisphere (dominant) | Right hemisphere | | --- | --- | | Language, math, analytical thinking | Visual and spatial awareness | | Trouble **understanding and using language** (aphasia) | **Unilateral neglect**: ignores the left side of the body | | **Slow, cautious**; anxious with new tasks | **Impulsive**, poor judgment, unaware of deficits, denial | | Depressed, guilty, quickly angry and frustrated (they know something's wrong) | Memory loss, disoriented | | Right-side weakness | Left-side weakness · top priority: **risk for injury** | Brain-area map slide: your instructor said **do not memorize it**. BE FAST: teach the public B**Balance**: loss of balance or coordination, dizzy E**Eyes**: blurred or double vision F**Face**: smile. One side drooping? A**Arms**: raise both. One weak or drifting down? S**Speech**: repeat "You can't teach an old dog new tricks." Slurred? Garbled? T**Time**: call **911** right away. Note the **exact time symptoms started**. **Why call 911 instead of driving?** The ambulance **calls ahead**: computed tomography (CT) room ready, stroke scale started, tissue plasminogen activator (tPA) prepared, oxygen and glucose checked. In the emergency room (ER): assessment & computed tomography (CT) - Priority = get them to a **stroke center**. Not the time for a full head-to-toe. - **airway, breathing, circulation (ABCs) first**, then a rapid neuro (stroke) assessment. - **National Institutes of Health (NIH) Stroke Scale**: trained, certified staff; checks level of consciousness (LOC), movement, feeling, speech, understanding. Broader than BE FAST. **Don't memorize its parts**; just know it's a valid, reliable, evidence-based tool for consistent tracking. **CT of the head WITHOUT contrast** (or magnetic resonance imaging (MRI)) is one of the first tests. Why no contrast? Contrast would look like a bleed. CT shows a **hemorrhage**, sets a **baseline**, rules out tumors. An ischemic stroke often **doesn't show for 24 hrs**, so a negative CT doesn't rule it out. tissue plasminogen activator (tPA) (alteplase): clot buster - For **ischemic only**. **Never** for hemorrhagic. - Must start within **3 hours** of symptom onset (often extended to **4.5 hrs**). Counted from when symptoms **started at home**, not emergency room (ER) arrival. You don't need the extension criteria. - Not everyone qualifies: check bleeding risk. **Before you hang tPA:** make sure the **head computed tomography (CT) is done** and shows no bleed. Not ordered? Get it ordered. - Big risk = **bleeding** → bleeding precautions. - Keep blood pressure (BP) controlled so ischemic doesn't turn hemorrhagic. - **Repeat CT** after the infusion to check for a new bleed. **Other procedures (know the name and idea only):** - **Intra-arterial thrombolysis**: tPA put directly into the clot; up to **6 hrs**. - **Endovascular thrombectomy**: catheter pulls the clot out. - **Prevent future strokes:** angioplasty with **stent** (filter catches pieces) or **carotid endarterectomy** (neck incision to remove plaque). **After any of these:** check the site for bleeding, vital signs, **neuro checks** (new stroke from loose clots?), **hoarseness and trouble swallowing** (nerves in the neck, like the vagus), and **cerebral hyperperfusion** (a rush of blood into an area used to low flow → can bleed). Signs to assess - **Cognition**: restless, confused, memory, focus. level of consciousness (LOC) drop = late. - **Motor**: hand grips, push/pull feet. Equal both sides? - **Flaccid** paralysis = limp, can't beat gravity (e.g., **foot drop**). **Spastic** = constant contraction → **contractures**. - **Sensory**: touch, pain, numbness, neglect. - **Eyes**: pupils equal, round, reactive to light and accommodation (PERRLA) *plus* the whole visual field (lost side vision?). - **Heart**: usually hypertensive; **murmur** (clot on a valve?); **rhythm** (A-fib). - Psychosocial: personality and emotion changes. Nursing priorities (acute stroke) 1. **Oxygen first.** oxygen saturation (SpO₂) under 94%? Think: **partial airway obstruction** (tongue), **hypoventilation**, **aspiration** (most common). 2. **intravenous (IV)** (emergency meds; they may not swallow). 3. **Cardiac monitor** (A-fib). 4. **nothing by mouth (NPO) until a swallow screen.** The registered nurse (RN) does the bedside screen. Coughing, pocketing food, slurred speech → **speech therapy** consult. 5. **Glucose under 140** (high sugar blocks reperfusion). 6. **blood pressure (BP) slightly high** to push blood to the brain. Book guideline **≤150 systolic**, but follow the patient's own orders and baseline. 7. Watch for **↑intracranial pressure (ICP)**. Neuro checks **every 15–30 min** acutely; BP at least every 15 min. **Never skip pupils.** **Patient declining 24 hrs after a stroke** (more lethargic, vitals changed, sluggish pupils)? **Call Rapid Response** and the provider. Expect a computed tomography (CT). - Most likely complication = **↑ICP** (→ seizures, respiratory failure, ↓level of consciousness (LOC)). - Don't take BP on the **affected arm**: inaccurate (less vascular tone). Aspirin & stroke core measures **Why no aspirin right away (unlike a myocardial infarction (MI))?** Could be a **bleed**, may be getting **tissue plasminogen activator (tPA)**, may have **dysphagia**. Giving it early doesn't improve stroke outcomes. - Give aspirin **325 mg within 24–48 hrs** after onset. - **No aspirin within 24 hrs of tPA.** **Core measures** (hospital must do + document to get paid): 1. **tPA** if they qualify (3–4.5 hrs). 2. **venous thromboembolism (VTE) prevention**: sequential compression devices (SCDs), enoxaparin/heparin, walking. 3. By end of **day 2**: **antiplatelet** or **anticoagulant** (A-fib/flutter → anticoagulant). Discharged on it. 4. Discharged on a **statin** (cholesterol med). 5. **Stroke education** documented (signs, 911, meds). 6. **physical therapy (PT)/occupational therapy (OT) rehab** assessment. Tests & swallow nerves (Mr. Stokes case) | Test | Why | | --- | --- | | Non-contrast computed tomography (CT) head | Rule out bleed, baseline, rule out tumor | | Cardiac monitor | A-fib (with rapid ventricular response (RVR)) | | **Echocardiogram** | Shows **heart valves** (clots?) and ejection fraction | | **Carotid ultrasound** | **% of plaque** blocking the carotids | | Swallow study | Diet texture (thickened liquids, pudding, no water) | **The 2 cranial nerves you MUST know:** **cranial nerve (CN) IX (glossopharyngeal)** and **CN X (vagus)**, the swallowing nerves. They must be intact before the patient eats or drinks. "If you don't know, pick vagus." **Delegation tip** from class: licensed practical nurse (LPN) can give **routine injections** (like insulin). Hygiene → **unlicensed assistive personnel (UAP)**. NCLEX wants you to use each person's role wisely. Hemorrhagic stroke treatment Goal: **stop the bleeding** and **lower pressure on the brain**. - Stop any meds that cause bleeding; may need blood products. - Anti-seizure meds (a seizure raises intracranial pressure (ICP)). - **Bed rest** and supportive care so the body can absorb the blood. Don't push them up to the chair. **Surgery:** - **Aneurysm** → **coiling** (coils fill the bulge) or **clipping** (clip at its base). - **arteriovenous malformation (AVM)** (arteriovenous malformation: tangled weak vessels, often in kids) → surgically removed. Read in book Iggy Ch. 38, pp. 941–955 · skipped per your list: National Institutes of Health Stroke Scale (NIHSS) table, Box 38.3, alteplase dosing, calcium channel blocker paragraph transient ischemic attack (TIA) workup (book)Read in book - Symptoms usually resolve in **30–60 min** but can last up to **24 hrs**. - Box 38.2 signs: blurred/double vision, tunnel vision, one-eye blindness; arm/leg weakness, **ataxia**; numbness, **vertigo**; aphasia, dysarthria. - Workup: National Institutes of Health Stroke Scale (NIHSS), labs (**prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT)**, lipids), electrocardiogram (ECG), **head computed tomography (CT)** then magnetic resonance imaging (MRI), computed tomography angiography (CTA)/magnetic resonance angiography (MRA) of brain and neck. - Common causes: **carotid stenosis** (narrowed artery from plaque) and **A-fib**. - **ABCD2 score** predicts stroke risk: **A**ge ≥60 · **B**P ≥140/90 · **C**linical signs (one-sided weakness, speech) · **D**uration · **D**iabetes. - Treatment: carotid endarterectomy or stent, **aspirin/clopidogrel**, lower blood pressure (BP). Stroke types & risk (book)Read in book Brain can't store oxygen or glucose. Blood flow cut for **a few minutes** → infarction. "Brain attack" = treat like a myocardial infarction (MI). | | Thrombotic | Embolic | Hemorrhagic | | --- | --- | --- | --- | | Onset | Gradual; steps/worsening | Sudden | Sudden (gradual if from hypertension (HTN)) | | level of consciousness (LOC) | Awake | Awake | Deepening lethargy → coma | | Linked to | HTN, atherosclerosis; transient ischemic attack (TIA) first | Heart disease (A-fib) | HTN, vessel problems, genetics | | Headache | Slight | — | **Severe**; seizures common | | Recovery | Weeks–months | Usually rapid | Variable; often permanent deficits | - **Intracerebral hemorrhage (ICH)**: bleeding into brain tissue, usually from **severe HTN**; cocaine can trigger it. - **Subarachnoid hemorrhage (SAH)**: bleeding between pia and arachnoid, usually a ruptured **aneurysm** or **arteriovenous malformation (AVM)**. **Vasospasm** (artery clamps down) afterward → more ischemia. - Leading causes: **smoking, obesity, HTN, diabetes, high cholesterol**. Also cocaine, heavy alcohol, birth control pills in at-risk women, family history. - 5th leading cause of death; #1 cause of long-term disability. "Stroke belt" = 8 southeastern states. - Prevent with the **ABCS**: **A**spirin when appropriate, **B**lood pressure, **C**holesterol, **S**moking cessation. Assessment (book)Read in book - First priority: get to a **stroke center**. Assess within **10 minutes** of arrival (ABCs, neuro). - History: **exact time symptoms started**, did they get better or worse, meds (anticoagulants), drug use. - Sudden drop in level of consciousness (LOC)? Rule out **low blood sugar or low oxygen** first. They look like a stroke but are easy to fix. - **subarachnoid hemorrhage (SAH)**: "worst headache of my life," nausea/vomiting, photophobia, stiff neck. - Most important ongoing check = **LOC** (GCS or National Institutes of Health Stroke Scale (NIHSS)). - **Impaired airway defense**: weak cough + dysphagia → aspiration pneumonia. Screen swallowing. - Heart: murmur, A-fib, heart failure, endocarditis. - **blood pressure (BP)**: often 180–200/110–120 on arrival. A somewhat high BP (about **150/100**) keeps the brain perfused; higher can extend the stroke. - **Psychosocial**: body image, coping, money worries; screen for **depression**. **Emotional lability** = sudden laughing or crying for no reason (frontal lobe or right brain). Tell the family it's the stroke, not them. - Labs: no test confirms stroke. High **Hgb/Hct** = severe stroke; high white blood cell count (WBC) = infection or stress; glucose and **hemoglobin A1C (A1C)** check diabetes. NIHSS (Table 38.2): your instructor said don't memorize it, just be familiar. It scores 0 (normal) to 42 (worst) and helps decide who gets tissue plasminogen activator (tPA). tissue plasminogen activator (tPA) (alteplase) rules (book)Read in book - Explain to patient/family and get **informed consent**. - Door-to-needle goal: **45 minutes** from emergency department (ED) arrival. - If blood pressure (BP) is too high, give a fast antihypertensive first. BP must be **below 185/110** to start, and kept there. **Box 38.4: care during and after alteplase** - Admit to critical care or a stroke unit. **Double-check** the drug. - Give with a **programmable pump** over 60 min (10% as a 1-minute bolus). **Never push it by hand.** - Neuro checks + vitals: **every 10–15 min during the infusion**, then **every 30 min for at least 6 hrs**, then **hourly for 24 hrs**. - Use the **same BP device** each time (manual vs. automatic vs. arterial line readings differ). - BP **≥185/110 before** tPA, or **>180/105 after** (first 24 hrs) → give antihypertensive as ordered, e.g., **intravenous (IV) labetalol**. - **No invasive tubes** (NG tube, Foley) until stable, usually **24 hrs** (bleeding). - **Stop the infusion** and call for severe headache, sudden high BP, nausea/vomiting. - Follow-up computed tomography (CT)/magnetic resonance imaging (MRI) **before** starting anticoagulants or antiplatelets. **Drug Alert:** watch closely for bleeding: brain bleed (headache, level of consciousness (LOC) change) and any other site. Procedures & intracranial pressure (ICP) after stroke (book)Read in book - **Endovascular**: intraarterial tissue plasminogen activator (tPA) (within **6 hrs**), mechanical embolectomy (pull clot out), carotid stent. - After a **carotid stent**, teach to report: severe headache, level of consciousness (LOC) change (drowsy), muscle weakness, severe neck pain, **neck swelling**, **hoarseness or trouble swallowing** (nerve damage). - Hemorrhagic from arteriovenous malformation (AVM)/aneurysm: procedure to stop bleeding. - **↑ICP risk is highest the first 72 hrs**. Reassess every 1–4 hrs. **Critical Rescue:** the **first sign of ↑ICP is a declining LOC**. Report any decline to the provider or Rapid Response right away. **Prevent ↑ICP:** - **head of bed (HOB) up** per protocol. **Head midline**, neutral. - O₂ if oxygen saturation (SpO₂) **under 95%**. - No sharp hip or neck bending. - **Don't cluster care** (bath right after linen change spikes ICP). - **Hyperoxygenate** before and after suctioning; avoid unneeded suctioning and coughing. - Quiet room, **dim lights**. - Watch blood pressure (BP), rhythm, SpO₂, glucose, temperature. **Box 38.5 signs of ↑ICP:** ↓LOC (earliest), restless/irritable/confused, headache, vomiting (may be projectile), speech changes, pupil changes (dilated nonreactive = "blown"), seizures, Cushing's triad and posturing (very late). Meds, blood pressure (BP) & swallowing (book)Read in book **BP Critical Rescue:** no tissue plasminogen activator (tPA) or embolectomy → BP may be allowed up to **220** systolic. After tPA/embolectomy → report systolic **above 180**. Avoid a sudden BP drop: it can cause brain ischemia. - **Aspirin and clopidogrel** = standard for ischemic stroke and preventing the next one. - **Anticoagulants** (heparin, warfarin, direct oral anticoagulants (DOACs)) for **A-fib**. High-alert: bleeding risk. - Low-dose **aspirin within 24–48 hrs**; **not within 24 hrs of tPA**. Teach to report bruising or bleeding. - Stool softeners (no straining = no intracranial pressure (ICP) spike), pain and anxiety meds. - **nothing by mouth (NPO) until a swallow screen**. Positive screen → speech-language pathologist. - Weigh daily; check prealbumin; dietitian. - **Flaccid arm**: support it on a pillow so the shoulder doesn't dislocate (subluxation). Don't pull on it. - Early mobility; prevent deep vein thrombosis (DVT) with **compression devices**. Aphasia & communication (book)Read in book | Expressive (Broca) | Receptive (Wernicke) | Global (mixed) | | --- | --- | --- | | **Frontal** lobe. Understands but **can't speak** (or write). Knows it → frustrated, angry. | **Temporoparietal**. **Can't understand**. Can talk, but words are often meaningless. | **Both**: can't speak **and** can't understand. Reading and writing are affected the same way. Usually a large stroke involving the **left** (dominant) side. | "Broca = broken speech. Wernicke = words wacky. Global = gone both ways." - One idea at a time. Simple one-step commands. - Speak **slowly, not loudly**. Use gestures. - Yes/no questions for expressive aphasia. - **Global aphasia**: rely on **gestures, pictures, touch, and facial expression**. Keep a calm tone; watch body language for needs. - Picture boards, tablets, flash cards. **Don't rush**. - Work with the speech-language pathologist. Vision, neglect & left vs. right (book)Read in book **Right-brain stroke** (trouble with space and distance, right vs. left): - Use frequent verbal and touch cues; break tasks into small steps. - **Approach from the unaffected side.** Patient faces the door. **Unilateral neglect** (usually right-brain stroke): ignores one side. - Teach to **touch and use both sides**. Dress the **affected side first**. - **Homonymous hemianopsia**: teach to **turn the head side to side (scan)** while eating and walking. Put objects in the field of vision. - **Diplopia**: patch the affected eye; switch every 2–4 hrs. **Left-brain stroke** (memory problems): - Reorient to day and time; **structured routine** with repetition. - **Apraxia**: give simple, short directions; be patient. Core measures & going home (book)Read in book **Core measures (ischemic stroke):** venous thromboembolism (VTE) prevention · discharged on antithrombotic · anticoagulant for A-fib/flutter · tissue plasminogen activator (tPA) when eligible · antithrombotic by end of day 2 · discharged on statin · stroke education · rehab assessed. **Box 38.6 discharge teaching:** - Drugs: name, purpose, dose, timing, side effects. - Climbing stairs, getting in and out of bed, chair, and car safely; using mobility aids. - Who to call with questions; what to do in an emergency. - They're **at risk for another stroke**. Teach **FAST** (face drooping, arm weakness, speech difficulty, time to call 911). - Watch for **depression or dementia within 3 months** (poststroke depression). - Caregivers get overwhelmed → **respite**, social services, American Stroke Association. - Return demonstrations to check family skills. Book · NCLEX Challenge 38.1 · Select all A client has a **left middle cerebral artery** embolic stroke. Which findings does the nurse expect? Left brain → right side of the body. The left side controls speech, so dysarthria fits. Ataxia and vertigo point to the back of the brain (vertebrobasilar). Book · NCLEX Challenge 38.2 A client was just admitted to the emergency department (ED) with new-onset ischemic stroke. Which drug does the nurse anticipate? New ischemic stroke in the time window = tPA (after the CT shows no bleed). Aspirin waits 24–48 hrs. Book · Mastery Q1 A client with an acute ischemic stroke is receiving alteplase. Priority nursing action? Bleeding (especially into the brain) is the biggest danger with tPA. Book · NGN Challenge 38.1 **Case:** 74-year-old with diabetes in the ED. Right arm felt weak and tingly; now feels "more normal." **Bilateral carotid bruits.** blood pressure (BP) 168/92, heart rate (HR) 88, oxygen saturation (SpO₂) 96%. History: type 2 diabetes, hypertension (HTN), alcohol, **69 pack-year smoking**. Glucose 231. Quick recall · tap to flip NCLEX The nurse has an order to start alteplase for a client with stroke symptoms. What must the nurse confirm first? tPA in a hemorrhagic stroke could be fatal. CT first, every time. NCLEX A client just admitted with an ischemic stroke asks for water. What does the nurse do? Aspiration is the most common cause of hypoxia in stroke. Screen first; refer to speech if any concern. NCLEX A client with a right-hemisphere stroke keeps trying to get out of bed alone. Priority problem? Right-brain strokes cause impulsivity and poor judgment. Safety first. NCLEX A client's wife says his face drooped "about 2 hours ago, then got better, now it's back." Most important info for the nurse? tPA eligibility is timed from first symptom onset. The 60-second version ## The skull is a closed box. Swelling has nowhere to go. - Normal **intracranial pressure (ICP) 10–15**. Over **20** = brain cells die. - **cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) − ICP**. Keep it **above 70**. - First sign of ↑ICP = **mental status change**. Late = **Cushing's triad**, posturing. - **Glasgow Coma Scale (GCS) 8 or less → intubate.** A **2-point drop** = call. - Head injury → **assume neck injury** too (jaw thrust). The skull holds 3 things: brain, blood, and cerebrospinal fluid (CSF). It's a full suitcase that can't stretch. If one thing gets bigger (swelling, a bleed, extra fluid), something gets crushed, starting with the blood vessels. Types of brain injury **Primary injury** = direct damage from the hit. Most common causes: **car crashes** and **falls** (teach seat belts, helmets, fall prevention). | Term | Meaning | | --- | --- | | **Open** head injury | Skull broken/pierced (e.g., gunshot) → **infection risk** | | **Closed** head injury | Blunt hit, skull intact. **More dangerous**: swelling has no escape → ↑intracranial pressure (ICP) | | Contusion | Bruised brain | | Laceration | Torn vessels (inside of skull is bumpy and sharp) | | Diffuse axonal injury | Widespread damage from high-speed crash (speed up, sudden stop) | | Severity | Glasgow Coma Scale (GCS) | Unconscious for | | --- | --- | --- | | **Mild** (= concussion) | — | Usually sent home | | **Moderate** | **9–12** | 30 min – 6 hrs | | **Severe** | **8 or less** | Over 6 hrs → intensive care unit (ICU) | Concussion discharge teaching Your instructor: "Don't memorize the list, but know it. You'll get yes/no examples." - **Acetaminophen** for pain is OK. **No nonsteroidal anti-inflammatory drugs (NSAIDs)** (Motrin, Advil): bleeding risk. - Return to the emergency room (ER) for signs of **↑intracranial pressure (ICP)** (swelling or bleed): worse headache, vomiting, confusion, hard to wake, weakness, seizures, vision changes. - **Clear fluid from the nose or ears** → return. Could be a **cerebrospinal fluid (CSF) leak** or **skull fracture**. The full book list (Box 38.8) is in the "Mild traumatic brain injury (TBI) teaching" chunk below. Secondary injury: hypoxia & ↑intracranial pressure (ICP) Happens **after** the first hit and makes it worse. End result: brain tissue damaged, blood flow interrupted. - **Post-concussion syndrome** (mild injury): headaches, dizziness, foggy thinking for weeks to months. - **Cerebral hypoxia**: from clots, respiratory failure, **low blood pressure (BP)**. Risk for **neurogenic shock**. Brain perfusion drops when **mean arterial pressure (MAP) is under 65–70**. **↑ICP numbers:** - Normal ICP = **10–15 mmHg**. Coughing, sneezing, straining (Valsalva) raise it briefly. OK. - **Over 20** for long = **neurons die**. - **cerebral perfusion pressure (CPP)** (blood flow to the brain) = **MAP − ICP**. Goal **above 70**. Example: MAP 85, ICP 25 → CPP = 60. Too low! The brain isn't getting enough blood. **ICP monitors** (just recognize the names): **ventriculostomy** (intraventricular catheter, can also drain cerebrospinal fluid (CSF)) and **subarachnoid screw / ICP bolt** (placed through a **burr hole**). Signs of ↑intracranial pressure (ICP) - **First: mental status change** (restless, confused). level of consciousness (LOC) drop comes later. - Pupil changes: unequal, dilated, **non-reactive**. **Cushing's triad** (late sign; near death). Really 4 parts:\ 1\. **Severe hypertension**\ 2\. **Bradycardia**\ 3\. **Widened pulse pressure**\ 4\. **Irregular breathing** (Cheyne-Stokes) | Decorticate | Decerebrate | | --- | --- | | Abnormal **flexion**: arms bent in toward the "core" | Abnormal **extension**: arms straight out. **Worse** | Both are late signs. Brain bleeds (hematomas) No room in the skull → life-threatening. Your instructor: "kind of something you just have to memorize." | Type | Where | Key sign | | --- | --- | --- | | **Epidural** | **Above** the dura ("epi" = above) | **Lucid interval**: knocked out → wakes up and talks (seems better) → **rapidly declines**. Emergency surgery. Neuro checks every 5–10 min. | | **Subdural** | **Below** the dura ("sub" = below) | **Slow**: weeks to months. Easy to miss. | | **Subarachnoid** | Subarachnoid space | **"Worst headache of my life,"** sudden | | **Intracerebral** | Deep in brain tissue | — | Hydrocephalus & herniation **Hydrocephalus** = too much cerebrospinal fluid (CSF) (not absorbed, or blocked) → big ventricles → ↑intracranial pressure (ICP). **Herniation** = brain shifts to make room: - **Uncal**: sideways (temporal lobe). - **Central**: downward onto the **brainstem**. Don't memorize which pupil means which. Know: pupils change (unequal, dilated), **always non-reactive** → call **Rapid Response** and the provider. level of consciousness (LOC) drops, Cheyne-Stokes breathing. Assessment after head injury - **airway, breathing, circulation (ABCs) first.** Assume a **cervical spine injury** → spinal precautions; open airway with **jaw thrust**. - **Autoregulation is lost**: blood pressure (BP) and heart rate (HR) can swing **either way**. Get a baseline; may seem stable then crash. - Do the **neuro exam BEFORE sedatives** or paralytics. - **Pupils**: any change → call right away. - **Motor**: deficit on the **opposite side** of the lesion. **Skull fracture signs:** - cerebrospinal fluid (CSF) leak: clear fluid from nose/ears; **positive glucose** on dipstick; **halo sign**. - **Battle sign**: bruising behind the ear (mastoid). - **Raccoon eyes**: bruising around the eyes. Glasgow Coma Scale practice Your instructor: **don't memorize the scale**. You'll be given it; know how to **apply** it. - Highest = **15**. Lowest = **3**. - **7 or less** = coma. "**Less than 8, intubate.**" - A **2-point drop** = clinically significant → Rapid Response / provider. Eyes open Verbal Motor Preloaded with the class example: opens eyes to pain (2) + withdraws (4) + moans (2) = **8**. Interventions to lower intracranial pressure (ICP) **Respiratory:** prevent low oxygen, and keep **carbon dioxide (CO₂) 35–45**. **"High CO₂ dilates, low CO₂ constricts."** High → brain vessels swell → ↑ICP. Low → vessels clamp → poor blood flow. Both bad. - **Cardiovascular:** know the patient's blood pressure (BP) range; call if above or below. **Cardiac monitor** (lost autoregulation → dysrhythmias). - **Therapeutic hypothermia:** cooling lowers the brain's oxygen demand. **Mannitol** (osmotic diuretic): - Pulls water **out of brain tissue into the blood** → kidneys pee it out → less swelling, lower ICP. - Dosed by **serum osmolality**; goal **310–320** (normal \~300), slightly "salty" blood. - Watch: **dehydration**, electrolyte imbalance, **acute kidney injury**. **Foley + hourly I&O** (an exception to avoiding Foleys). - Often given with **furosemide**: mannitol pulls fluid from the brain, furosemide removes it from the body. **Hypertonic saline (3% or 5%)** works like mannitol. intensive care unit (ICU) only, and it shows why it's dangerous for regular patients. Your instructor said a case study (due next week, from the book) covers ICP prevention in detail, plus post-op craniotomy care. Brain tumors & craniotomy - **Primary** = starts in the brain. **Secondary** = spread from elsewhere (lung, breast). - Any tumor → **↑intracranial pressure (ICP)** and squeezes brain tissue and vessels. - **Meningioma** (benign, common) → usually removed with a good outcome. Malignant → surgery + radiation/chemo. - Common signs: **headache, seizures**, dizziness, memory loss. | Craniotomy | Decompressive craniectomy | | --- | --- | | Skull opened, fixed, closed right away | Piece of skull **removed** and frozen; put back weeks/months later. Leaves room to swell. Patient wears a **helmet**. | Read in book Iggy Ch. 38, pp. 956–973 · skipped per your list: chronic traumatic encephalopathy (CTE) paragraph, pinpoint/ovoid pupil sentences, supra/infratentorial paragraph, chemo & direct drug delivery traumatic brain injury (TBI) basics (book)Read in book - **TBI** = brain damage from an outside force. Affects cognition, movement, senses, and emotions. - **Acceleration** injury = something hits the still head. **Deceleration** = moving head hits something still. Shearing → diffuse axonal injury. - **Open** = skull or dura broken (infection risk). **Closed** = skull intact. - Top causes: **falls**, self-harm, car crashes, assaults. Alcohol/drugs contribute. Young men most; **falls** most in older adults and kids. | Mild (concussion) | Moderate | Severe | | --- | --- | --- | | Blow to the head + brief confusion or feeling dazed, plus one or more: out **up to 30 min**, memory loss right before/after, focal neuro deficit. **Doesn't need** loss of consciousness. **computed tomography (CT)/magnetic resonance imaging (MRI) normal.** Symptoms usually gone in **72 hrs**. | Out **30 min–6 hrs**; Glasgow Coma Scale (GCS) **9–12**. CT/MRI often shows injury. Memory loss up to **24 hrs**. Short acute/critical care stay to watch for swelling, bleeding. | GCS **3–8**; out **over 6 hrs**. Critical care: hemodynamic, neuro, possibly **intracranial pressure (ICP) monitoring**. High risk for secondary injury. | - **Postconcussion syndrome** (most common secondary injury after mild TBI): headache, foggy thinking, dizziness for **4+ weeks**. Also posttraumatic headaches or vertigo; irritability, depression, anxiety, mood swings; insomnia; trouble concentrating or memory loss; **lower alcohol tolerance**. - **Second-impact syndrome**: a second hit before the brain heals → rapid brain swelling, can be catastrophic. Mostly athletes. Teach return-to-play rules. Secondary injury numbers (book)Read in book - **Hypotension** = mean arterial pressure (MAP) **under 70**. **Hypoxemia** = partial pressure of arterial oxygen (PaO₂) **under 80**. Both starve the brain → swelling → worse perfusion (vicious cycle). - intracranial pressure (ICP) normal **10–15**; coughing or straining spikes are OK. Sustained **over 20** → neurons die. - Body compensates: shifts cerebrospinal fluid (CSF), absorbs more CSF, moves venous blood out. When it can't, ICP rises → herniation. - **↑ICP is the leading cause of death** in head-trauma patients who reach the hospital alive. Bleeds & herniation (book)Read in book | Bleed | Book detail | | --- | --- | | **Epidural** | **Arterial** (middle meningeal artery), often a temporal skull fracture. Brief unconsciousness → **lucid interval** (awake, talking for minutes) → rapid decline. **Critical Rescue:** neuro checks **every 5–10 min**; loss of consciousness = **neurosurgical emergency** → provider/Rapid Response now. Document trends. | | **Subdural (SDH)** | **Venous**, slower. Acute (within 48 hrs), subacute (48 hrs–2 wks), chronic (weeks–months). Common in **older adults** and people on **anticoagulants/antiplatelets**. Signs: worsening headache, confusion, ↓level of consciousness (LOC). | | **Intracerebral (ICH)** | Bleeding into brain tissue; may appear up to 10 days later. | - **Uncal herniation**: pushes on **cranial nerve (CN) III** → dilated nonreactive pupil, **ptosis**, fast LOC decline. - **Central herniation**: downward onto the brainstem → **Cheyne-Stokes** breathing, then nonreactive pupils, unstable vitals. - All herniations are life-threatening → **Rapid Response / provider immediately**. - **Hydrocephalus**: **communicating** = cerebrospinal fluid (CSF) not absorbed (after subarachnoid hemorrhage (SAH) or meningitis); **noncommunicating** = outflow blocked (swelling, tumor, debris). traumatic brain injury (TBI) assessment (book)Read in book - History: **when, where, how**; lost consciousness, and how long? Get it from witnesses if needed. Amnesia is common. Older adults: screen for abuse/neglect. - **carbon dioxide (CO₂)**: high (over 45) → vasodilation → ↑intracranial pressure (ICP). Low (under 35, from hyperventilating) → vasoconstriction → ischemia. Track with **end-tidal carbon dioxide (ETCO₂)**. - Treat as a **cervical spine injury** until x-rays prove otherwise. **Rigid collar**; spine precautions: bed rest, no neck or back bending or twisting, **log roll**, check skin under the collar. Spine "clearance" is the provider's call. - Brainstem injury → Cheyne-Stokes or apnea; may need a ventilator. - **Cushing's triad** = severe hypertension (HTN), widened pulse pressure, bradycardia → **death is near**. - **Glasgow Coma Scale (GCS) change of 2 points** = report. **level of consciousness (LOC) is the most important thing to assess**; a change is the **first sign** of worsening. - Pupils: unequal, sluggish, or dilated = herniation until proven otherwise. **Fixed and dilated ("blown") = poor prognosis**. - Check vision (read your name tag, count fingers). - Late ↑ICP signs: severe headache, vomiting (often projectile), seizures. **Papilledema = always ↑ICP**. - Highest ICP risk: first hours, up to **3–4 days** after injury. - Motor loss is on the **opposite** side. - **cerebrospinal fluid (CSF) leak**: clear fluid from nose/ear, **positive glucose**, **halo sign** on white gauze. **Raccoon eyes**, **Battle sign** = basilar skull fracture. - **computed tomography (CT) first**. magnetic resonance imaging (MRI) shows diffuse axonal injury but **not with ICP monitors**. **Critical Rescue:** check pupils (size, shape, reaction) often, especially if they can't follow directions. Report any change to Rapid Response; it may mean ↑ICP. traumatic brain injury (TBI) interventions (book)Read in book - Vitals every **1–2 hrs** or more. Report dysrhythmias, high or low blood pressure (BP); get target ranges from the provider. - **Fever** = worse outcomes. Goal is **normal temperature** (targeted temperature monitoring). - Keep partial pressure of arterial carbon dioxide (PaCO₂) normal; avoid over-hyperventilating. **Positioning Action Alert:** head **midline**, no extreme neck flexion/extension. **Log roll**. head of bed (HOB) **at least 30°** (or as ordered). Avoid sudden HOB changes; a big BP drop when sitting up can hurt the brain. **Mannitol** (book adds): - Pulls water out of swollen brain tissue. Works best as **boluses**, not a continuous drip. - Give through a **filter** in the intravenous (IV) tubing, or draw up with a **filtered needle** for IV push (removes tiny crystals). - Serum **electrolytes and osmolarity every 6 hrs**; goal osmolarity **310–320**. Serum and urine osmolarity and sodium checked **at least daily**. - **Strict hourly urine output**, I&O. Watch for **severe dehydration**, **acute kidney failure**, weakness, edema, urine output changes. - **Furosemide** (loop diuretic) is often added: prevents mannitol "rebound," boosts its effect, lowers edema and blood volume, and **reduces cerebrospinal fluid (CSF) production**. **Hypertonic saline (HTS)**: draws fluid out like mannitol. Usually **3%** sodium chloride (NaCl) (can be up to 23%). Nursing: constant neuro checks, **serial sodium levels**, fluid status, watch for **pulmonary edema** (especially heart or kidney disease). Some hospitals require **intensive care unit (ICU) + central line**. Evidence box: HTS is at least as effective as mannitol for lowering intracranial pressure (ICP); some studies say better. Choice depends on the patient. **Opioids** (fentanyl, morphine) and sedation (propofol, dexmedetomidine) may help ventilated patients; check neuro first. **Brain death** requires: coma of known cause, temp **above 96.8°F (36°C)**, systolic **≥100**, at least 1 neuro exam. Before it's declared, call the **organ procurement** agency (the nurse doesn't bring up donation alone). Support grieving families; ethics, chaplain, social work. Cognition, seizures & trauma-informed care (book)Read in book - **Memory and thinking**: cognitive rehab; reorient; hazard-free room. - **Sensory stimulation** for comatose patients: one stimulus at a time (show a family photo and say who it is). Audio no longer than **10–15 min** or it becomes "white noise." - Seizure precautions and antiepileptic drugs (AEDs) as ordered. - **Trauma-informed care** (6 principles): **safety**, **trust and transparency** (plain language), **peer support**, **collaboration**, **empowerment** (patient has a voice), **cultural and historical sensitivity**. Mild traumatic brain injury (TBI) teaching: Box 38.8Read in book - Headache → **acetaminophen every 4 hrs** as needed (no nonsteroidal anti-inflammatory drugs (NSAIDs)). - **No sedatives, sleeping pills, or alcohol** for at least **24 hrs** (unless the provider says otherwise). - **No strenuous activity** for at least **48 hrs**. - Caregiver: balance problems can cause falls; plan safe movement. - **Call 911 / return** for: seizure, severe or worsening headache, persistent vomiting, blurred vision, **clear drainage from ear or nose**, increasing weakness, slurred speech, **progressive sleepiness**, **unequal pupils**. - Keep follow-up appointments. Home care after traumatic brain injury (TBI) (book)Read in book - Rehab goal: **highest possible function** (OT, physical therapy (PT), speech). - Home safety: working **smoke and fire alarms**; brain injury often takes away the **sense of smell**. - Dietitian: many gain weight within a year (inactivity, stress eating). - Personality and behavior changes: **structured, consistent routine** with repetition. Reinforce **positive** behavior. - Expect fatigue, irritability, temper outbursts, depression, memory problems. Some need constant supervision. - Families feel isolated → regular **respite**, support groups (Brain Injury Association of America). Brain tumors (book)Read in book - **Primary** tumors start in the central nervous system (CNS) and rarely spread out of it. **Secondary** tumors spread from lung, breast, kidney, skin, gastrointestinal (GI). - Any tumor → swelling, ↑intracranial pressure (ICP), possible herniation. Pituitary tumors can cause **syndrome of inappropriate antidiuretic hormone (SIADH)** or **diabetes insipidus** (fluid and sodium problems). - **Meningiomas** (benign) can usually be removed with a good outcome. - Malignant tumors mostly at ages **40–70**. **Signs:** **headache worse on waking**, nausea/vomiting, seizures, numbness or vision changes, dizziness, one-sided weakness, trouble speaking, personality changes. **Diagnosis:** computed tomography (CT) first, then magnetic resonance imaging (MRI) for detail. **Symptom meds:** - Codeine/acetaminophen for headache. - **Dexamethasone** (steroid) for brain swelling. - **Levetiracetam** or other antiepileptic drugs (AEDs) to prevent seizures. - proton pump inhibitors (PPIs) to prevent **stress ulcers**. **Gamma Knife / CyberKnife** (stereotactic radiosurgery): focused radiation, no incision, for hard-to-reach tumors or arteriovenous malformations (AVMs). **Tumor Treating Fields**: electric fields through skin pads. **Glioblastoma** = most aggressive; few survive 5 years. Craniotomy care (book)Read in book **Before surgery:** very anxious (head opened, hair shaved, fear of new deficits). Reassure; teach what to expect after. **Action Alert:** neuro checks + vitals **every 15–30 min for 4–6 hrs**, then **hourly**. Stable 24 hrs → every 2–4 hrs. Report: ↓level of consciousness (LOC), new weakness or paralysis, aphasia, less feeling, **sluggish pupils**, agitation, personality change. | Supratentorial (top of brain) | Infratentorial (brainstem/back) | | --- | --- | | **head of bed (HOB) 30°** (venous drainage). Head midline; no extreme hip or neck bending. Turn side to side or supine. | Keep **flat or 10°**. **Side-lying**, alternating every 2 hrs, for 24–48 hrs. **nothing by mouth (NPO) until fully awake** (swelling near medulla → vomiting, aspiration). | - Check the head **dressing every 1–2 hrs**; mark drainage once a shift. - Drain (Hemovac/Jackson-Pratt (JP)): measure every 8 hrs; usually **30–50 mL / 8 hrs**. **Critical Rescue:** report a **saturated dressing** or drainage **over 50 mL in 8 hrs** right away. Watch for ↑intracranial pressure (ICP). - Swollen, bruised eyes are normal → **cool compresses**; rinse with warm saline or artificial tears. - Cardiac monitor (dysrhythmias). Strict **I&O for 24 hrs**; fluid limit \~**1500 mL/day** if the pituitary is involved. - Labs: complete blood count (CBC), electrolytes, osmolality, clotting. Watch for **low sodium** (SIADH, steroids) → confusion, weakness. **High sodium** (DI, dehydration) → thirst, restlessness. - venous thromboembolism (VTE): compression devices until walking. Deep breathing every 2 hrs. **Box 38.9 complications:** - **Early:** ↑ICP, hematomas, subarachnoid hemorrhage (SAH), hypovolemic shock, hydrocephalus, breathing problems (atelectasis, pneumonia, neurogenic pulmonary edema). - **Late:** wound infection, meningitis, fluid/electrolyte problems, seizures, **cerebrospinal fluid (CSF) leak**, cerebral edema. Book · NCLEX Challenge 38.4 A client just returned from an open craniotomy for a frontal lobe tumor. Which finding needs immediate report to the surgeon or Rapid Response? ↓level of consciousness (LOC) = possible ↑intracranial pressure (ICP) or bleeding. Headache and eye swelling are expected; 25 mL is under the 50 mL limit. Book · NCLEX Challenge 38.3 A client with a mild traumatic brain injury (TBI) is learning about home care. Which statement shows a need for **more teaching**? Box 38.8: no strenuous activity for at least 48 hrs, and balance problems make construction work unsafe. The others are correct teaching. Book · Mastery Q3 Which finding is an **early** change in LOC in a client with a mild TBI? Behavior changes (irritable, restless) come first. Posturing and lost reflexes are late. Book · Mastery Q2 · Select all The nurse is giving mannitol to a client with a severe TBI. Which actions are appropriate? Only A is wrong: urine output is measured **every hour**, not every 4–8. Filtered needle, electrolytes, osmolarity, and dehydration watch all match p. 964. (My answer; check your book's key.) Book · NGN Challenge 38.2 **Case:** 79-year-old fell at home 2 days ago and broke her right arm. Over 2 days: Glasgow Coma Scale (GCS) **15 → 14**, headache **4 → 5 → 8/10**, blood pressure (BP) and pulse creeping up. Review class: Joline head-injury case (what she stressed) Review class From the in-class exam review (Joline case study + NCLEX questions). Joline fell from a third-story balcony. Think: head injury **and** spine injury until proven otherwise. 1. **Most important thing to monitor: level of consciousness (LOC).** First sign of trouble = changes in behavior. 2. **Cushing's triad** (the "triad" that has **4** parts): severe hypertension, widened pulse pressure, **bradycardia**, irregular breathing. Normally high blood pressure makes the heart speed up, so slow heart rate + high blood pressure is the weird exception. It is a **late** sign of increased intracranial pressure. **Be able to apply it:** "blood pressure 200/80, heart rate 40" = Cushing's. 3. **Neuro assessment, know what's wrong AND how you check it:** pupils equal, round, reactive to light and accommodation (PERRLA), LOC, Glasgow Coma Scale (GCS), motor (squeeze my hands, push/pull feet, raise arms), sensory, reflexes, cranial nerves, vital signs (which part is off and why), breathing pattern. 4. **Orogastric (OG) tube, not nasogastric (NG)**, with severe facial trauma or skull fracture (like basal skull fracture). A tube through the nose could go up through the fracture into the brain. Going through the mouth avoids that. 5. **Blood alcohol** makes the neuro assessment **unreliable**. 6. **When she wakes up:** first tell her where she is and what happened ("You're in the hospital. You were in an accident."). This lowers fear. **Then** check orientation. (Students often pick "ask where she is." That's second.) 7. **Epidural hematoma:** knocked out right away → **lucid interval** (seems better, "it's a trick") → then crashes. 8. **Bruising and swelling around the eyes** (periorbital edema and ecchymosis) is expected with this injury. Apply **cold compresses** (decrease swelling) and **artificial tears** (comfort). Assess, and notify the provider as needed. 9. **3 reasons for a fever:** infection, inflammation (body's response to brain injury), and damage to the **hypothalamus** (the body's thermostat). **Glasgow Coma Scale:** don't memorize the scale. The test will give it to you. Just know how to apply it. The tricky part is motor: **withdraws / pulls in = 4**. **Pushes the stimulus away = 5** (localizes pain). Her examples: eyes to pain 2 + verbal none 1 + withdraws 4 = **7**. Eyes to sound 3 + incomprehensible sounds 2 + localizes 5 = **10**. Review class: spinal precautions + preventing ↑intracranial pressure (ICP) Review class From the in-class exam review (Joline case study + NCLEX questions). **Backboard and cervical collar:** used because spinal cord injury and head injury go together. They stay until spinal cord injury is ruled out. - **Spinal precautions:** supine (bed rest), spine in **neutral** position. No twisting, no neck flexion forward or back, **no pillow**. - **Remove the long backboard as soon as possible**: go back to basics: a hard board causes **skin breakdown**. - **Repositioning = log roll** as a unit, with help. - **Every time the patient is moved** (turns every 2 hrs, trip to head computed tomography (CT) scan), do **another neuro assessment**. - **Head of bed position depends on cerebral perfusion pressure (CPP).** Up can pull blood away from the brain; flat can send too much and raise ICP. It's individualized. **Don't memorize** the book's exact rules; just know CPP guides the choice. **Nursing care to avoid increasing ICP:** 1. **Quiet, calm room.** Noise, bright light, anxiety, agitation all raise ICP. Limit upsetting visitors (a screaming parent may need to step out). 2. **No Valsalva** (bearing down): give **stool softeners**; manage coughing. 3. **Suction only if you must** (airway, breathing, circulation (ABCs) come first). Try repositioning and other measures first. If you suction, **hyperoxygenate first**. 4. **Keep the whole body straight:** no head flexion, **no pillow under the knees** (bent knees block blood flow back from the head). 5. **Frequent vital signs + neuro checks.** 6. **Arterial blood gas (ABG): watch carbon dioxide (CO₂)** closely. CO₂ is a **potent vasodilator** → more blood in the brain → ↑ICP. 7. **Do NOT cluster care.** Exception to the rule! Repositioning + bath + linen change + suppository all at once = ICP spike. **Space activities out.** 8. **Control fever.** Fever → shivering → more oxygen demand → more CO₂ → vasodilation → ↑ICP. 9. **Mannitol** (see below). | Mannitol: know it cold | | | --- | --- | | Class | Osmotic diuretic | | How it works | Treats brain swelling. Pulls water out of the brain tissue into the blood vessels → kidneys excrete it. Sometimes given with **furosemide** (loop diuretic) to work together. | | Dosing guide | **Serum osmolality.** Normal ≈ 300 (just remember 300). Goal = slightly hypertonic, **310–320**. Pump rate is adjusted to stay there. | | Filter needle | **Always.** It has microscopic crystals. Any time you read "use a filter needle," remember it. | | Monitor | Intake and output (I&O); urinary catheter is often used here (an exception, we usually avoid catheters); dehydration; blood pressure; labs: **sodium, potassium, serum osmolality** | **Legal/ethical (organ donation):** Joline is an adult whose **driver's license** says organ donor. In **Michigan, Ohio, and Kentucky** that is **legally binding**, so the hospital follows it even if family disagrees (it varies by state). Help the grandmother: let her express feelings; involve the **chaplain, social services, organ donation team**, and possibly the **ethics committee**. Quick recall · tap to flip NCLEX A client hit his head, was knocked out, then woke up talking normally. An hour later he's hard to wake. The nurse suspects: Lucid interval then rapid decline = epidural. Emergency surgery. NCLEX MAP 80, ICP 22. What is the CPP, and what does the nurse do? 80 − 22 = 58. Under 70 means poor brain perfusion, and ICP over 20 is dangerous. NCLEX A client's GCS dropped from 13 to 11. Best action? A 2-point drop is clinically significant. NCLEX Which finding in a client on mannitol needs follow-up first? Mannitol should cause big diuresis. Very low output suggests acute kidney injury. NCLEX Clear fluid is draining from a head-injury client's nose. Best assessment? CSF contains glucose and forms a halo on gauze. Possible skull fracture. The 60-second version ## Migraine = overexcited nerves + swollen, widened brain blood vessels - One-sided, **throbbing** pain. Nausea. Light and sound hurt. Some get an **aura** first. - **Pain management is the priority.** First step: avoid triggers. - Most migraine meds work by **narrowing the blood vessels**. - **Triptans:** NO for heart disease, high blood pressure (BP), peripheral vascular disease (PVD), or with selective serotonin reuptake inhibitors (SSRIs). The vessels are like a garden hose that's swollen too wide and throbbing. The fixes squeeze the hose back down: caffeine, triptans, even a cool cloth. Signs & finding the cause - Usually **one-sided**, throbbing. - Nausea, **photophobia**, **phonophobia**. - **Aura** = warning before it hits (vision changes). **Nurse's job:** detailed interview. How often? How long? What sets it off? **Headache diary** → finds patterns and triggers. Common triggers: **caffeine, red wine, monosodium glutamate (MSG)** (a food flavor additive). Treatment step 1 & 2: triggers + comfort 1. **Avoid triggers.** 2. **Comfort measures:** lie down in a **dark room**, **cool cloth** on the forehead, relaxation, yoga, massage, acupuncture. 3. **Medications** if still needed. Abortive meds (stop it now) Take **as soon as symptoms start**, ideally during the aura. - **First:** acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen, naproxen), or over-the-counter (OTC) combos with **caffeine** (like Excedrin). Caffeine narrows blood vessels. - **Next: triptans**, like **sumatriptan (Imitrex)** and **rizatriptan (Maxalt)**. They activate serotonin → narrow brain arteries → less pain. **Triptan safety:** they narrow vessels *everywhere*, not just the brain.\ • Think twice with **high blood pressure (BP)** or **heart disease**.\ • **Peripheral vascular disease: absolutely not.**\ • Teach: report **chest pain** right away (heart not getting enough blood).\ • Don't mix with **selective serotonin reuptake inhibitors (SSRIs)** (sertraline, fluoxetine) or **St. John's wort** → **serotonin syndrome**. **Lasmiditan:** newer, doesn't narrow vessels outside the brain, so safer. Side effects: **sleepiness, dizziness**. **Rebound headache:** a new headache after the first one goes away. Caused by taking the medicine **too often or too much**. Preventive meds (stop it from coming) For migraines that are **frequent** or **severe**: - nonsteroidal anti-inflammatory drugs (NSAIDs) - **Beta blockers** - **Topiramate** (an anti-seizure drug) Read in book Iggy Ch. 36, pp. 899–902 · crossed-out parts skipped Migraine basics (book)Read in book - Recurrent attacks of head pain that serve **no protective purpose**. - Throbbing, unilateral. Nausea + sensitivity to **light, sound, or head movement**. - Lasts **4 to 72 hours**. Runs in families. **Women** more than men. - Linked to **major depression**, and higher risk of **stroke** and **epilepsy**. **How the pain happens:** cerebral arteries dilate → **prostaglandins** released → inflammation, swelling, leaking → throbbing pain. Full trigger listRead in book - **Caffeine**, **red wine**, **monosodium glutamate (MSG)** - High-intensity light, stress, excessive fatigue, change in weather - **Tyramine**: pickled foods, aged cheese, smoked sausage, beer - Preservatives, artificial sweeteners Triggers set off **hyperexcitable neurons**. Each patient's triggers are different. Types & phases (Box 36.8)Read in book | With aura ("classic") | Without aura ("common") | | --- | --- | | Aura right before the headache | **Most migraines** are this type | **Chronic** = 15+ days a month. **Episodic** = less often. 1. **Prodrome** (1–2 days before): yawning a lot, constipation, mood changes, food cravings. 2. **Aura** (5–60 min, usually one-sided): flashing lights, spots, zigzag lights; numb or tingling lips/tongue, confusion, aphasia, vertigo, one-sided weakness, drowsiness. 3. **Migraine phase**: nausea/vomiting; one-sided throbbing pain, often worse **behind one eye or ear**; photophobia, phonophobia. Without aura: pain gets worse with routine activity; often early morning, with stress, or premenstrual. **Diagnosis:** history + physical, neuro, and psych assessment. Patients tend to have the same symptoms each time. **Women over 50 with migraines:** teach cardiovascular risk factors. **Call 911** for facial drooping, arm weakness, or trouble speaking (stroke). Abortive drugs: the full lineupRead in book **Priority of care = pain management.** | Severity | Drugs | | --- | --- | | Mild | Acetaminophen; nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen, naproxen); over-the-counter (OTC) nonsteroidal anti-inflammatory drug (NSAID) + caffeine | | Nausea | Antiemetics; **metoclopramide** with NSAIDs (speeds stomach emptying) | | Severe | Triptans, ditans | **Caffeine** narrows vessels by blocking **adenosine** (which widens vessels and adds inflammation). **Triptans** (sumatriptan, eletriptan, naratriptan, almotriptan) activate **5-HT (serotonin)** receptors → vasoconstriction. Sumatriptan comes as a pill, injection, or nasal spray. **Contraindicated:** ischemic heart disease, cerebrovascular ischemia, hypertension (HTN), peripheral vascular disease (PVD), **Prinzmetal angina** (coronary vasospasm risk). **Triptan teaching (Drug Alert):** take as soon as symptoms start · report chest pain right away · **use birth control** (not safe in pregnancy) · expect **flushing, tingling, hot feeling** that fades · no selective serotonin reuptake inhibitors (SSRIs) or St. John's wort. **Ditans (lasmiditan):** block one serotonin receptor **without** constricting vessels → safer and more effective than triptans. When to start preventive drugsRead in book Start prevention when **any** of these is true: - More than **2 migraines a month** - Headache lasts more than **24 hours** - Interferes with activities of daily living (ADLs) for **3+ days** - Abortive meds used more than **twice a week** - Not relieved by acute treatment | Drug | Key point | | --- | --- | | **Beta blockers** (propranolol, timolol) | Calm hyperexcitable neurons, block vasodilation. **Lower blood pressure (BP) and heart rate (HR).** | | **Calcium channel blocker** (verapamil) | | | **Topiramate** (AED) | Use in **low doses** | | **Nortriptyline** (TCA) | Dry mouth, urinary retention, constipation. **Not for older adults** (delirium). | **beta blocker (BB) / calcium channel blocker (CCB) teaching:** take your **pulse** · report **bradycardia**, fatigue, shortness of breath · change position slowly (orthostatic hypotension). Diary, comfort & complementary careRead in book - **Headache diary**: type of headache + response to meds. - Report if the headache **changes** in quality or intensity, has **new visual changes**, or the drug stops working. - At onset: lie down, dark room, **both eyes covered**, cool cloth, undisturbed. - **Cannabis:** cannabidiol (CBD) eases pain better; tetrahydrocannabinol (THC) is the mind-altering part. Tolerance can develop. - Yoga, meditation, massage, exercise, **biofeedback**, acupuncture/acupressure. - Riboflavin and **magnesium** supplements may help prevent migraines. - All herbs must be **approved by the provider** first (drug interactions). Heads-up: the book prints "vitamin B12 (riboflavin)," but riboflavin is actually **vitamin B2**. Book · NCLEX Challenge 36.4 · Select all Client prescribed propranolol (prevention) and sumatriptan (acute). Which teaching statements should the nurse include? Beta blockers cause **bradycardia** (report a LOW pulse, not >100) and orthostatic hypotension. Triptans go in early, and chest pain = possible ischemia. Vitamin D isn't part of this plan. Review class: migraine meds (prevent vs. abortive) Review class From the in-class exam review (Joline case study + NCLEX questions). | Goal | Drug | Key point | | --- | --- | --- | | **Prevent** migraines | **Propranolol** (beta blocker) | Taken regularly to prevent attacks | | **Abortive** (once headache starts) | **Triptans** (sumatriptan): "triptan" is in the name | Activates serotonin → **vasoconstriction** of the dilated brain vessels | Triptans squeeze blood vessels. They don't only squeeze the brain's vessels, they squeeze them **everywhere**. **Do NOT give triptans with:** - **Hypertension**, **peripheral vascular disease** (vessels already narrowed) - **Angina / heart disease**: chest pain after a triptan = coronary vasoconstriction - **Selective serotonin reuptake inhibitors (SSRIs)** like fluoxetine (Prozac), paroxetine → too much serotonin = **serotonin syndrome** - **St. John's wort** (and grapefruit) interact with lots of meds. If it shows up as an answer choice, don't pick it. Quick recall · tap to flip NCLEX A client is prescribed sumatriptan. Which history should the nurse report first? Triptans narrow blood vessels, which makes PVD worse. NCLEX After taking a triptan, the client says "my chest feels tight." What does the nurse do? Narrowed vessels can starve the heart of oxygen. Chest pain is a red flag. NCLEX Which statement shows the client understands migraine self-care? The diary finds triggers. Meds go early, daily use causes rebound headaches, and red wine is a trigger. The 60-second version ## A seizure is an electrical storm in the brain - Seizure with a clear cause (fever, electrolytes, alcohol withdrawal, brain injury) = **NOT epilepsy**. Treat the cause. - **Epilepsy** = seizures that keep coming back on their own. - During a seizure: **turn to side, move objects, never restrain, nothing in the mouth**. - **Status epilepticus** (>5 min) = emergency → **airway** first, then **lorazepam intravenous (IV)**. Think of a power surge in a house. Anti-seizure meds are surge protectors: they keep surges from happening, but they don't rewire the house (no cure). **Caption alert:** the video captions say "fentanyl," but your instructor means **phenytoin** (Dilantin). "Phosphantinoin" = **fosphenytoin**. Seizure vs. epilepsy **Seizure** = sudden, uncontrolled burst of electrical activity in brain cells. **Secondary causes** (fix these first): **high fever, electrolyte imbalance, alcohol withdrawal, brain injury**. These are NOT epilepsy. **Epilepsy** = chronic, **recurrent, unprovoked** seizures. Cause: abnormal brain cells or a chemical imbalance (like **gamma-aminobutyric acid (GABA)**, the brain's calming chemical). Diagnosis starts with a detailed **history and physical**. Seizure types (slides)Slides Your instructor said these are **review from Peds**. You won't be tested on each type directly, but the words may show up in a question. **Generalized** = **both** sides of the brain: - **Tonic-clonic** (2–5 min): stiffening + level of consciousness (LOC) (tonic), then rhythmic jerking (clonic). Tongue biting, incontinence. - **Myoclonic:** quick jerks of arms or legs. - **Atonic:** suddenly goes limp → falls → injury. - **Absence:** brief blank stare; lip smacking or picking (automatisms). **Partial (focal)** = **one** side: **complex** (blacks out 1–3 min, no memory after) or **simple** (stays awake, has an aura). electroencephalogram (EEG) test prep EEG records the brain's electrical activity. Electrodes are glued to the scalp. - **Clean hair**: no conditioner, gel, or spray (electrodes won't stick). - **Eat before the test.** Low blood sugar changes the reading. - **No sedatives, stimulants, or caffeine.** - Quiet room, sign on the door. We want a picture of the brain's normal self. Anything that speeds it up, slows it down, or starves it ruins the picture. Anti-seizure meds **Slide drugs:** phenytoin (Dilantin), carbamazepine (Tegretol), valproic acid (Depakote), topiramate (Topamax). You don't need to know which drug is for which seizure type. Know these rules: - They slow the brain → **drowsiness**. - Can cause **depression and suicidal thoughts**. Screen mood. - **Liver damage** → check liver enzymes. **Low white blood cells (WBCs)** → infection risk. - **Narrow safe range** → regular **blood levels**. - **Phenytoin** → **gums overgrow** (gingival hyperplasia). Teach: soft toothbrush, regular dentist visits. **Never stop suddenly.** Seizures come back and can turn into status epilepticus. - **Pregnancy category D**: can cause birth defects, but uncontrolled seizures hurt the baby too. Tough decision with the provider. - **Birth control pills** work less well → use a **second method**. - **Warfarin** needs close monitoring. **No grapefruit** (toxicity). Vagal nerve stimulator (VNS) For seizures meds can't control. A device in the **left chest** (like a pacemaker) sends pulses up the **vagus nerve** to the brain. - Feels an **aura**? **Swipe the magnet** over the device to stop the seizure. - Like a pacemaker: **magnetic resonance imaging (MRI) can be dangerous**, sets off airport metal detectors, wear a **medical alert bracelet**, carry a wallet card. Before: seizure precautions - **Suction + oxygen** at the bedside. - **intravenous (IV) access** (saline lock). They can't swallow pills during a seizure. - **Padded side rails?** Debated (could count as a restraint). **Follow hospital policy.** Some use a mattress on the floor. - Keep them **active and independent**. Don't keep them stuck in bed. **NO padded tongue blades.** A chipped tooth can be breathed in, or the blade can block the airway. During a seizure **Patient safety is the priority.** 1. Turn to the **side** so spit drains out → no aspiration. 2. **Move objects** away so they don't get hurt. 3. **Never restrain.** Nothing in the mouth. 4. **Watch and document** what happens, in order. It tells the provider the seizure type → which drug. Status epilepticus: emergency Seizure lasting **longer than 5 minutes**, or seizures back-to-back over 30 minutes. Over 10 minutes can be deadly. **Call the Rapid Response Team.** 1. **Airway** (may need intubation) + **oxygen**. 2. **intravenous (IV) with normal saline**. Draw blood: **arterial blood gases (ABGs), electrolytes, drug levels**. 3. **Stop it:** **lorazepam (Ativan)** or diazepam (Valium) IV push. 4. **Prevent the next one:** **fosphenytoin** (preferred, safer) or phenytoin. Firefighter first (lorazepam puts out the fire). Then the sprinkler system (fosphenytoin stops the next fire). Patient & family teaching - Meds: take every dose, know interactions, keep blood level appointments. - Family knows what to do during and after a seizure, and when to call 911. - **Seizure diary.** Medical alert bracelet or card. - **Driving laws** by state: **Michigan = 6 months** seizure-free · Wisconsin = 3 months · Ohio = no waiting period. - Employment concerns → refer to **social services / case manager**. - Support groups: Epilepsy Foundation. Read in book Iggy Ch. 36, pp. 902–907 · crossed-out parts skipped (seizure types, Table 36.2) Definitions & secondary causesRead in book **Seizure** = sudden, excessive, uncontrolled electrical discharge of neurons → changes in level of consciousness (LOC), motor/sensory ability, or behavior. **Epilepsy** = chronic, **repeated, unprovoked** seizures. Cause: abnormal electrical activity and/or neurotransmitter imbalance, especially **gamma-aminobutyric acid (GABA)**. **Primary (idiopathic)**: no clear cause, likely genetic. **Secondary**: from a brain lesion (tumor, trauma) or: - Metabolic disorders, **electrolyte problems** (hyperkalemia, water intoxication, hypoglycemia) - Acute alcohol withdrawal, substance abuse - High fever, stroke, head injury, heart disease **Triggers:** more physical activity, stress, fatigue, alcohol or caffeine, certain foods or chemicals. Assessment & diagnosisRead in book - How many seizures, how long, any **pattern**? Have family describe them. - Any **aura** before (the **preictal phase**)? - Meds, herbs, head trauma, high fever, alcohol or drug use, past stroke or hypertension (HTN). - New seizures: ask about any past **loss of consciousness or brain injury**, even in childhood. **Tests:** electroencephalogram (EEG), computed tomography (CT), magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT)/positron emission tomography (PET). antiepileptic drug (AED) teaching (book adds)Read in book - Provider adds **one AED at a time**. - Keep lab appointments: **complete blood count (CBC) + liver enzymes** (most antiepileptic drugs (AEDs) cause **leukopenia** and liver dysfunction) + drug levels. - Take on time. Sensitivity can build with age ("drug decline and sensitivity") → frequent levels. - **Phenytoin + warfarin** = don't combine. - **Grapefruit juice** raises drug levels → toxicity. **Women with epilepsy:** hormones and birth control pills change AED effects → monitor more often. AEDs can add to **osteoporosis** after menopause. During a seizure: Box 36.9Read in book - Protect from injury; **nothing forced in the mouth**. - Turn to the **side** (prevents aspiration, keeps airway clear). - Remove objects; **suction gently** if possible; **loosen clothing**. - **Don't restrain**; guide movements if needed. - **Record start and end time.** **After:** vital signs, neuro checks, keep on side, let them rest. **Document:** pupils and eye deviation, level of consciousness (LOC), apnea/cyanosis/salivation, incontinence, eye fluttering, how motor activity spread, lip smacking, tongue biting, length, aura, behavior after, time to return to baseline. **Cyanosis** during tonic-clonic seizures is common and usually self-limiting. High-risk patients may get O₂ postictally. Status epilepticus: book detailsRead in book **Acute seizures** (more intense, more often, or in clusters) → lorazepam or diazepam to **prevent** status. **Common causes of status:** **suddenly stopping antiepileptic drugs (AEDs)**, infection, alcohol/drug withdrawal, traumatic brain injury (TBI), cerebral edema, metabolic problems. **Critical Rescue:** **airway is the priority** → call provider / Rapid Response → O₂ → **large-bore intravenous (IV)** with 0.9% sodium chloride (NaCl) → usually intensive care unit (ICU). **Untreated:** hypoxia, hypotension, hypoglycemia, dysrhythmias, lactic acidosis. Muscle breakdown → **myoglobin → acute kidney injury** (especially older adults). - **Lorazepam IV push over 2 minutes** (may repeat). Diazepam rectal gel is an option. - **Phenytoin IV:** infusion pump · **normal saline only** (precipitates in other fluids) · flush normal saline (NS) before and after · then oral doses. - **Fosphenytoin:** water-soluble, works with most IV fluids **including dextrose**, fewer heart complications. vagal nerve stimulator (VNS): book detailsRead in book - Device in the **left chest wall**, lead on the **left vagus nerve**. \~2 hrs under general anesthesia. - Turned on in the operating room (OR) or, more often, **2 weeks after surgery**. Runs continuously. - **Voice change** = the nerve is being stimulated (expected). - Complications: **hoarseness (most common)**, cough, dyspnea, neck pain, dysphagia. - Avoid **magnetic resonance imaging scans (MRIs), microwaves, shortwave radios, ultrasound diathermy**. Patient & family teaching: Box 36.10Read in book - Know drug name, dose, timing, side effects, what to do if a dose is missed. - **Never stop antiepileptic drugs (AEDs)**, even if seizures stop. - Keep blood-level appointments. No over-the-counter (OTC) drugs without asking. - Wear a **medical alert** bracelet or carry an ID card. - Family knows how to help during a seizure and **when to call emergency medical services (EMS)**. - Follow **state driving and machinery laws**. - Avoid **alcohol and excessive fatigue**. Balanced diet, rest, stress reduction. **Seizure diary.** - Can't afford meds? Refer to **social services** / case manager. - Discrimination is illegal, but risky jobs (construction, heavy equipment, pilots) may need to change. Book · Mastery Q3 · Select all A hospitalized client has a tonic-clonic seizure. Which actions are most appropriate *during* the seizure? During: suction gently, remove hazards. Nothing goes in the mouth. Vitals come **after**. Benzos are for status or clusters, not every single seizure. Book · NGN Challenge 36.1 **Case:** 54-year-old had **3 tonic-clonic seizures** (2–3 min each) in the past hour. Got intravenous (IV) lorazepam; fosphenytoin infusing; O₂ 2 L. Now back to baseline, A&O ×4, vitals normal. Review class: seizure priorities + meds Review class From the in-class exam review (Joline case study + NCLEX questions). - **Tonic-clonic seizure, loses consciousness → priority: turn to the side** (aspiration risk). If there's no trauma/fall in the story, you're not worried about spinal injury. - **Status epilepticus** = seizure that keeps going. **Stop it** with a benzodiazepine ending in **-pam**: **diazepam** or lorazepam. - **Phenytoin / fosphenytoin** (fosphenytoin more common) **do NOT stop** a seizure in progress. They **prevent future** seizures. Quick recall · tap to flip NCLEX A client is having a tonic-clonic seizure in bed. What should the nurse do first? Side-lying protects the airway. Never restrain, never put anything in the mouth, never leave. NCLEX A client has been seizing for 6 minutes. Priority action? Over 5 minutes = status epilepticus. Airway first. Nothing by mouth. NCLEX A client on an anti-seizure drug takes birth control pills. Best teaching? These drugs make the pill less effective. Never stop them suddenly, and no grapefruit. NCLEX Which finding in a client on long-term anti-seizure meds needs follow-up first? These drugs can cause depression and suicidal thoughts. Safety first. The 60-second version ## Infected brain covering = pressure + sepsis danger - **Meningitis** = inflamed **meninges** (the wrapping around brain and spinal cord). - **Viral** = more common, gets better in 7–10 days. **Bacterial** = emergency, can kill in 24 hrs. - **Meningococcal** (bacterial) → **droplet precautions**. - Diagnose with a **lumbar puncture**, but **computed tomography (CT) first** if signs of ↑intracranial pressure (ICP). - Top 3 checks: **neuro, vital signs, circulation**. The brain sits in a sealed jar. Swelling raises the pressure inside. Opening the bottom of the jar (lumbar puncture) can make the brain shift down. Check the pressure with a computed tomography (CT) before you open it. How it gets in A germ gets into the blood and **crosses the blood-brain barrier**. - Sources: **brain or spine surgery**, **ear or sinus infection**, **flu or pneumonia**. - Prevention = **vaccines**: flu, pneumonia, meningococcal. - **Meningococcal vaccine: age 11–12, booster at 16.** Viral vs. bacterial | | Viral | Bacterial (meningococcal) | | --- | --- | --- | | How common | **More common** | Less common | | How bad | Most recover in **7–10 days** | **Emergency.** Can kill within **24 hrs** | | Spread | — | Highly contagious; outbreaks in **dorms**, group homes | | Isolation | **Standard** | **Droplet** | **Encephalitis** = inflamed **brain tissue** itself. Same signs, but more **long-term brain damage**. Signs & symptoms - **Nuchal rigidity**: stiff, sore neck. - **Severe headache**, **photophobia**, **nystagmus**, pupil changes. - Altered mental status, **seizures**, **↑intracranial pressure (ICP)**, **positive Babinski**, **sepsis**. **Fever may be missing. Why?**\ 1\. **Older adults** run cooler, so 98.6°F might already be a fever for them.\ 2\. They're **already on antibiotics** for the first infection (like sinusitis). The drug didn't kill the germ, and it reached the brain. Babinski reflex **How:** stroke the bottom of the foot from the **heel up to the toes**. | Toes do… | Name | Adult meaning | | --- | --- | --- | | **Curl down** | Absent Babinski | **Normal** (what we want) | | Big toe **up**, others **fan out** | Positive Babinski | **Problem in the brain or spinal cord** | **Exception:** positive Babinski is **normal under age 2**. Their nervous system isn't mature yet. Lumbar puncture (spinal tap) Meningitis is diagnosed by testing **cerebrospinal fluid (CSF)**. - Position: **side-lying, knees to chest** (fetal position). - Patient must stay **very still** (may need help holding or sedation). **Danger:** if there are signs of ↑intracranial pressure (ICP), letting CSF out fast can make pressure worse. **computed tomography (CT) scan first.** Cultures & antibiotics: the exception **Normal rule:** get cultures first, then antibiotics. **Exception** (signs of ↑intracranial pressure (ICP), no time for computed tomography (CT) + lumbar puncture (LP)): 1. Draw **blood cultures** immediately. 2. Start a **broad-spectrum antibiotic right away**. 3. Skip the cerebrospinal fluid (CSF) culture (LP too risky). 4. Germ identified → switch to a **narrow-spectrum** antibiotic. Top 3 nursing priorities 1. **Neuro status.** **First sign of ↑intracranial pressure (ICP) = change in behavior** (restless, irritable, "something's off"). Seizure precautions. 2. **Vital signs**: clues to rising ICP. 3. **Circulation check**: color, temperature, cap refill, pulses in hands and feet. Watch for **bleeding** (gums, urine, intravenous (IV) site). **Why bleeding?** Sepsis makes tons of tiny clots. They use up all the platelets and clotting factors, so none are left for normal clotting → bleeding. This is **disseminated intravascular coagulation (DIC)** (disseminated intravascular coagulation). Read in book Iggy Ch. 36, pp. 907–909 · crossed-out parts skipped What & how it enters (book)Read in book Infection of the **pia mater and arachnoid mater**. Usually bacterial or viral; also fungal or protozoal. **Sterile meningitis** can come from cancer, nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, intravenous (IV) immunoglobulin. **Ways in:** bloodstream, or directly through penetrating trauma, brain/spine surgery, ruptured brain abscess. **Basilar skull fracture:** clear "runny nose" (**rhinorrhea**) or ear drainage (**otorrhea**) may actually be **cerebrospinal fluid (CSF)** → path for infection. **Higher risk:** head/neck infections (otitis media, sinusitis, tooth abscess, even tongue piercing); immunocompromised (no spleen, immunosuppressants, transplant, cancer); older adults. Can cause permanent cranial/spinal nerve damage and **↑intracranial pressure (ICP)**. Organisms & vaccinesRead in book **Viral = "aseptic" meningitis** (no organism grows in cerebrospinal fluid (CSF) culture): enterovirus, herpes simplex virus (HSV)-2, varicella zoster, mumps, human immunodeficiency virus (HIV). **Bacterial:** *Streptococcus pneumoniae* and *Neisseria meningitidis* (= meningococcal). Outbreaks: dorms, **military barracks**, crowded housing. **Vaccine schedule (CDC):** highest risk = **ages 16–21**. First meningococcal dose at **11–12**, booster at **16**. Adults: shared housing, travel, or no spleen. Booster OK as early as 8 weeks after first dose. Other vaccines that prevent meningitis: **Hib**, pneumococcal, mumps, varicella, meningococcal. Key features: Box 36.11Read in book - **↓level of consciousness (LOC)**, disorientation - **Photophobia**, **nystagmus** (jerky repetitive eye movements) - Motor normal early → later hemiparesis/hemiplegia - Cranial nerve problems: **cranial nerve (CN) III, intravenous (IV), VI, VII, VIII** - Short attention span, personality changes - Severe, unrelenting headache; myalgia; N/V; fever, chills; tachycardia - **Red macular rash** = meningococcal Nuchal rigidity, **Kernig** and **Brudzinski** signs show up in only a **small percentage**. Diagnostics (book)Read in book **computed tomography (CT) before lumbar puncture (LP)** for: age **over 60**, immunocompromised, or signs of ↑intracranial pressure (ICP). - LP delayed? Draw **blood cultures** (C&S) first. - Broad-spectrum antibiotic **right after the LP** (or right away if LP is delayed). - cerebrospinal fluid (CSF) tested for cell count, differential, protein, glucose, culture, Gram stain. - **complete blood count (CBC):** white blood cell count (WBC) well above normal. Electrolytes checked. - X-rays of chest, sinuses, mastoids (find the infection source). - CT/magnetic resonance imaging (MRI): ↑ICP, hydrocephalus, abscess. Treatment & isolationRead in book - Broad-spectrum antibiotic until culture and Gram stain return. - Bacterial: usually a **2-week intravenous (IV) antibiotic course**. Start within **1–2 hours** of the order. - **Mannitol** for ↑intracranial pressure (ICP); antiepileptic drugs (AEDs) for seizures. **Droplet Precautions** (in addition to Standard) for *N. meningitidis* and *H. influenzae*: private room · stay **3 feet** away without a mask · patient wears a mask outside the room · teach visitors. All other meningitis: **Standard Precautions**. Nursing care: Box 36.12Read in book **Most important nursing action:** accurately monitor and document **neuro status**. Neuro checks + vital signs (VS) **every 2–4 hours**. - airway, breathing, circulation (ABCs) first. Cranial nerve checks. - **Vascular check every 4 hrs**, especially the **hands**: temp, color, pulses, nail cap refill. Missed compromise → gangrene → loss of the arm. - Strict I&O, prevent fluid overload; **daily weight**. - Quiet room, **dim lights** (photophobia). - Bed rest, **head of bed (HOB) 30°**. Reposition (pressure injuries); range of motion (ROM) every 4 hrs. - Watch for: ↑intracranial pressure (ICP), vascular problems, fluid/electrolyte imbalance, seizures, shock. Also septic shock, clotting disorders, acute respiratory distress syndrome (ARDS), septic arthritis. Book · NGN Challenge 36.2 **Case:** 21-year-old with suspected bacterial meningitis. Temp 101.6 → **102.4°F** → 100.8°F. white blood cell count (WBC) **18,000**. At 0600: A&O ×4, headache 8/10. At 0700: **drowsy, oriented ×2**, unsure of day and time, "very sleepy," headache 5/10. Review class: bacterial meningitis: order of actions Review class From the in-class exam review (Joline case study + NCLEX questions). 1. **Isolation first** (protect yourself and the team). **Droplet** precautions: regular **surgical mask**, private room. No negative-pressure room needed. 2. **Insert an intravenous (IV) line** (circulation; emergency meds). 3. **Computed tomography (CT) of the head before the lumbar puncture**: rule out ↑intracranial pressure (ICP). A lumbar puncture with high ICP pushes it even higher. 4. **Broad-spectrum antibiotic** right away while waiting on the culture and sensitivity (C&S). 5. Once the organism is identified → switch to a **narrow-spectrum** antibiotic. **NCLEX mindset:** even if the patient is blue, you don't skip your own protection. Quick recall · tap to flip NCLEX A client with suspected bacterial meningitis becomes newly restless and irritable. Priority? Behavior change is the earliest sign of ↑ICP. Sedation would hide the neuro exam. NCLEX A college student has meningococcal meningitis. Which precautions? Meningococcal spreads by droplets. Viral meningitis uses standard precautions. NCLEX Stroking an adult's sole makes the big toe go up and the toes fan out. This means: In adults, toes should curl down. Fanning up signals a brain or spinal cord problem. The 60-second version ## Not enough dopamine → movement gets shaky, stiff, and slow - Progressive brain disease that affects **movement**. - Signs = **TRAP** + low blood pressure (BP) when standing, drooling, peeing at night. - Main drug: **carbidopa-levodopa (Sinemet)**. Take with carbs, **not protein**. - Biggest nursing job: **fall prevention** and nutrition. Acetylcholine is the gas pedal. Dopamine is the brake. In Parkinson's the brake wears out but the gas stays the same → shaky, jerky, hard-to-control movement. Signs: TRAP T**Tremor**: "pill rolling" (thumb rubs finger) at rest. Handwriting gets tiny and squiggly. R**Rigidity**: muscles can't relax → **mask-like face**, less blinking/smiling, trouble speaking, **trouble swallowing**, drooling. A**Akinesia/bradykinesia**: slow movement. Eating, writing, shaving get hard. P**Postural instability**: stooped, shuffling, **freezing gait** ("feet stuck to the floor") → **falls**. Automatic-body problems Dopamine also helps run the "fight or flight" system. Less dopamine → it underperforms: - **Orthostatic hypotension**: blood pressure (BP) drops on standing → dizzy → falls. - **Drooling**: less automatic swallowing. - **Nocturia**: peeing at night. Meds: carbidopa-levodopa (Sinemet) Your instructor said these are the most common Parkinson's meds and **the only ones you need to know**. Replaces the missing dopamine (the brake). - **Nausea** is common → take with food, but **carbs, not protein** (protein blocks absorption). - Long-term: **dyskinesia** (uncontrolled movements). - **"On-off"**: symptoms controlled (on), then back (off), several times a day. Meds: dopamine agonists Copy dopamine. Side effects are less common but **more serious** → often **not safe for older adults**. - **Impulse control problems**: gambling, hypersexuality (dopamine = pleasure). - Mood changes. Tolerance, toxicity & drug holiday | Tolerance | Toxicity | | --- | --- | | Med just isn't working as well | **Delirium** (sudden confusion) | **Delirium = sudden. Dementia = slow and long-term.** **Fix for both:** lower the dose or frequency, change meds, or a **drug holiday** (off the med 1 week up to 10 days, then restart). Deep brain stimulation (DBS) When meds aren't enough. Approved for **severe tremors**. - Electrodes go into the brain; wires run under the skin to a device in the **left chest** (like a pacemaker). - Sends pulses that **decrease involuntary movements** and block tremors. - **Not a cure.** Disease still progresses. - Same precautions as a pacemaker: avoid **electromagnetic fields and magnetic resonance imaging scans (MRIs)**. Nursing management (slides)Slides - **Injury prevention (falls)**: muscle strengthening, stretching, flexibility, balance and coordination. - Exercise, range of motion (ROM), walking; self-care; sleep problems. - Communication and speech help; emotional support; support groups. - **Nutrition:** **high protein, high calorie** (unless liver or kidney disease) · soft diet, thickened liquids · **weigh weekly** · swallow evaluation. Watch the trap: high-protein diet for weight, but keep protein away from the Sinemet dose. Captions mishear: `Echinacea` = bradykinesia · `pastoral` = postural · `cinnamon` = Sinemet · `bacteria` = nocturia Read in book Iggy Ch. 36, pp. 894–899 · crossed-out parts skipped (stages box, monoamine oxidase (MAO)-B/catechol-O-methyltransferase (COMT) drugs, imaging, other surgeries) Patho & early signs (book)Read in book **Primary (idiopathic)** is most common. **Secondary** parkinsonism: brain tumors, some **antipsychotics**. Substantia nigra degenerates → less dopamine. Protein **alpha-synuclein** is thought to drive it. Symptoms appear only after a big dopamine drop (book: 70–80%). **Non-motor signs can appear YEARS before TRAP:** constipation, soft voice, **micrographia** (tiny handwriting), **loss of smell**, sexual dysfunction, sleep problems. - **traumatic brain injury (TBI)** raises Parkinson's disease (PD) risk → teach contact-sport athletes to wear **helmets**. - Veterans: TBI, **Agent Orange** exposure. - **Lewy bodies** (abnormal proteins) → some get Lewy body dementia. - About **50% more men** than women. Assessment (book)Read in book - **Rigidity** = resistance to **passive** movement; present early. - Stage 4: needs a **walker** and help with activities of daily living (ADLs). Stage 5: trouble chewing and swallowing. - Late: dementia, psychosis (delusions, paranoia, hallucinations), depression, anxiety, apathy. - Autonomic: **excessive sweating**, orthostatic hypotension. - Speech: soft, slurred, monotone, halting, or rapid. - Bladder: incontinence **or** trouble urinating. Bowel: **constipation**. **No specific test.** Diagnosis is clinical, after ruling out other neuro diseases. **Priority problems:** 1) ↓mobility (self-care deficit) · 2) impaired cognition. **Priority of care: keep mobility and activities of daily living (ADL) independence as long as possible.** Box 36.7: best-practice careRead in book - Give patients **extra time** to answer and to do activities of daily living (ADLs); help only as needed. - Give meds **on time, on their individual schedule** (steady drug levels). - Fall Precautions; physical therapy (PT)/occupational therapy (OT). - Prevent immobility complications: constipation, pressure injuries, contractures. - Schedule activities **late morning** or at their best time of day. - Teach to speak slowly and clearly; communication board; refer to **speech-language pathologist (SLP)**. - Monitor swallowing and intake; **high-protein, high-calorie** foods. - Focus on strengths (self-esteem). Assess depression, anxiety, cognition, insomnia. Drug details (book)Read in book **Dopamine agonists** (apomorphine, pramipexole, ropinirole; **rotigotine patch**): best in the first **3–5 years**; fewer dyskinesias and less "wearing off." **Agonist Drug Alert:** orthostatic hypotension, hallucinations, **sleepiness** → no driving or heavy machinery · rise slowly · shouldn't be prescribed to older adults. **Carbidopa/levodopa:** nearly everyone takes it eventually. Cheaper and better for motor function than agonists. Comes as immediate-release (IR), controlled-release (CR), enteral infusion, and an **inhaled form for "off" periods**. **Safinamide** is an add-on. **Book says:** give levodopa **before meals** for better absorption. **Lecture says:** if it causes nausea, take with carbs, not protein. Both point the same way: **keep protein away from the dose**. **Toxicity** = delirium, hallucinations, less effect. Compare to the pre-drug baseline. **Tolerance** = effects wear off sooner. Drug holiday lasts up to 10 days; monitor and document Parkinson's disease (PD) symptoms during it. **Symptom helpers:** baclofen (spasms), **sublingual atropine** (drooling), zolpidem (insomnia). Medical cannabis: stay **nonjudgmental**. Freezing gait, sleep, eating & speechRead in book **Freezing gait tricks:** step **sideways, then forward** · shift weight side to side, then step · picture an object on the floor to **step over**. Yoga and tai chi help early. range of motion (ROM), stretching, out of bed. **Sleep:** poor nights + short naps they may not notice → risk of **falling asleep while driving**. - speech-language pathologist (SLP) swallowing evaluation. **Soft diet, thick cold fluids** (milkshakes), small frequent meals, thickener (Thick-It). - **Elevate the head** to prevent aspiration. Weigh **weekly**. - Speech: slow, deep breaths, exaggerate words; reduce background noise; listener watches lips. Cognition, home care & deep brain stimulation (DBS) (book)Read in book - About **50%** develop cognitive problems. Depression is common (venlafaxine may be used). - Don't force social events; emphasize strengths. - Teach to report **dizziness, falls, delirium, hallucinations**. - Constipation: fluids, high fiber, bowel program. Sleep hygiene: no alcohol or caffeine, dark room. - Impulse control problems: remind family the patient **can't control** them. Watch for caregiver strain. - Late disease → palliative or hospice care. - **DBS**: reduces the need for levodopa; usually **not offered while meds still work**. Book · Mastery Q2 An ambulatory client was recently diagnosed with **early** Parkinson's. What finding does the nurse expect? Resting tremor is an early sign. Dementia and swallowing problems come late. Book · NCLEX Challenge 36.3 · Select all Client prescribed **ropinirole**. Which teaching statements should the nurse include? Ropinirole is a dopamine agonist: orthostatic hypotension, sleepiness, possible dyskinesias. The patch is rotigotine, and the food rule is for monoamine oxidase inhibitors (MAOIs). Review class: Parkinson's meds + earliest sign Review class From the in-class exam review (Joline case study + NCLEX questions). - **Earliest (initial) sign: tremor.** All the classic signs are Parkinson's, but tremor usually comes first. - **Ropinirole = dopamine agonist** (mimics dopamine). **Caution in older adults:** orthostatic hypotension and drowsiness → falls. - **Carbidopa-levodopa** (Sinemet): levodopa is turned into dopamine. Causes **nausea** → take **with food, but NOT protein** (protein blocks absorption: no peanut butter, eggs). Quick recall · tap to flip NCLEX Which breakfast is best with the morning carbidopa-levodopa dose? Protein blocks levodopa. Carbs help nausea without blocking it. NCLEX Top safety concern for a client with Parkinson's? Low BP on standing + poor balance = high fall risk. NCLEX A family says their dad on a dopamine agonist is suddenly gambling a lot. The nurse knows: Dopamine drives pleasure and reward, so agonists can cause impulse control problems. The 60-second version ## Inherited disease: dementia + "dancing" movements - **Hereditary.** Symptoms start at **age 30–50**. - Brain cells die → **progressive dementia** + **chorea**. - Child of a parent with it: **50/50 chance**. - **No cure.** Control symptoms, prevent complications. "Chorea" is Greek for dance (like "choreography"). Picture fast, jerky dance moves the person can't stop. Chorea & treatment **Chorea** = rapid, jerky movements of the **arms, legs, and face**. The term is used only for Huntington's. - The movements have **no purpose**. - The patient **can't stop or control them**. Care is the same as for anyone with a movement or memory disorder (Parkinson's, Alzheimer's): - Assistive devices; physical therapy (PT), occupational therapy (OT), speech therapy. - **Keep familiar routines.** Break tasks into **small steps**. - **Avoid open-ended questions** (ask yes/no or simple choices). - To-do lists and calendars. Genetics & testing - Parent has it → each child has a **50% chance**. - Child **doesn't carry the gene** → won't get it and **can't pass it on**. - A test can show the gene. Hard question: is it better to know? - **Not done under age 18**: they may feel pressured and aren't mature enough for the results. - **Genetic counseling** is very important for the children (ethical dilemma). Quick recall · tap to flip NCLEX A 16-year-old whose father has Huntington's asks to be tested. Best response? No testing under 18. Risk is 50%, and it doesn't skip generations. NCLEX Which communication works best for a client with Huntington's? Avoid open-ended questions. Simple yes/no choices work better with cognitive decline. The 60-second version ## multiple sclerosis (MS): the immune system strips the wire coating - **Autoimmune.** Damages **myelin** in the brain and spinal cord → signals weak or blocked. - Comes in waves: **flare-ups** and **remissions**. - Top symptoms: **fatigue, mobility problems, vision changes**. - Avoid **heat, stress, fatigue**. No hot showers, no hard exercise. - amyotrophic lateral sclerosis (ALS): **movement only**. Mind and senses stay intact. Myelin is the plastic coating on a phone charger cord. Strip patches off and the signal flickers or cuts out. What multiple sclerosis (MS) is - Myelin **cushions and protects** nerves and helps signals travel between brain, cord, and body. - Demyelination → signals are **weaker**, or don't get through. - Progresses at **different speeds** in different people. **Why diagnosis takes so long** (frustrating for patient and family): - No single test confirms it. - Symptoms look like other neuro problems, which must be ruled out. - Symptoms go away for a while, so people don't seek care. Signs & symptoms - **Overwhelming fatigue.** - **Weak, stiff legs**: hard to move them, hesitant → **fall risk**. - **Vision** (optic nerve): **nystagmus**, **double vision**, blurry vision. - **Dysarthria**: slurred or **scanning speech** (long pauses between words; can sound like stuttering). - Spasticity, numbness/tingling, **intention tremor** (shakes when reaching), poor coordination, positive Babinski. - Trouble swallowing; bowel, bladder, and sexual problems; memory and focus problems. **Don't mix up tremors:** Parkinson's = shakes **at rest**. multiple sclerosis (MS) = shakes **when moving** (intention). Nursing care **Prevent flare-ups:** avoid **fatigue, stress, temperature extremes** (hot showers). **Keep them independent:** - Stay organized; keep often-used items **within reach** (saves energy). - Speech therapy for swallowing trouble. **Eye patch** for double vision. - **Strength and stretching** exercises (PT/occupational therapy (OT)) for balance and coordination. - **No rigorous exercise**: raises body temp → more fatigue, less movement. **Main goal = symptom control.** multiple sclerosis (MS) meds (only 2 to know) No cure. **Immunomodulators** slow the disease and make attacks fewer and milder. Your instructor said know only these: | Drug | Key points | | --- | --- | | **Interferon beta** | Shot under the skin (every other day or weekly). **Infection risk**, bone marrow suppression, **flu-like symptoms**. | | **Glatiramer** | Shot under the skin. **Fewer side effects.** | amyotrophic lateral sclerosis (ALS) (Lou Gehrig's disease) - **Motor neurons** die → weakness, muscle wasting, stiffness → **paralysis**. Cause unknown. - **Only movement is affected.** They can still see, hear, and feel, and **thinking stays intact**. - Starts in one area, then spreads. Lose the ability to talk, swallow, and breathe. - Signs: tired while talking, **tongue shrinking**, slurred speech, trouble swallowing, **face twitching** (fasciculations). - Death usually within **3 years**, from **respiratory failure**. - No cure. Meds treat pain, spasms, **extra secretions**, sleep problems. Communication aids. - May need a feeding tube and ventilator. Get **advance directives** early. **Hospice** supports the family. Read in book Iggy Ch. 37, pp. 913–920 · crossed-out parts left out (MS types except relapsing-remitting multiple sclerosis (RRMS), cerebrospinal fluid (CSF)/evoked potentials, other MS drugs) What happens in multiple sclerosis (MS)Read in book - Cause: **immune, genetic, and/or infectious** factors. - **Demyelination** slows or stops nerve signals → patchy **plaques** in white matter. - Early on, myelin repairs itself and symptoms fade. Over time, damage builds and **muscle atrophy** sets in. - Often hits the **optic nerves**, spinal tracts, brainstem, and the area around the ventricles. - A leading cause of neuro disability in **young and middle-age adults**. Types of multiple sclerosis (MS)Read in book | Type | Pattern | | --- | --- | | **relapsing-remitting multiple sclerosis (RRMS)** (relapsing-remitting) | **Most common.** Flares over weeks to months, then back to baseline. | RRMS is a roller coaster that returns to the station. Who gets itRead in book - **Women 2–3×** more than men (some studies say up to 4×). - Ages **20–50**. About 1 million people in the US. - More common in **colder climates** (Great Lakes, Pacific Northwest). - A **first-degree relative** with multiple sclerosis (MS) raises risk. multiple sclerosis (MS) vs. amyotrophic lateral sclerosis (ALS) (Table 37.1)Read in book | | MS | ALS | | --- | --- | --- | | Cause | Immune attack on myelin; remissions + flares | Unknown (genetic + environmental); progressive muscle wasting → **respiratory paralysis** | | Who | Common; women 2× men; ages 20–50 | Uncommon; **men** more; ages 40–60 | | Signs | Fatigue, spasticity, **diplopia**, scotomas, nystagmus, paresthesias, bladder problems, intention tremor | Fatigue, muscle atrophy (incl. tongue), twitching of face and tongue, dysarthria, dysphagia | | Outlook | Many disease-modifying drugs | **100% fatal**; no cure. Supportive + palliative care | Signs & symptoms (Box 37.1)Read in book **History:** early symptoms are **vague** and come and go, so diagnosis often takes years. Ask about vision, motor, and sensory changes. Ask what makes it worse: **fatigue, stress, temperature extremes, hot showers or baths**. **Common:** - Muscle **weakness and spasticity**; flexor spasms - **Fatigue**, worse with heat - **Paresthesia** (numbness, tingling) - Vision: **diplopia** (double vision), **nystagmus**, ↓acuity, **scotomas** (blind spots) - Bowel and bladder problems (flaccid or spastic); sexual dysfunction - Cognitive changes: memory, judgment, problem solving - Depression, emotional changes - **"MS hug"** (dysesthesia): squeezing feeling around the torso. Often an early sign. - Trouble walking, **dysmetria** (can't control movement range), vertigo, pain, itching **Less common:** **intention tremor** (shaking when reaching for something), hypalgesia, dysarthria, dysphagia, hearing loss, tinnitus, loss of taste, seizures. **Don't mix up the tremors:** Parkinson's = **resting** tremor (pill-rolling at rest). multiple sclerosis (MS) = **intention** tremor (during movement). PsychosocialRead in book - Long road to diagnosis → **anger and frustration**. Let them vent. - After diagnosis: anxiety. Later: apathy, emotional lability. - **Secondary depression** is the most common mental health problem in multiple sclerosis (MS). - Some are **euphoric** (from the disease or the drugs). - Cognition changes are usually **late**: memory, concentration, calculation, judgment. - Fatigue affects sexuality. Women: less sensation and orgasm. Men: erection and ejaculation problems. DiagnosisRead in book **No single test.** Results are put together. - **magnetic resonance imaging (MRI)** of brain and spinal cord showing plaques in **at least 2 areas** = diagnostic. Drug therapyRead in book Goal: slow the disease and reduce flares. Most drugs **suppress immunity** → infection risk. Teach: **avoid crowds and sick people**, wash hands. | Drug | Key nursing point | | --- | --- | | **Interferon beta**; **glatiramer** | Subcutaneous self-injections. **Rotate sites**. Flulike symptoms → acetaminophen/ibuprofen. Bone marrow suppression → report infection. | **Symptom drugs:** **baclofen** or tizanidine (spasticity; severe → intrathecal baclofen pump) · carbamazepine or tricyclic antidepressants (TCAs) (paresthesia) · propranolol, clonazepam (ataxia). Medical cannabis may ease pain and stiffness. Stem cell therapy is being studied. multiple sclerosis (MS) drugs are **very expensive** (health equity issue). Nursing care: mobility, vision, cognitionRead in book - physical therapy (PT)/occupational therapy (OT): **range of motion (ROM)**, stretching, strengthening. - **Avoid things that raise body temp** (worsen fatigue and vision). - Home safety: remove rugs and clutter; adapt for a wheelchair. Plan rest periods. - **Dysarthria / dysphagia** → speech-language pathologist (SLP); thickened liquids if needed; watch for aspiration. - **Diplopia:** **eye patch, switched eye to eye every few hours**. - Peripheral vision loss: teach **scanning** (turn the head side to side). - Cognition: single-date calendar, written lists, keep items in familiar places, phone reminders. Going homeRead in book **Teach to avoid triggers:** overexertion, stress, **temperature extremes** (fever, hot baths, saunas, hot tubs, overheating, getting chilled), humidity, people with infections. - Energy conservation: balance rest and activity. - Know every med: dose, time, route, side effects. - Personality changes: family can agree on a signal for inappropriate behavior. - Sexual dysfunction: phosphodiesterase (PDE)-5 inhibitors (sildenafil) for men; refer to counseling or urology. - Refer to the National multiple sclerosis (MS) Society. Book · NCLEX Challenge · Select all A client was recently diagnosed with MS. Which common findings does the nurse expect? Weakness, vision changes, spasticity, and fatigue are common early. Cognitive changes come later; hallucinations aren't typical. Book · Mastery Q2 · Select all A client will start **interferon beta-1a**. What should the nurse teach? Interferon = immune suppression, subcutaneous injections, flulike aches. The pulse and confusion options belong to other MS drugs that are crossed out of your reading. Quick recall · tap to flip NCLEX Which MS client statement needs more teaching? Heat worsens MS symptoms. NCLEX A client starting interferon beta asks what to watch for. Best answer? Interferon suppresses immunity and often causes flu-like symptoms. NCLEX The family of a client with late ALS asks if he still understands them. Best response? ALS spares thinking and senses. The 60-second version ## Spinal cord injury: protect the neck, watch the blood pressure (BP), find the trigger - Trauma = **safety first**, then **airway, breathing, circulation, disability, exposure (ABCDE)**, then head-to-toe. - Open the airway with a **jaw thrust** (protects the neck). - **Neurogenic shock** = low BP + **LOW heart rate**. - **Autonomic dysreflexia** = sudden **HIGH BP** → **sit up**, check the bladder. The spinal cord is the phone line between brain and body. Cut it, and messages can't get through either way. Below the cut, the body can panic, and the brain's "calm down" message never arrives. Basics - Top causes: **car crashes** and **falls**. About **80% are men**. - **Complete** = no messages below the injury. **Incomplete** = some movement or feeling left. - **Primary injury** = the trauma: bending forward too far (hyperflexion), back too far (hyperextension), crushed downward (axial loading), twisted, or stabbed/shot. - **Secondary injury** = makes it worse: bruising, **swelling** presses on the cord → low blood flow; bleeding; neurogenic shock. Trauma steps: safety, A & B 1. **Safety first**: scene and team. **personal protective equipment (PPE) on** (gloves, gown, eye protection, mask, cap, shoe covers). 2. **Primary survey (ABCDE)**: find and fix life threats. 3. **Secondary survey**: head-to-toe exam. **A = Airway.** Suction; check for face injuries blocking it. **Protect the neck:** **jaw thrust**, not head tilt. Keep the neck straight and in line. **"C3, 4, 5 keeps the diaphragm alive."** These nerves run the breathing muscle. A high neck injury can stop breathing. **Glasgow Coma Scale (GCS) under 8 → intubate.** **B = Breathing.** Breathing isn't enough; it must be **effective**. - Weak effort (gasping, respiratory rate (RR) about 6) → **bag-valve mask**. Oxygen alone won't help. - Breathing well on their own → **non-rebreather mask**. - Check **both sides of the chest rise equally** (collapsed lung?). C, D & E **C = Circulation.** - Outside bleeding: **direct pressure**, pack the wound, **tourniquet above** it. Log roll to check the back. - Inside bleeding shows as **shock**: low blood pressure (BP), fast heart rate (HR), weak pulse. Check the belly and **pelvis**. - **Two big intravenous lines (IVs) (16-gauge)** in the inner elbows. - **No BP cuff? Feel for pulses.** Systolic is at least: **radial 80 · femoral 70 · carotid 60**. **Exception:** **massive uncontrolled bleeding** → order becomes **C-A-B**. Stop the bleeding first. **D = Disability** (quick neuro): Glasgow Coma Scale (GCS), pupils, can they feel and move all 4 limbs? **E = Exposure.** Remove clothing to see everything. - Burns: clothing can melt into skin. - **Save evidence** (weapons, rape kits) for court. - Prevent **hypothermia**: blankets, warm room, warm intravenous (IV) fluids. Cover for dignity. **Secondary survey:** head-to-toe exam, splints, dressings, **nasogastric (NG) or orogastric (OG) tube** (empties stomach), **urinary catheter** (monitors kidneys). Neurogenic shock vs. spinal shock | | Neurogenic shock | Spinal shock | | --- | --- | --- | | What | Lost "fight or flight" tone → vessels go slack | Cord's reaction to injury and **swelling** (not a true shock) | | Signs | **Low blood pressure (BP)** (SBP \<90 or mean arterial pressure (MAP) \<65) + **LOW heart rate**, low temp, abnormal rhythms | Temporary loss of movement, feeling, reflexes, and automatic functions below the injury; **limp paralysis**; bowel stops (**paralytic ileus**) | | Care | **Emergency!** Fluids, vasopressors | Usually gone within **48 hrs** as swelling goes down | **The trick:** every other shock has a **fast** heart rate. Neurogenic shock has a **slow** one. Positioning, collars & halo - **Constant, detailed** movement and feeling checks catch problems early. - Keep the body **aligned**: log roll, turning sheet, slider board. - Thoracic or lumbar injury: may wear a **brace** out of bed. - Possible neck injury: **hard cervical collar** stays on until a **specific provider order** says remove. - Cord being squeezed → **surgery**: remove blood clot, bone pieces, or object; **spinal fusion**. **Halo device** (pins in skull, ring, vest), worn **8–12 weeks**: - **Never** tighten or loosen the screws. **Never** pull on it to move them. - **Wrench taped to the vest** for emergencies (CPR). - **Pin care**: watch for redness, drainage; clean them. Prevents skull bone infection. - Check skin under the vest. Itchy? **Nothing goes inside** (like a cast). - Drinks through a **straw**. Autonomic dysreflexia: emergency A huge, uncontrolled "fight or flight" surge. Usually after the acute phase (often first seen **3–6 months** after injury). **Cause:** something irritating below the injury. Most often a **full bladder** or **constipation**. Also pressure sores, pain, a wrinkled sheet. | Sign | Why | | --- | --- | | **Sudden severe high blood pressure (BP)** | Vessels below clamp down → risk of **stroke** | | **Slow heart rate** | Body tries to lower BP | | Severe **headache**, vision changes | High BP | | **Sweating + flushing ABOVE** injury | Vessels above open up | | **Cool, pale skin BELOW** injury | Vessels below stay tight | 1. **Sit them up** (High Fowler's) right away. 2. **Find and fix the cause.** Kinked Foley? Feel for a full bladder. No catheter → insert one. Check for constipation. 3. **Call the provider.** **Nifedipine** or a nitrate as ordered. 4. Check BP every **2–5 minutes**. Body systems after spinal cord injury (SCI) | System | Watch for / do | | --- | --- | | Lungs | Secretions build up → assisted coughing, incentive spirometer | | Heart | Low blood pressure (BP), low heart rate (HR), low temp, abnormal rhythms, **dizzy when sitting up**, autonomic dysreflexia, **blood clots** (compression devices, low molecular weight heparin) | | Gut | Belly bleeding, paralytic ileus, nutrition | | Bowel/bladder | Retention or incontinence; constipation (fluids, fiber, stool softeners); may learn self-cath | | Muscles/bones | Muscle wasting, spasticity → contractures; **osteoporosis** → fractures | | Skin | Turn **every 1–2 hrs** in bed. In a wheelchair, shift weight **more than every hour** (**wheelchair push-ups**, chair pad) | | Feelings | **Anger** (don't want to depend on others), depression. Check the home for safety and equipment. | Read in book Iggy Ch. 10 (trauma), pp. 208–210 Mechanism of injury (MOI)Read in book | Type | Examples | | --- | --- | | **Blunt** | Car crash, fall, assault (fists, kicks, bat), **blast effect** from a bomb | | **Acceleration-deceleration** (a blunt type) | High-speed crash, fall from a height → tearing, shearing, compression of tissues | | **Penetrating** | Knives, ice picks, gunshot wounds (GSW), shrapnel, falling onto a sharp object | A **GSW to the chest or abdomen** or a **stab wound to the neck** automatically calls the trauma team. Safety & primary survey (book)Read in book - **Scene safety** first, in the field and the emergency department (ED). Standard Precautions every time. - personal protective equipment (PPE): impervious gown, gloves, eye protection, facemask, surgical cap; shoe covers if heavy blood loss is expected. - Resuscitation happens **at the same time** as the survey. Fix airway, breathing, circulation, disability, exposure (ABCDE) problems before lower priorities like splints and dressings. **Airway Critical Rescue:** minutes without oxygen → anoxic brain injury. Clear the airway (suction or by hand), keep the neck **neutral and in line**, use a **jaw thrust**, give O₂. - Breathing on own → **non-rebreather**. Needs help → **bag-valve mask (BVM) with 100% O₂**. - **Glasgow Coma Scale (GCS) 3–8** → endotracheal tube + ventilator. - Breathing check: breath sounds, effort, chest expansion, chest trauma. **Circulation:** - Firm **direct pressure** with thick dry dressing first. Tourniquet if pressure fails. Wound packing, hemostatic dressings. - Suspect **internal bleeding** in any shock state. - **Hypotension is a late sign**: the body's compensation is already used up. - intravenous lines (IVs): two **16-gauge antecubital**; central line or **intraosseous** if veins can't be reached. - Fluids: **lactated Ringer's or 0.9% normal saline (NS)**; hypertonic saline for head trauma. **Warm** all fluids and blood. - Blood: packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, or whole blood. But the priority is always to **stop the bleeding**. **Disability:** **AVPU** = Alert, responds to Voice, responds to Pain, Unresponsive. **GCS** 3 (totally unresponsive) to 15 (normal). Low blood sugar, hypoxia, drugs, or alcohol can lower level of consciousness (LOC). Reassess often. **Exposure:** **cut clothing off with scissors** (fast access, avoid moving injured limbs, burned fabric stuck to skin). Preserve **evidence** (clothing, weapons, bullets, drugs) for rape, abuse, assault, homicide, overdose. Nurses may testify in court. **Hypothermia** = 96.8°F (36°C) or lower. Secondary survey & after (book)Read in book - Gastric tube (prevent vomiting and aspiration), urinary catheter (urine output), diagnostic tests, head-to-toe exam, splints, temporary dressings. - **Disposition:** straight to operating room (OR) or interventional radiology, admit, or **transfer to a trauma center**. - Then assess **psychosocial needs**: social services, rehab, pastoral care, mental health, substance use counseling. Include the family. Book · NCLEX Challenge 10.3 Which mechanism of injury does the nurse document for a client with one gunshot entry point and two stab wounds? Bullets and knives both pierce the body = penetrating trauma. Read in book Iggy Ch. 37, pp. 920–929 · crossed-out parts left out (neuro level/dermatomes, clonidine) Types & mechanisms of injuryRead in book **Complete** spinal cord injury (SCI) = no function below the injury. **Incomplete** = some function left (more common). | Mechanism | Example | | --- | --- | | **Hyperflexion** | Head snaps forward: head-on crash, diving | | **Hyperextension** | Head snaps back: rear-end crash, fall hitting the chin | | **Axial loading** | Vertical compression: diving, landing on buttocks or feet | | **Excessive rotation** | Head turned past normal range | | **Penetrating** | Knife (low speed) or gunshot (high speed) | **Secondary injury** (worsens the first): hemorrhage, ischemia, hypovolemia, low perfusion from neurogenic shock, swelling. **Top causes of death:** **pneumonia** and **septicemia**. **Leading cause:** trauma (more than 1/3 vehicle crashes); falls in older adults; violence; sports. **Prevention:** helmets and padding, seat belts, no impaired driving, water at least **9 feet deep** before diving. Assessment termsRead in book | Term | Meaning | Injury level | | --- | --- | --- | | **Tetraplegia** (quadriplegia) | Paralysis of all 4 limbs | Cervical / upper thoracic | | **Quadriparesis** | Weakness of all 4 limbs | | | **Paraplegia** | Paralysis of legs only | Lower thoracic / lumbosacral | | **Paraparesis** | Weakness of legs only | | - Reflexes: biceps **C5**, triceps **C7**, patella **L3**, ankle **S1**. Absent during spinal shock. Autonomic dysreflexia: book detailsRead in book **Box 37.2 key features:** - Sudden big rise in blood pressure (BP) **+ bradycardia** - Profuse **sweating above** the injury (face, neck, shoulders) - **Flushing above** the injury; goose bumps - **Blurred vision, spots** in the visual field - **Nasal congestion** - Severe **throbbing headache** - Feeling of apprehension **Triggers:** bladder distention, urinary tract infection (UTI), scrotal compression, constipation/impaction, hemorrhoids, pain, **tight clothing**, hard or sharp objects, temperature changes. **Box 37.3: what to do** 1. **Sit them up** (first priority). 2. Check the bladder: retention, catheter **kinks**. No catheter → check for distention and catheterize (anesthetic ointment on the tip). 3. Check for UTI or bladder stones. 4. Check for **fecal impaction** using anesthetic ointment. 5. Check skin for pressure injuries. 6. BP every **10–15 minutes**. 7. **Nifedipine** or a nitrate as ordered. Lecture said BP every 2–5 min; the book says 10–15 min. Go with your instructor on exams, but know both. Airway & breathing (book)Read in book **Airway is the priority** for cervical spinal cord injury (SCI). Injuries at or above **T6**: risk of respiratory distress and **pulmonary embolism (PE) in the first 5 days**. - Breath sounds every **2–4 hrs** the first few days. Act if **oxygen saturation (SpO₂) drops below 95%**. - Incentive spirometer; suction as needed. - **Cough assist** ("quad cough"): hands on the upper abdomen below the ribs; push **inward and upward** as the patient coughs. Neurogenic shock: book detailsRead in book Usually within **24 hrs**, in injuries **above T6**. **Critical Rescue (check at least hourly):** warm, flushed skin (temp dysregulation) · symptomatic bradycardia · ↓level of consciousness (LOC) · ↓urine output · systolic blood pressure (SBP) \<90 or mean arterial pressure (MAP) \<65 → Rapid Response. - intravenous (IV) and oral fluids. **Dextran** (plasma expander). - **Atropine** if heart rate (HR) drops below 50–60. - Severe hypotension: IV vasopressors (phenylephrine, dopamine). Collar, surgery & halo (book)Read in book - Hard collar (**Miami J, Philadelphia**) until an order says remove. Pad pressure points, especially the **back of the head**. - Keep alignment; **log roll**. - After spinal fusion: neuro checks + vital signs (VS) **every hour for 4–6 hrs**, then every 4 hrs. - Thoracic/lumbar fusion: Harrington rods, molded plastic brace. **Halo:** 4 pins into the skull, worn **6–12 weeks** (lecture said 8–12). **Halo Action Alert:** never move the patient by the halo · never adjust screws · **one finger** should fit between the jacket and skin · **wrench taped to the vest** · nothing sharp under the vest · pin care per policy. Report fever or pus from pins. Serious complications: **osteomyelitis of the skull**, subdural abscess. Meds for spinal cord injury (SCI)Read in book | Drug | Why | | --- | --- | | **Pantoprazole** (PPI) | Prevent **stress ulcers** | | Anticoagulant (LMWH) | Prevent venous thromboembolism (VTE) | | Bulk laxatives, stool softeners | Prevent constipation | | Celecoxib | Prevent heterotopic ossification (↑myocardial infarction (MI) and stroke risk) | | Calcium, bisphosphonates | Prevent osteoporosis | | **Intrathecal baclofen (ITB)** | Spasticity. Sedation, fatigue, headache, hypotension. **Never stop suddenly** → seizures, hallucinations. | Long-term complicationsRead in book - **Paralytic ileus** within **72 hrs**; check bowel sounds. Stress ulcers. - **Heterotopic ossification (HO)**: bony overgrowth into muscle. Not visible on x-ray for several weeks. - Pressure injuries, venous thromboembolism (VTE), osteoporosis → fractures, contractures (splints, range of motion (ROM)). - **Orthostatic hypotension**: change position slowly. - Transfers: paraplegic patients often transfer alone; tetraplegic may use a **sliding board**. | Lesion | Bowel/bladder | Care | | --- | --- | --- | | **Upper motor neuron** (cervical, high thoracic) | **Spastic**; reflex emptying still works | Bladder/bowel training; rectal suppositories | | **Lower motor neuron** (lower thoracic, lumbosacral) | **Flaccid**; no reflex | Intermittent catheterization; manual disimpaction | All: **1.5–2 L fluid a day** + stool softeners. Psychosocial, sexuality & rehabRead in book - Often **young men**; may feel guilt (diving, racing). Many veterans (blast injuries). - Be realistic but offer hope. - Men with injuries **above T6** may have reflex erections. A vasodilator before sex can prevent autonomic dysreflexia (AD). - Women can still become pregnant. - Rehab goal: **live independently**. Functional electrical stimulation (FES), exoskeletons. - Older adults with spinal cord injury (SCI): vaccines (respiratory infections are the top cause of death), osteoporosis prevention, skin care. Book · NCLEX Challenge A client with a recent **T1** spinal cord injury (SCI) is flushed and sweating on the face and neck and reports "seeing spots." Which action first? Autonomic dysreflexia. Sitting up lowers blood pressure (BP) immediately. Then find the cause. Book · NCLEX Challenge 37.3 A client with SCI is in a halo fixator with vest. Which action is **most important** for safety? The wrench lets staff remove the vest fast for cardiopulmonary resuscitation (CPR). That's life-saving; the others are routine care. Book · Mastery Q1 A client with a **C6** fracture just got a halo device. Which statement needs **immediate** follow-up? A **new** change in sensation moving upward = possible worsening cord injury. Numb feet were already there. Book · NGN Challenge 37.1 (C7 SCI, halo + vest) **Case:** 21-year-old, C7 SCI. At 1435: new throbbing frontal headache, blurred vision, very sleepy, face and neck flushed with sweating. T 99°F, **heart rate (HR) 58**, **BP 184/95**, oxygen saturation (SpO₂) 95%. Foley draining. At 1450: BP 192/98, headache 8/10. Review class: spinal shock, autonomic dysreflexia, trauma priority Review class From the in-class exam review (Joline case study + NCLEX questions). - **Spinal shock:** swelling right after the injury knocks out movement, feeling, and reflexes. It does **not** mean permanent paralysis. The injury **can't be classified until spinal shock resolves** (about **48 hours**). - **Spinal shock is over when** things come back: they can urinate, reflexes return, they feel an itch or pain, they can move. - **Autonomic dysreflexia:** blood pressure shoots up + pounding headache. Caused by any irritating stimulus. Even a **fan's cool breeze** can trigger it. Find and remove the cause. - **Trauma (Ch. 10 pages):** normally airway, breathing, circulation, disability, exposure (ABCDE), but **massive uncontrolled external bleeding comes first**. No airway will help if they bleed out. Exception to the rule. Quick recall · tap to flip NCLEX A client with a T4 injury suddenly has BP 210/110, HR 48, a pounding headache, and a flushed face. First action? Autonomic dysreflexia. Sitting up lowers BP right away. Then check the bladder. NCLEX Which vital signs suggest neurogenic shock? Low BP with a LOW heart rate. Low BP + fast HR points to bleeding (hypovolemic shock). NCLEX A trauma client is gasping with a respiratory rate of 6. Priority? Weak breathing needs breaths given. Oxygen alone won't help. NCLEX A client in a halo vest says the skin under it itches. Best response? Nothing inside the vest. Never touch the screws or pull on the frame. The 60-second version ## Back pain: mostly a squished disc pressing a nerve - **Neck** and **low back** get hurt most (most flexible parts). - #1 cause of **workplace injury**. Protect your own back! - Comfort: **Williams position**, heat or ice, nonsteroidal anti-inflammatory drugs (NSAIDs). - After back surgery: **cerebrospinal fluid (CSF) leak** = lower head of bed (HOB), call. Must **void** before going home. - After neck surgery: **airway first**. A disc is a jelly donut between two bones. Squeeze it wrong and the jelly (nucleus pulposus) leaks out and presses on the nerve next to it. Protect your own back - **Bend at the knees**, not the back. - **Raise the bed** when repositioning a patient or giving a 2–3 minute intravenous (IV) push. - Good posture, proper shoes, weight control, ergonomics. - Use **ceiling lifts** and get help. No equipment? **Advocate** for it. Disc problems & nerve pain - Disc's jelly center = **shock absorber**. - **Bulging** disc = pushes out. **Herniated** disc = **much worse**, the wall breaks open. - Pressure on a nerve → **burning or stabbing** pain, spasms, numbness, tingling. - Low back → pain down the **leg** (sciatic nerve). Neck → pain down the **arm**. - Big herniation can press on the **spinal cord** → leg/arm weakness, bladder or bowel problems. - **Spinal stenosis** = narrowed spinal canal (from a disc, arthritis, infection, trauma, swelling). Tests | Test | Shows | | --- | --- | | **magnetic resonance imaging (MRI)** | Cord, bones, discs, and **nerve root compression** | | **electromyography (EMG)** | Needle in the muscle checks its electrical activity → nerve damage | | **Nerve conduction study** | **How fast** nerves send signals | Comfort & meds - **Williams position**: semi-Fowler's with a **pillow under the knees**. A recliner works too. - **Firm mattress.** Change positions often. - **Moist heat or ice: 20–30 min, 4 times a day** (whichever works for them). - physical therapy (PT), weight control, massage, chiropractor, acupuncture, **transcutaneous electrical nerve stimulation (TENS) unit**. | Med | Know this | | --- | --- | | **nonsteroidal anti-inflammatory drugs (NSAIDs)** (first choice) | Block prostaglandins (inflammation). Side effect: **gastrointestinal (GI) upset**. Adverse: **bleeding**. | | **Muscle relaxants** (baclofen, cyclobenzaprine) | **Drowsiness, fatigue** | | **Gabapentin** | Anti-seizure drug used for nerve pain | | **Tramadol (Ultram)** | If an opioid is needed: least potent, low dependency | | **Epidural injection** | Steroid + numbing med | Surgery | Minimally invasive | Open | | --- | --- | | Scope removes the piece pressing the nerve. Less pain and blood loss. **Home same or next day**. Walk daily. | Bigger incision. Used when the **spinal cord is compressed**. | - **Discectomy** = remove disc. **Laminectomy** = remove part of a vertebra. - Spine unstable → **spinal fusion**, often with bone from the **hip** → 2 painful sites that can get infected. After open back surgery - Vitals + neuro checks **every hour for 4–6 hrs**, then every 4 hrs. - Watch for fever, low blood pressure (BP), fast heart rate (HR). **cerebrospinal fluid (CSF) leak:** clear drainage, a **"halo"** ring on the dressing, bulging at the incision, or a sudden headache → **lower the head of the bed** and **call the provider**. - Check for a **hematoma**. Check the hip donor site. - Patient **must void before discharge**. - Turn **as a unit** (log roll). **No twisting. No overhead trapeze.** Neck (cervical) surgery - **Front of the neck** (anterior) is most common. Back (posterior) = more pain. **Priority = airway.** Swelling can press on the windpipe. Check **swallowing** and **hoarseness**. Read in book Iggy Ch. 37, pp. 929–937 · crossed-out parts left out (muscle relaxant list, ziconotide, failed back surgery syndrome) Nonsurgical care (book pp. 932–933)Read in book - **Non-drug measures come first.** A short period of bed rest with **heat** may help; heat gives short-term relief. - Start stretching and **resume normal activity as soon as possible**. Aerobic exercise has good evidence. - **Change position often**: long standing, sitting, or lying increases pain. Shoe insoles or floor pads can help. - **Williams position** for acute low back pain from a bulging or herniated disc. - Reassure patients: many fear the pain won't go away. Most won't have another episode with good care. - Chronic pain: stress reduction, mindfulness, progressive muscle relaxation, yoga. **cognitive behavioral therapy (CBT) + physical therapy (PT)** helps pain lasting over 12 months. - **McKenzie exercises** (extension and flexion) move pain toward the center of the back. Start only **after acute pain eases**. Water therapy builds muscle without strain. - **Weight loss** if more than 10% over ideal weight. Meds & muscle relaxant alert (book)Read in book - **nonsteroidal anti-inflammatory drugs (NSAIDs)** (aspirin, ibuprofen, naproxen) help. - Antidepressants and gabapentin are often prescribed, but national guidelines **don't recommend them** for low back pain (antidepressants OK if the patient is also depressed). - Opioids: very limited role, used sparingly and short-term for acute pain. - Topical **capsaicin**: short-term relief. Lidocaine patches: no real benefit. - **Ziconotide**: strong analgesic for severe persistent pain. **Drug Alert:** centrally acting muscle relaxants cause **sedation, dizziness, lightheadedness** and anticholinergic effects (dry mouth, urinary retention, blurred vision, constipation, tachycardia). **Avoid in older adults** (falls). No driving, alcohol, or other central nervous system (CNS) depressants. **Metaxalone** can damage the liver. Surgery details (book)Read in book Done when conservative care fails or **neuro deficits keep getting worse**. minimally invasive surgery (MIS) isn't used if the disc presses on the spinal cord. **Pre-op teaching:** getting in and out of bed, turning, **report new numbness, tingling, or weakness** in the legs, home restrictions. | Minimally invasive | Open | | --- | --- | | **Microdiskectomy** (1-inch incision, endoscope) · **PED** (percutaneous endoscopic diskectomy, may add laser) · **Laser-assisted laparoscopic** (belly-button incision; bulging discs only; risks: infection, nerve root injury) · robot-assisted. Home same day or in 23–48 hrs. | **Diskectomy** (remove disc) · **laminectomy** (remove part of the lamina) · **spinal fusion** (bone graft, metal rods/screws) · interbody cage fusion (titanium mesh) · artificial disc. Pain control may use intrathecal or epidural patient-controlled analgesia (PCA). | **Open-surgery complications:** nerve injury, **diskitis** (disc inflammation), **dural tears**. - Book: vital signs (VS) **at least every 4 hrs for 24 hrs** (fever, hypotension, severe pain); neuro checks every 4 hrs (movement, strength, sensation in legs). - Check ability to **void after catheter removal**. Pain and lying flat make voiding hard, **especially for men**. Lecture said VS every hour for the first 4–6 hrs, then every 4 hrs. The book only says "at least every 4 hrs." Use your instructor's version for exams. Causes & risk factorsRead in book - Muscle strain or spasm, ligament sprain, disk degeneration, **herniated nucleus pulposus (HNP)**. - **Spinal stenosis**: narrowing of the spinal canal, usually over age 50. - Most common in ages 30–60; women a bit more than men. - Risks: heavy lifting, falls, crashes, repetitive bending and twisting, **obesity**, **smoking** (less blood flow to disks), scoliosis. - Older adults: osteoporosis, vertebral fractures, arthritis. Prevention (Box 37.5)Read in book - Safe lifting; ask for help with heavy chores. - Regular exercise: swimming, walking, back strengthening. - No high heels; good posture; footstool and ergonomic chairs. - Avoid prolonged sitting or standing. - Weight within **10% of ideal**. Enough calcium and vitamin D. - **Stop smoking.** **Nurses:** avoid lifting patients by hand. Use the lift equipment. AssessmentRead in book - Main complaint: **continuous pain**. Stiff, flexed posture; limp; can't bend. - **Sciatic pain:** sharp, burning down the back of the thigh or calf, maybe to the ankle or toes. Worse with **sneezing, coughing, straining**. - Raising the straight leg causes severe pain (nerve compression). - Check both legs for sensation (cotton ball, paper clip) and strength. - Ask about **bladder or bowel changes** (new incontinence or retention). - Ask about sadness and suicidal thoughts with persistent pain. - Tests: imaging only if severe; **electromyography (EMG)** and nerve conduction studies. Treatment & meds (slides)Slides **Diagnosis:** magnetic resonance imaging (MRI), electromyography (EMG), nerve conduction study. **Interventions:** positioning · moist heat or cold · physical therapy · weight control · complementary therapies · meds (NSAIDs, muscle relaxants, gabapentin, tramadol, epidural injection). | Class | Examples | | --- | --- | | **NSAIDs** (block prostaglandins → less inflammation and nerve sensitivity) | over-the-counter (OTC): aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve). Rx: **celecoxib** (Celebrex), **meloxicam** (Mobic) | | **Muscle relaxants** | Baclofen, **cyclobenzaprine** (Flexeril), tizanidine (Zanaflex), methocarbamol (Robaxin) | **Surgery:** minimally invasive (microscopic or endoscopic discectomy: shorter stay, less blood loss and pain) or open (**discectomy, laminectomy, spinal fusion**). **Post-op (slide):** vital signs (VS) **hourly for 4–6 hrs**, then every 4 hrs (fever, ↓blood pressure (BP), tachycardia) · neuro checks (movement, strength, sensation) · cerebrospinal fluid (CSF) leak signs → **head of bed (HOB) flat** and call the provider · ability to void · log roll · pain control. After lumbar surgery (Table 37.2)Read in book | Complication | Watch for / do | | --- | --- | | **cerebrospinal fluid (CSF) leak** | Clear fluid on dressing; "halo" ring. **Lay flat**, report to surgeon now. | | Fluid deficit | I&O, hypotension, tachycardia | | **Urinary retention** | Get them to the bathroom early; men may stand to void | | Paralytic ileus | Flatus or stool, distention, N/V | | Fat embolism | Chest pain, dyspnea, anxiety, confusion; **petechiae** on neck, chest, mouth | | Nerve root pain | Pain not relieved by meds | | Infection | Temp spike after **day 2** post-op | **Critical Rescue:** a sudden headache + clear drainage = possible CSF leak. Keep on bed rest, lower the head of the bed, report right away. Bulging at the incision = CSF leak or hematoma. - **Log roll every 2 hrs**. **No overhead trapeze** (strains the back). - Sit in a straight-back chair, feet flat. - venous thromboembolism (VTE) prevention: early mobility, compression devices, anticoagulant. **Home (first 4–6 weeks):** limit stairs and driving · lift nothing over **5 lb** · no bending or twisting · walk daily. Clear drainage from incision → call the surgeon. **Spinal cord stimulation** may help persistent pain: check neuro status below the device and make sure they can void. Cervical neck painRead in book - Usually a herniated disk at **C5–C6** or **C6–C7**. - Pain radiates to the shoulder and arm with numbness or tingling; may disrupt sleep. - Conservative care: exercises (shoulder shrugs, squeezes); soft collar at night, **no longer than \~10 days**. - Surgery: anterior cervical discectomy and fusion (ACDF) (fusion with bone graft) or newer anterior interbody cervical fusion (AICF)/lateral interbody cervical fusion (LICF) (titanium device; shorter recovery). Collar for 2–3 weeks after ACDF. **After ACDF, priority = airway.** Neck swelling can narrow the trachea; the surgery can affect swallowing. Check **swallowing** and breathing; keep suction ready; sit upright; report changes now. **Box 37.6 discharge:** someone stays with them the first few days · no lifting · no driving until cleared · walk daily · call if pain, numbness, or swallowing get worse. Book · Mastery Q3 · Select all A nurse teaches a community group about preventing back injury. Which recommendations are correct? Log rolling is post-op care, not prevention. Everything else is in Box 37.5. Review class: after disc surgery Review class From the in-class exam review (Joline case study + NCLEX questions). - **Distended bladder = urinary retention** → possible spinal nerve damage. Priority finding. - **Reposition every 2 hours** (not every 4). - **Nothing by mouth (NPO) is based on sedation / gag reflex return**, not on whether they've voided or have nausea. - An indwelling catheter, echo, or dietary assessment isn't needed unless the story gives a reason. Quick recall · tap to flip NCLEX Best position for a client with low back pain? Bent knees take pressure off the nerve and relax back muscles. NCLEX After lumbar fusion, a client wants to use the overhead trapeze. Best response? No twisting after back surgery. NCLEX After a laminectomy, the dressing has a clear ring around blood and the client has a sudden headache. First action? Halo sign + headache = possible CSF leak. The 60-second version ## Problems in the wires outside the brain and cord - **Myasthenia gravis**: muscles get weak with use. Keep meds with them always. - **Peripheral nerve injury**: protect the numb area. - **Trigeminal neuralgia (CN V)**: lightning-bolt face pain. - **Bell's palsy (CN VII)**: one side of the face droops. Protect the eye. **Cranial nerves:** your instructor said **don't memorize all 12**. Know V (trigeminal) and VII (facial), plus the swallowing nerves **IX (glossopharyngeal) and X (vagus)** from the stroke lecture. Myasthenia gravis: what it is Acetylcholine is a key. The muscle has locks. In myasthenia gravis (MG), the immune system jams the locks, so the key can't make the muscle move. - **Autoimmune.** Attacks **acetylcholine receptors** where nerve meets muscle. - **Extreme fatigue**; muscles weaken very easily. - First: **eyes** (droopy eyelid = ptosis, double vision). Then **face**: hard to smile, chew, swallow, shave, brush teeth. - Advanced: all muscles, including bowel, bladder, and **breathing**. Edrophonium test & pyridostigmine **Edrophonium (Tensilon) test:** gives more acetylcholine. myasthenia gravis (MG) → muscles improve **within 1 minute**, lasting 4–5 min. **Can cause serious bradycardia.** **Atropine** (the antidote) must be at the bedside. **Pyridostigmine:** keeps more acetylcholine around. Controls symptoms; **doesn't cure**. - Dose can change day to day (weaker days = higher dose). - **Eat 45–60 min after** the dose: muscles strongest → **no aspiration**. Myasthenic vs. cholinergic crisis | | Myasthenic crisis | Cholinergic crisis | | --- | --- | --- | | Cause | **Not enough** medicine | **Too much** medicine | | Edrophonium test | Muscles **improve** | No improvement; may get **weaker** | | Clue | Worsening weakness, **breathing trouble** (may need ventilator) | **Extra secretions**: drooling, sweating, lung secretions | | Treat | More medicine | **Atropine** | Memory trick: **cholinergic = "too much choline" = too much fluid pouring out** (spit, sweat, secretions). Other myasthenia gravis (MG) treatments - **Steroids** (calm the immune system). - **Plasmapheresis & intravenous immunoglobulin (IVIG)**: **short-term only**, for emergencies like breathing distress. Work fast; last weeks to a couple of months. - **Plasmapheresis** = filters out the plasma carrying the bad antibodies; returns the blood cells. Watch for: **low blood pressure (BP)** (fluid loss), **electrolyte imbalance**, **hypothermia**, **access-site infection**. - **IVIG** = donor antibodies that block the bad antibodies. - **Thymectomy** = remove the thymus. MG is linked to a thymus tumor, and the bad antibodies are made there. myasthenia gravis (MG) nursing care - **Breathing support** first. - Plan activities around **peak medicine times**. - Keep pyridostigmine **with them always**: nightstand, car, work. - **Rest is essential.** Repetitive movement can trigger a myasthenic crisis. - Help with communication and nutrition (weak face muscles). - **Eye protection** at night (eyes may not close); **artificial tears** during the day. Peripheral nerve injury From a cut, burn, crush, stretch, and more. The nerve past the injury dies back → weakness, limp paralysis, burning, numbness. - Both nerve ends try to grow back together. **Lined up** → normal function. **Not lined up** → weakness, spasms, less feeling. - **Infection** or **older age** slows healing. - Some function can return early through **backup (collateral) nerves**. - Treatment: **splint or cast** to rest it; surgery to realign the ends. **Teach:** they can't feel the area well → **protect it**. Cover it in cold and heat. Keep skin moisturized. Trigeminal neuralgia (CN V) Irritated **cranial nerve 5** (one on each side of the face) → **one-sided**, excruciating, sharp, shooting bursts of pain. - Triggers: touch, chewing, **brushing teeth**, even **smiling**. Patients start avoiding these things. **Priority = pain management.** 1. **Antiepileptics**: carbamazepine (Tegretol), gabapentin, pregabalin. 2. **Nerve block.** 3. **Surgery** (see below). - **Rhizotomy**: heated needle destroys nerve fibers → that side is **permanently numb**. Teach to **look for injuries** (poked eye, cavity) they can't feel. - **Microvascular decompression**: moves an artery pressing on the nerve. More serious: needs a **craniotomy**. Bell's palsy (CN VII) Sudden paralysis of the **facial nerve (CN 7)**, triggered by the **herpes simplex virus** waking up (infection, cold exposure). - **One side** of the face: can't close the eye, smile, or wrinkle the forehead. Taste is affected. - Can hurt **body image**. - **Antivirals**: acyclovir, valacyclovir. - **Protect the eye** (can't blink or close it). - Nutrition, massage, warm moist heat, facial exercises, emotional support. - Most recover fully in **weeks to months**; a few keep some weakness. Review class: myasthenia gravis + trigeminal neuralgia Review class From the in-class exam review (Joline case study + NCLEX questions). **Pyridostigmine**: **cholinesterase inhibitor** for **myasthenia gravis**. Keeps more acetylcholine around so nerve signals reach the muscles. - **Never miss a dose.** - **Take it so it peaks before activities that need energy**, like **eating**. Eating at a low level → weak swallow → **aspiration**. - **Dose changes daily** based on symptoms and energy (like sliding-scale insulin). Exception to the rule! | Myasthenic crisis | Cholinergic crisis | | --- | --- | | **Not enough** pyridostigmine → weakness, poor oxygenation | **Too much** pyridostigmine ("cholin-" is in the name) | - **Plasmapheresis** (myasthenia gravis treatment) risks: fluid and electrolyte loss, blood pressure changes, site infection. - **Trigeminal neuralgia:** brushing teeth or shaving triggers intense pain, so patients may stop doing them. Address hygiene. Quick recall · tap to flip NCLEX A client with myasthenia gravis (MG) has severe weakness, drooling, sweating, and heavy lung secretions after extra pyridostigmine. The nurse suspects: Too much medicine → too much acetylcholine → secretions. Atropine reverses it. NCLEX Most important teaching for an MG client going home on pyridostigmine? Weakness can hit anytime. Eat 45–60 min after the dose, and rest often. NCLEX Priority teaching for a client with Bell's palsy? The eye can't close, so it can dry out and get hurt. NCLEX A client with a nerve injury to the hand is going outside in winter. Best teaching? Decreased sensation means they can't sense cold or heat injury. Cover it and keep skin hydrated. The 60-second version ## Every med from your lectures & slides, in one place - Only meds your instructor mentioned (no book-only drugs). - **★** = your instructor stressed it most. - Learn the **one big safety point** for each, not every detail. Think of each drug as having one "headline." Sinemet: no protein. Phenytoin: gums. Pyridostigmine: eat 45–60 min later. Mannitol: hourly urine. Migraine | Drug | Know this | | --- | --- | | Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen, naproxen), over-the-counter (OTC) + **caffeine** (Excedrin) | First try. Caffeine narrows vessels. Take at first sign/aura. | | **★ Triptans**: sumatriptan (Imitrex), rizatriptan (Maxalt) | Activate serotonin → narrow vessels. **NO** with heart disease, hypertension (HTN), **peripheral vascular disease (PVD)**. Report **chest pain**. No selective serotonin reuptake inhibitors (SSRIs) or St. John's wort (serotonin syndrome). | | Lasmiditan | Doesn't narrow body vessels. Causes sedation, dizziness. | | Prevention: NSAIDs, **beta blockers**, **topiramate** | For frequent or severe migraines | **Rebound headache** = taking meds too often or too much. Seizures | Drug | Know this | | --- | --- | | **★ Phenytoin (Dilantin)** | **Gingival hyperplasia** → soft toothbrush, dentist | | Carbamazepine (Tegretol), valproic acid (Depakote), topiramate (Topamax) | Same class rules below | **All anti-seizure meds:** drowsiness · depression/**suicidal thoughts** · liver damage · low white blood cells (WBCs) · **blood levels** (narrow range) · **never stop suddenly** (status epilepticus) · pregnancy category D · birth control less effective (use 2nd method) · watch **warfarin** · no **grapefruit**. **Status epilepticus:** 1. **★ Lorazepam (Ativan)** or diazepam (Valium) intravenous (IV) → **stops** the seizure 2. **Fosphenytoin** (preferred, safer) or phenytoin → **prevents** the next one Meningitis - **Broad-spectrum antibiotic** right away (after blood cultures) if ↑intracranial pressure (ICP) signs. Switch to **narrow-spectrum** once the germ is known. - **Vaccines**: meningococcal (age 11–12, booster 16), flu, pneumonia. Parkinson's | Drug | Know this | | --- | --- | | **★ Carbidopa-levodopa (Sinemet)** | Replaces dopamine. Nausea → take with **carbs, NOT protein**. Long-term: dyskinesia, "on-off." | | Dopamine agonists | **Impulse control** problems (gambling). Not for older adults. | **Tolerance** (stops working) or **toxicity** (delirium) → lower dose, change meds, or **drug holiday** (1 week–10 days). multiple sclerosis (MS) (only 2 to know) | Drug | Know this | | --- | --- | | **★ Interferon beta** | Shot under the skin. **Infection risk**, bone marrow suppression, **flu-like symptoms** | | **★ Glatiramer** | Shot under the skin. Fewer side effects | Both slow the disease and make attacks fewer and milder. **No cure.** Spinal cord injury - **Nifedipine** or a nitrate → autonomic dysreflexia (after sitting up and fixing the cause). - **Fluids, vasopressors** → neurogenic shock. - **Low molecular weight heparin** → prevent blood clots. - **Stool softeners** → constipation. Back & neck pain | Drug | Know this | | --- | --- | | **nonsteroidal anti-inflammatory drugs (NSAIDs)** (first choice): aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve), celecoxib (Celebrex), meloxicam (Mobic) | Block prostaglandins. Side effect: **gastrointestinal (GI) upset**. Adverse: **bleeding** | | **Muscle relaxants**: baclofen, cyclobenzaprine (Flexeril), tizanidine (Zanaflex), methocarbamol (Robaxin) | **Drowsiness**, fatigue (act on central nervous system (CNS)) | | Gabapentin | Anti-seizure drug for **nerve pain** | | **★ Tramadol (Ultram)** | If an opioid is needed: least potent, low dependency | | Epidural injection | Steroid + numbing med | Myasthenia gravis | Drug | Know this | | --- | --- | | **★ Pyridostigmine** | Keeps more acetylcholine (ACh) around. **Eat 45–60 min after** (no aspiration). **Carry it always.** Dose changes daily. | | Edrophonium (Tensilon) | **Test** drug. myasthenia gravis (MG) improves within 1 min. Can cause **bradycardia**. | | **★ Atropine** | Antidote for edrophonium; treats **cholinergic crisis**. Keep at bedside. | | Corticosteroids, intravenous immunoglobulin (IVIG) | Calm the immune system; IVIG is short-term for crises | **Too little med** = myasthenic crisis. **Too much** = cholinergic crisis (secretions). Trigeminal neuralgia & Bell's palsy - **Trigeminal**: carbamazepine (Tegretol), gabapentin (Neurontin), pregabalin (Lyrica); nerve block. - **Bell's palsy**: antivirals **acyclovir**, **valacyclovir** (HSV-1). Stroke & transient ischemic attack (TIA) | Drug | Know this | | --- | --- | | **★ tissue plasminogen activator (tPA) (alteplase)** | Ischemic only. Within **3 (up to 4.5) hrs** of symptom onset. **computed tomography (CT) first.** Bleeding risk. Repeat CT after. | | **Antiplatelets**: aspirin, clopidogrel | Prevent clots. Both together = dual antiplatelet therapy | | **Anticoagulants**: heparin, warfarin, direct oral anticoagulants (DOACs) | For **A-fib** | | Aspirin 325 mg | 24–48 hrs after stroke. **Not within 24 hrs of tPA** | | Statin | Must be discharged on one (core measure) | | Enoxaparin / heparin | Prevent blood clots | | Anti-seizure meds | Hemorrhagic stroke (seizure ↑intracranial pressure (ICP)) | Head injury & intracranial pressure (ICP) | Drug | Know this | | --- | --- | | **★ Mannitol** | Pulls water out of the brain. Osmolality goal **310–320**. **Hourly urine** (Foley). Watch dehydration, electrolytes, kidney injury. | | Furosemide | Given with mannitol; removes fluid from the body | | Hypertonic saline (3% or 5%) | Works like mannitol. intensive care unit (ICU) only | | Acetaminophen | Concussion pain. **No nonsteroidal anti-inflammatory drugs (NSAIDs)** (bleeding) | Dialysis (kidney lecture) - **Hold** antihypertensives and antidysrhythmics until after (low blood pressure (BP)). - **Give after**: antibiotics, anticonvulsants, vitamins (dialyzed out). - **Heparin** during dialysis lasts **4–6 hrs**. Antidote: **protamine sulfate**. Review class: med "exceptions" she stressed Review class From the in-class exam review (Joline case study + NCLEX questions). - **Mannitol:** filter needle; dose by serum osmolality (goal 310–320); intake and output (I&O); sodium, potassium. - **Propranolol** prevents migraine; **triptans** abort it (avoid with hypertension, peripheral vascular disease, angina, selective serotonin reuptake inhibitors (SSRIs)). - **Diazepam/lorazepam** stop status epilepticus; **phenytoin/fosphenytoin** only prevent future seizures. - **Ropinirole**: careful in older adults (orthostatic hypotension). **Carbidopa-levodopa**: with food, not protein. - **Pyridostigmine**: don't miss doses, take before eating, dose changes daily. Quick recall · tap to flip NCLEX Which med should the nurse hold before a client's dialysis? Antihypertensives wait until after dialysis (low blood pressure (BP) risk). NCLEX A client on phenytoin says, "I feel fine, so I stopped my pills." Priority concern? Stopping anti-seizure meds suddenly can trigger status epilepticus. NCLEX Which client should NOT get sumatriptan? Triptans narrow vessels everywhere. NCLEX A client on a dopamine agonist starts gambling heavily. The nurse: Impulse control problems are a known adverse effect. The 60-second version ## Dialysis = an artificial kidney - Started based on **symptoms**, not lab numbers. - **Fistula/graft arm:** feel the **thrill**, hear the **bruit**. No blood pressure (BP), intravenous lines (IVs), or sticks in that arm. - **Hold** antihypertensives and dialyzable meds until **after** dialysis. - After: watch for **low BP** and **bleeding** (heparin lasts 4–6 hrs). - Peritoneal dialysis: biggest risk = **peritonitis**. The dialyzer is a coffee filter. Blood flows on one side, a clean solution (dialysate) on the other. Waste and extra fluid pass through the filter and get thrown away. **Note:** this is renal (kidney) content from a different lecture. It's here because you asked to add it. What dialysis is - **Kidney replacement therapy** = umbrella term for **dialysis or transplant**. Those are the only 2 options. - Used when kidneys fail (acute or chronic) to remove extra **fluid and waste**. - Blood passes through an artificial **semipermeable membrane** in the **dialyzer** (artificial kidney). - **Dialysate** = solution that looks like plasma. Fixes electrolytes and acid-base balance. Pause activity: added vs. removed during dialysis. The answer slide wasn't in your transcript; standard answer: **removed** = urea (BUN), creatinine, potassium, uric acid, extra fluid; **added** = bicarbonate (fixes acidosis). Check against your slide. When to start dialysis - Based on **signs and symptoms**, NOT labs (BUN, creatinine, glomerular filtration rate (GFR)). - chronic kidney disease (CKD): started when **uremic** symptoms appear. **Emergency dialysis:** - **Pulmonary edema** - Severe electrolyte or acid-base imbalance, e.g., **hyperkalemia with electrocardiogram (EKG) changes** - **Pericarditis** Pause question: why does pericarditis need emergency dialysis? Standard answer: it's caused by **uremic toxins** irritating the heart sac. Fluid can build up around the heart → **cardiac tamponade**. Dialysis removes the toxins. Check against your slide. Intermittent vs. continuous | | Intermittent hemodialysis | Continuous (CRRT) | | --- | --- | --- | | Schedule | **3×/week, 4 hrs** each | Over **24 hrs** | | Flow | \~300–500 mL/min → **big fluid shifts**, blood pressure (BP) changes | Only 10–80 mL/min (gentler) | | Who | Stable patients | **Unstable** (heart problems) · **intensive care unit (ICU) only** | | Also called | — | Hemofiltration, ultrafiltration | Access: dialysis catheter Regular veins can't handle the high flow, so special access is needed. - **Short-term** (a few sessions or weeks). - Tip in the **superior vena cava** (just above the right atrium); 2 ports: one out to the machine, one back. - Watch for **infection and bleeding** at the site. - **Sterile** dressing changes by the **dialysis nurse only**, not floor nurses. **Dialysis only.** Nothing else goes through it: no intravenous (IV) fluids, no meds. Access: arteriovenous (AV) fistula or graft - **Long-term** dialysis. - **Fistula** = artery and vein sewn together in the arm. **Graft** = synthetic tube connects them. - Needs time to **mature** (fistula \~**12 weeks**). Meanwhile, a catheter is used, so a patient may have **both**. **"Feel the thrill, hear the bruit."** **Thrill** = palpate (buzzing). **Bruit** = auscultate (whooshing, like a loud murmur). Check and document **every 4 hrs**. Also check circulation below the site to the fingertips. **Protect the arm (keep it from clotting):** - **No intravenous lines (IVs), no blood pressure (BP), no compression** on that arm. - No carrying heavy things with it. - Don't sleep on it. Caring for patients after hemodialysis **Meds:** - Most meds are **dialyzable** (removed by dialysis). Give **antibiotics, anticonvulsants, vitamins AFTER**. - **Hold antihypertensives and antidysrhythmics** until after (dialysis already drops blood pressure (BP)). - **Heparin** is used during dialysis and stays active **4–6 hrs** → **no invasive procedures**, watch for bleeding. Antidote = **protamine sulfate**. **Vital signs** for several hours: - **Hypotension** is the big risk. - Slightly **warm** temp is normal (dialysate is warmed: prevents hypothermia, vasodilation speeds toxin removal). **Ongoing fever** → infection or **sepsis**. **Weights** before and after. After = **dry weight**. **1 kg = 1 L** of fluid. Peritoneal dialysis (PD) The **peritoneum** (belly lining) is the filter. Done at home; more freedom (even on vacation). **Won't work** with belly scarring or adhesions from past surgery. 1. **Infuse**: 1–2 L dialysate flows in by gravity. 2. **Dwell**: stays 4–8 hrs. Patient disconnects and walks around. Extra weight can cause **back pain**. 3. **Drain**: fluid flows out by gravity into a bag. Outflow = **effluent**. Types: continuous ambulatory (CAPD), small machines, or overnight while sleeping. Depends on needs and insurance. peritoneal dialysis (PD) complications | Problem | Fix | | --- | --- | | **Peritonitis** (#1) | From contamination at the connection. **Sterile technique**: hand hygiene, sterile gloves, clean and assess site, **mask** when connecting/disconnecting. | | Pain with infusion | Common the first 1–2 weeks. **Warm** the dialysate (warmer or heating pad). **Never the microwave.** | | Poor flow | Kinks or clots. Top causes: **position** (turn to other side, supine or low Fowler's, align body) and **constipation** (high fiber, stool softeners). | | Leakage | Clear fluid around catheter, from too much volume at first. Builds up to a full \~**2 L** over a couple weeks. | Non-compliance (Carlos) - Dialysis for life, 3–4 hrs, 3 days a week. Many feel **denial**: "I feel better, I'll skip today." - Find the **reason** first: money, work, **no ride** to the clinic. - Don't just tell them what to do. Ask what they're **thinking and feeling**. Class prep: how will you bring up non-compliance with Carlos? Try an open question, like "Tell me what makes getting to dialysis hard." Quick recall · tap to flip NCLEX A client returns from hemodialysis. Which order should the nurse question? Never use the access arm for IVs, BP, or compression. NCLEX A client is scheduled for dialysis at 0900. Which 0800 med should the nurse hold? Dialysis already lowers BP. Antihypertensives wait until after. NCLEX A client on peritoneal dialysis has cloudy effluent and belly pain. The nurse suspects: Peritonitis is the major PD complication, from contamination at the connection. NCLEX A client weighed 82 kg before dialysis and 79.5 kg after. How much fluid was removed? 82 − 79.5 = 2.5 kg = 2.5 L.

German when to use certain set of words

AP U.S. Government Midterm Study Guide UNIT 1: FOUNDATIONS OF AMERICAN DEMOCRACY Topic 1.1: Ideals of Democracy Required Foundational Document: Declaration of Independence 1. Enlightenment Philosophical Foundations John Locke (Second Treatise of Civil Government): Natural law dictates that all individuals are born free and equal with natural rights (life, liberty, property). Government authority derives solely from the consent of the governed. If a government breaks the social contract or violates natural rights, citizens are obligated to alter or abolish it. Thomas Hobbes (Leviathan): Believed human nature in a state of nature is "solitary, poor, nasty, brutish, and short," resulting in anarchy. People surrender freedoms in a social contract to an absolute sovereign (Leviathan) in exchange for peace and social order. Jean-Jacques Rousseau (The Social Contract): Envisioned popular sovereignty—the people as the ultimate ruling authority—where free individuals abandon certain natural freedoms to form a body politic committed to the general good. Baron de Montesquieu (The Spirit of the Laws): Championed a republican government with defined, limited powers and advocated for the separation of powers into executive, legislative, and judicial branches to prevent tyranny. 2. Core Democratic Ideals & Foundational Documents Key Ideals: Natural rights, popular sovereignty, social contract, republicanism (electing representatives for a limited term to make laws in the public interest), and limited government (government restricted by law, checks, and balances). Declaration of Independence (1776): Authored primarily by Thomas Jefferson. Drafted by a committee of five (Jefferson, Adams, Franklin, Sherman, Livingston). Provided a moral and legal justification for rebellion against King George III by arguing that abusive taxation and British tyranny violated natural rights and the social contract. U.S. Constitution (1787): Codified ideals of self-government, checks and balances, separation of powers, and majority rule balanced with minority rights into a functional blueprint for a representative republic. Topic 1.2: Types of Democracy Model of Democracy Core Definition & Characteristics Historical & Contemporary Examples Participatory Democracy Emphasizes broad, direct participation of citizens in politics and civil society. Citizens vote directly on laws rather than relying exclusively on elected representatives. Town hall meetings, state/local ballot initiatives (citizens place measures on ballot), referendums (citizens vote to approve/defeat legislative acts). Pluralist Democracy Non-governmental interest groups activate to compete for political influence in a "marketplace of ideas." Policymaking is a result of bargaining, negotiation, and compromise among diverse interest groups. Interest groups testifying at congressional hearings, filing lawsuits, lobbying (e.g., NRA, NAACP, NOW, AFL-CIO, environmental groups). Elite Democracy Elected representatives act as trustees for voters; power is concentrated among educated, wealthy, or well-resourced individuals who possess the expertise to govern wisely. The Electoral College choosing the President, lifetime appointments of federal judges, original election of U.S. Senators by state legislatures. Topic 1.3: Government Power and Individual Rights Required Foundational Documents: Federalist No. 10, Brutus No. 1 1. Federalist vs. Anti-Federalist Debate Federalists (Hamilton, Madison, Jay): Supported ratifying the 1787 Constitution. Favored a strong central national government to maintain order, national security, and economic stability. Argued that a large, extended republic would protect individual rights by taming factions. Anti-Federalists (Patrick Henry, George Mason, Robert Yates): Opposed the new Constitution. Feared a strong national executive would replicate a British monarch and warned that the "Necessary and Proper" and "Supremacy" clauses gave the national government unchecked power, threatening state sovereignty and individual rights. Demanded a Bill of Rights. 2. Required Document Comparison Feature Federalist No. 10 (James Madison) Brutus No. 1 (Anti-Federalist Pseudonym) Central Argument A large, diverse representative republic is the best mechanism to control the "mischiefs of faction." A large, extended republic will destroy state sovereignty, erode individual liberty, and result in tyranny. View on Factions Factions are inevitable due to human nature. They cannot be eliminated without destroying liberty. Therefore, their effects must be controlled through a large republic where competing interest groups neutralize one another. In a large country, citizens' interests are too diverse ("clashing of opinions"), leading to constant legislative gridlock or government overreach to maintain order. Representation A large pool of voters ensures qualified, virtuous leaders are elected as representatives (trustees), insulating government from rash popular passion. Representatives in a large nation will be distant, unacquainted with local constituent needs, unaccountable, and prone to abuse their elevated power. Topic 1.4: Challenges of the Articles of Confederation Required Foundational Document: Articles of Confederation 1. Structure of Government Under the Articles (1781–1789) Unicameral Confederation Congress; each state possessed exactly one vote regardless of size or population. No executive branch to enforce national laws; no national judicial system to resolve disputes between states. Passing national legislation required approval by 9 of 13 states; amending the Articles required unanimous consent (13 of 13 states). 2. Key Weaknesses & Consequences Provision / Limitation Systemic Weakness & Impact No Direct Power to Tax Congress could only request funds from states. The national government faced immense Revolutionary War debt and could not pay foreign creditors or military veterans. No Power to Raise/Maintain a Standing Army The federal government relied on state militias and could not effectively secure national borders or suppress internal civil unrest. Inability to Regulate Interstate Commerce States imposed tariffs on goods from other states, issued conflicting paper currencies, and engaged in economic trade wars, paralyzing economic growth. Unanimity Amendment Requirement A single state (e.g., Rhode Island) could veto necessary tax reforms or constitutional adjustments, creating legislative paralysis. 3. Catalyst for Change: Shays' Rebellion (1786–1787) Impoverished Revolutionary War veteran Daniel Shays led an armed insurrection of Massachusetts farmers facing mortgage foreclosures and high state taxes. The insurgents forcibly closed debt courts and attacked the Springfield federal arsenal. Because the national government lacked funds and an army, Massachusetts had to rely on a privately funded militia to suppress the rebellion. Significance: Exposed the dangerous weakness of the central government under the Articles of Confederation, convincing national leaders (such as Washington, Madison, and Hamilton) to convene the Philadelphia Convention in May 1787. Topic 1.5: Ratification of the U.S. Constitution Required Foundational Document: The Constitution of the United States 1. Constitutional Compromises Virginia Plan vs. New Jersey Plan: Virginia Plan (James Madison): Bicameral legislature with representation in both houses based on population; favored large states. New Jersey Plan (William Paterson): Unicameral legislature with equal representation (one state, one vote); preserved state sovereignty for small states. Great (Connecticut) Compromise: Authored by Roger Sherman. Created a bicameral Congress consisting of: House of Representatives: Apportioned by state population (appeased large states); directly elected by voters. Senate: Equal representation (2 senators per state, appeased small states); originally chosen by state legislatures. Three-Fifths Compromise: Agreed that three out of every five enslaved persons would count toward a state's total population for House representation and federal direct tax assessments. Slave Trade Compromise: Prohibited Congress from banning the international slave trade for 20 years after ratification (until 1808) and included a fugitive slave extradition clause. Electoral College Compromise: Reconciled debates over whether Congress or direct popular vote should select the president. Each state chooses electors equal to its total congressional representation (House + Senate) to elect the executive. Commerce Compromise: Allowed Congress to regulate interstate and foreign commerce and levy tariffs on imports, but prohibited taxing exports. 2. The Constitutional Framework (Articles I–VII) Article I: Legislative Branch (Structure, Enumerated Powers, Necessary & Proper Clause). Article II: Executive Branch (Qualifications, Commander-in-Chief, Executive Duties). Article III: Judicial Branch (Supreme Court and Inferior Federal Courts). Article IV: Relations Among States (Full Faith and Credit, Privileges and Immunities, Extradition). Article V: Amendment Process (Two-stage process requiring 2/3 vote in Congress/Conventions to propose, 3/4 state legislatures/conventions to ratify). Article VI: National Supremacy Clause (Constitution and federal laws are supreme law of the land). Article VII: Ratification procedure (Required approval by 9 of 13 state conventions). 3. Modern Policy Debates Over Central Power Individual Rights vs. National Security: USA PATRIOT Act (2001) expanded executive surveillance authority after 9/11, sparking Fourth Amendment privacy concerns. The USA FREEDOM Act (2015) curtailed bulk phone metadata collection. Education Policy: Federal legislation such as No Child Left Behind (2002) and Every Student Succeeds Act (2015) reflect ongoing tension between federal standard-setting and state control under the 10th Amendment. Topic 1.6: Principles of American Government Required Foundational Document: Federalist No. 51 1. Foundational Theory: Federalist No. 51 (James Madison) "Ambition must be made to counteract ambition": Human nature is prone to self-interest. To prevent tyranny, government authority must be divided among distinct branches, giving each branch the constitutional means and motives to check the others. Division of Legislative Power: Because legislative power naturally predominates in a republic, Madison argued for dividing Congress into two branches (House and Senate) with different election modes and responsibilities. Double Security of Federalism: Power is first divided between two distinct governments (federal and state) and then subdivided among three branches within each, providing multiple layers of protection for individual rights. 2. Practical Checks and Balances System Branch Possessing Power Constitutional Check Over Legislative Constitutional Check Over Executive Constitutional Check Over Judicial Legislative (Congress) Bicameralism (House and Senate check each other). Overriding vetoes (2/3 vote), power of the purse, impeachment (House) and trial/removal (Senate), Senate advice and consent on appointments/treaties. Senate confirmation of judges, impeachment/removal of federal judges, altering court size/jurisdiction, proposing constitutional amendments. Executive (President) Vetoing legislation, calling special sessions, pocket vetoes. Internal administrative oversight. Nominating federal judges, power to grant pardons and reprieves. Judicial (Courts) Declaring laws passed by Congress unconstitutional (Judicial Review). Declaring executive actions or orders unconstitutional (Judicial Review). Chief Justice presides over presidential impeachment trials in the Senate. Topic 1.7: Relationship Between the States and Federal Government 1. Constitutional Allocation of Powers Exclusive (Delegated/Expressed) Powers: Granted solely to the federal government (e.g., declaring war, coining money, regulating interstate commerce, conducting foreign diplomacy, defining naturalization). Reserved Powers (10th Amendment): Powers not delegated to the federal government nor prohibited to the states are reserved to the states or the people (e.g., police powers—regulating health, safety, welfare, morals; operating schools; issuing licenses). Concurrent Powers: Powers shared by both national and state governments (e.g., levying taxes, enforcing laws, establishing court systems, borrowing money). 2. Fiscal Federalism & Financial Intergovernmental Relations Categorical Grants: Federal grants given to states for specific, narrowly defined purposes with strict requirements ("strings attached"). Gives the federal government significant leverage over state policy (e.g., National Minimum Drinking Age Act of 1984 tied highway funding to raising drinking age to 21, upheld in South Dakota v. Dole). Block Grants: Federal funds provided to states for broadly defined policy areas (e.g., community development, social services) with minimal federal conditions, granting states significant discretion (advocated during Devolution). Federal Mandates: Directives issued by the federal government requiring states to comply with national standards: Funded Mandates: Accompanied by federal financial aid. Unfunded Mandates: Requirements imposed without federal funding, forcing states to absorb compliance costs (e.g., Americans with Disabilities Act [ADA] of 1990, Clean Air Act Amendments). Devolution: The political movement to transfer power and administration from the federal government back to state and local governments (popularized during the Reagan administration and the 104th Congress, leading to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996). Topic 1.8: Constitutional Interpretations of Federalism Required Supreme Court Cases: McCulloch v. Maryland (1819), United States v. Lopez (1995) Required SCOTUS Cases Comparison Case Name McCulloch v. Maryland (1819) United States v. Lopez (1995) Constitutional Issue Necessary and Proper Clause (Art. I, Sec. 8); Supremacy Clause (Art. VI). Commerce Clause (Art. I, Sec. 8); 10th Amendment Reserved Powers. Essential Facts Congress chartered the Second Bank of the U.S. The state of Maryland levied a tax on the bank to drive it out of state. Cashier James McCulloch refused to pay. Alfonso Lopez carried a concealed firearm into a Texas high school and was charged under the federal Gun-Free School Zones Act of 1990. Holding / Decision Unanimous (6–0) for McCulloch. Congress has the authority to charter a bank; states cannot tax federal institutions. Majority (5–4) for Lopez. The Gun-Free School Zones Act is unconstitutional because gun possession in a school zone does not substantially affect interstate commerce. Constitutional Impact Established national supremacy and solidified implied powers under the Necessary and Proper Clause ("The power to tax involves the power to destroy"). Expanded federal authority. Marked a major shift toward Devolution and state rights. Restricted Congress's reliance on the Commerce Clause, re-establishing limits on federal power over local policing/education. Topic 1.9: Federalism in Action 1. Impact on Policymaking Multiple Access Points: Stakeholders, interest groups, and citizens can influence policy across multiple levels (local, state, national) and branches (executive, legislative, judicial). If a group fails at the federal level, it can pursue initiatives at the state level. Laboratories of Democracy: States can experiment with novel social and economic policies without risking the entire nation (e.g., marijuana legalization, environmental regulations, healthcare reform models). 2. Federal-State Policy Conflicts Environmental Policy: Federal laws like the Clean Air Act and international agreements (e.g., Paris Agreement) face friction when federal rules conflict with state industrial standards or state-led cap-and-trade initiatives. Marijuana Legalization: While cannabis remains a Schedule I illegal drug under federal law (Controlled Substances Act of 1970, upheld in Gonzales v. Raich), numerous states have legalized medical and recreational marijuana through direct ballot initiatives. Federal enforcement relies heavily on executive department discretion. UNIT 2: INTERACTIONS AMONG BRANCHES (CONGRESSIONAL BRANCH) Topic 2.1: Congress: Senate and House of Representatives Required Foundational Document: U.S. Constitution (Article I) Institutional Differences Between Houses Feature / Institutional Metric House of Representatives U.S. Senate Membership Size 435 members (apportioned by population via Reapportionment Act of 1929). 100 members (2 per state). Term Length & Cycles 2-year terms; entire House up for election every 2 years. 6-year terms; staggered elections (1/3 of Senate up every 2 years; continuous body). Constituency Local single-member congressional districts (~700,000+ constituents). State at-large voters (broad, diverse constituency). Qualifications At least 25 years old, U.S. citizen for 7 years, resident of state represented. At least 30 years old, U.S. citizen for 9 years, resident of state represented. Exclusive Powers Originates all revenue/tax bills, initiates impeachment charges, selects President if Electoral College ties. Advice and consent on presidential nominations and foreign treaties (2/3 vote), conducts impeachment trials (2/3 vote to convict/remove). Debate & Debate Structure Highly structured, formal, centralized. Strict time limits on debate controlled by the Rules Committee. Less formal, decentralized. Unlimited debate permitted (filibusters allowed unless stopped by cloture). Constitutional Amendment Impact 14th Amendment protection; original popular election preserved. 17th Amendment (1913): Shifted election of Senators from state legislatures to direct popular vote. Powers of Congress (Article I, Section 8) Power of the Purse: Authority to levy taxes, collect revenue, coin money, and pass statutory appropriations funding federal programs. Regulating Commerce: Power to regulate international and interstate trade (Commerce Clause). Foreign & Military Powers: Exclusive power to declare war, raise and fund armies/navies, regulate military draft, and pass the War Powers Act of 1973 (requiring president to notify Congress within 48 hours of deploying troops and withdraw after 60 days unless authorized). Implied Powers: Authority grounded in the Necessary and Proper Clause to enact laws and execute delegated powers. Topic 2.2: Structures, Powers, and Functions of Congress 1. Congressional Leadership System Speaker of the House: Only House leadership position mandated by Constitution. Elected by majority party; presides over House, assigns bills to committees, recognizes speakers, and influences legislative agenda. Floor Leaders (Majority/Minority Leaders): Lead debate for their respective parties, guide strategy, and serve as national party spokespersons. Whips (Majority/Minority Whips): Enforce party discipline, tally prospective votes, and persuade members to vote along party lines. President of the Senate: The Vice President of the U.S.; non-voting presiding officer except to break tie votes. President Pro Tempore: Senior member of Senate majority party; presides over Senate in VP's absence. Senate Majority Leader: Most powerful figure in the Senate. Sets legislative calendar, controls floor debate, and determines which bills reach the floor. 2. The Committee System Committee Type Primary Role & Function Standing Committees Permanent panels handling specific policy areas (e.g., House Ways and Means, Senate Judiciary, Armed Services). Conduct hearings, mark up bills, and perform legislative oversight. Select / Special Committees Temporary committees established for a specific, limited investigation or study (e.g., Select Committee on Benghazi, Watergate). Joint Committees Panels containing members from both House and Senate to coordinate routine administrative issues or long-term studies (e.g., Joint Committee on Taxation). Conference Committees Temporary compromise panels formed to reconcile differing versions of House and Senate bills into a single, identical draft before sending to the president. 3. Chamber-Specific Rules & Procedures House Rules Committee: Acts as the "traffic cop" of the House. Determines rules for floor debate (time limits, open vs. closed amendment rules) and schedules bills. Committee of the Whole (House): Procedure designed to relax House rules, speed up debate, and require a reduced quorum of only 100 members. Discharge Petition (House): A petition signed by a simple majority (218 members) that forces a stalled bill out of a reluctant committee onto the House floor for a vote. Filibuster & Cloture (Senate): Tactical delay weapon using unlimited debate to block action on a bill or nomination. Stopped only by a Cloture Motion (Rule 22) requiring a 3/5 supermajority (60 votes). Holds & Unanimous Consent (Senate): Hold: An informal request by a senator to delay or prevent a bill or nomination from reaching the floor. Unanimous Consent Agreement: Set procedure rules to speed up Senate business by bypassing formal rules with unanimous approval. 4. The Federal Budgetary Process Mandatory Spending: Spending required by existing law for entitlement programs (e.g., Social Security, Medicare, Medicaid). Consumes over 60% of federal budget. Discretionary Spending: Spending that congressional committees debate and alter annually (e.g., defense spending, education, transportation). Deficit & National Debt: A budget deficit occurs when federal expenditures exceed federal tax revenue in a fiscal year. Accumulated annual deficits constitute the overall National Debt. Pork-Barrel Spending & Earmarks: Congressional add-ons to bills that direct federal funding to specific local projects in a member's district. Often attached to broader Omnibus ("Christmas Tree") Bills. Logrolling: The practice of trading votes among members of Congress to secure passage of individual legislative priorities. Topic 2.3: Congressional Behavior Required Supreme Court Cases: Baker v. Carr (1962), Shaw v. Reno (1993) 1. Member Voting Models Delegate Model: Lawmakers vote strictly according to the expressed desires of their constituents. Trustee Model: Lawmakers use their independent judgment, expertise, and moral conscience to make policy decisions, even if it contradicts constituent desires. Politico Model: A hybrid approach where lawmakers vote as delegates on high-profile issues with clear constituent consensus, but act as trustees on complex, low-visibility issues. 2. Gerrymandering & Redistricting Dynamics Reapportionment & Redistricting: Every 10 years following the U.S. Census, seats in the House are reapportioned. State legislatures redraw congressional district boundaries. Partisan Gerrymandering: Drawing district lines to give one political party an unfair advantage, creating a large number of "safe seats" (districts where a party consistently wins by 55%+). This practice leads to increased political polarization, as members fear primary challenges from ideologically extreme opponents ("getting primaried"). 3. Required SCOTUS Redistricting Cases Case Name Baker v. Carr (1962) Shaw v. Reno (1993) Constitutional Issue 14th Amendment Equal Protection Clause (Urban vs. Rural Apportionment). 14th Amendment Equal Protection Clause (Racial Gerrymandering). Essential Facts Tennessee failed to redraw its state legislative districts for over 60 years. Population growth in urban areas created massive population disparities between rural and urban districts, diluting urban votes. North Carolina created a wildly irregular, 160-mile majority-black district ("I-85 District") to comply with Justice Department demands for additional minority representation. White voters challenged the map. Holding / Decision 6–2 for Baker. Apportionment and redistricting claims are justiciable in federal court (not merely political questions). 5–4 for Shaw. Redistricting plans that cannot be explained on grounds other than race are subject to strict scrutiny under the Equal Protection Clause. Constitutional Impact Established the landmark "One Person, One Vote" principle, requiring legislative districts within a state to contain roughly equal populations. Prohibited race from being the predominant factor in drawing district lines, restricting racial gerrymandering even if intended to benefit minority representation. 4. Divided Government & Institutional Gridlock Divided Government: Occurs when one political party controls the White House and the opposing party controls one or both houses of Congress. Impacts: Causes policy gridlock, increases legislative stalemates, slows down statutory confirmation of presidential appointments, and heightens conflict during Supreme Court judicial nominations (e.g., blocking "lame duck" judicial nominees).

GESTION DU BÂTIMENT/ CHANGEMENT CLIMATIQUE Partie 1 Information du client sur les incidences du changement climatique sur le patrimoine immobilier Chapitre 1 : enjeux sociétaux et environnementaux du changement climatique 1. Le changement climatique 1.1 l’importance du changement climatique A. Évolution rapide du climat Au cours des deux derniers millions d’années, le climat de notre planète a connu des changements climatique (CC). Ils s’effectuer sur des millions d’années, ce qui permettaient à l’environnement de s’adapter lentement. Un réchauffement climatique globale est observé depuis le 19ème siècle. Ce changement climatique se produit bien plus rapidement que ce étudier pour les 10 000 dernières années et les périodes des grandes déglaçations. Cette rapidité pose des problèmes d’adaptations à l’environnement. (mettre la frise envoyé sur doc pronote) demander à tatiana chaque photo quand on s’ennuie avant novembre 1972 premier sommet de la terre stockolm 1987 rapport de brundtland 1992 sommet de rio et convention des cadres des nations unis sur les CC agenda 21 décision futur 1997 protocole de kyoto 2015 accord de Paris 2026 rio B. La prise de conscience de la spécificité du changement climatique actuel Depuis que la communauté scientifique a prit conscience de l’empleurs du réchauffement et de son rythme, elle alerte sur les risques que cela engendre. l’origine humaine du changement climatique fait désormais consensus. GIEC = groupe international d’expert climatique C. Aténuer le changement Compte tenu de l’inertie climatique, l’augmentation des températures au niveau mondiale est devenue inéductable. Cependant cette augmentation sera plus au moins importante selon l’évolution des comportements humains. Les modes de production et plus généralement les modes de vie ont un impact sur le réchauffement climatique. En fonction des politique mise en oeuvre et de l’évolution des comportement, le réchauffement climatique sera plus au moins important. Les experts du GIEC estiment que chaque demi degrés compte. Les pays signataires de l’accord de Parie en 2015 lors de la Cop21 se sont donnés pour objectif de limiter le réchauffement climatique à 2 degrés maximum par rapport à l’air pré industriel, car ils ont jugés qu’au de-las les effets pourraient être dévastateurs. 1.2 les causes du changement climatique A. l’équilibre des énergies (image principe de effet de serre pronote aussi) Le changement climatique global est le résultat d’une perturbation de l’équilibre entre le rayonnement solaire absorbé par la terre et l’énergie thermique qu’elle résitue dans l’espace. l’augmentation de la concentration atmophsérique de gaz à effet de serre (GES) lié aux émissions humaines entraine ce déséquilibre et provoque l’élévation de la température de la terre en surface. B. l’usage des énergies fossiles Depuis le début de la révolution industrielle au 19eme siècle homme utilise massivement les énergies fossiles (charbon, pétrole, gaz naturel) ce qui a considérablement augmenter les émissions de GES.(gaz à effet de serre) L’usage de machine a profondemment transformé des modes de productions et des modes de vie. Les mécalisations de la production agricole, développement de l’industrie, augmentation de la productivité, développement des moyens de transports, internationalisation des échanges... ont été rendu possible par l’usage mssif d’énergie principalement fossiles. Hors l’utilisation des combustibles fossiles a un impact sur le climat car il émettent des gaz à effet de serre GES. C. Les différentes activités humaines et la place de l’immobilier dans les causes du changement climatique Pronote (batiment construction dans empreinte carbone et l’autre schéma Les modes de vies actuels sont très consommateurs d’énergie surtout dans les pays développés. l’industrie, le transport, l’énergie, la mode, l’agriculture intensive, l’immobilier sont autant de secteurs qui nuisent à l’équilibre inmatique car ils consomment beaucoup d’énergie, sont polluant et émettent des gaz à effet de serre qui ont un impact sur le climat L’immobilier constitue un axe stratégique pour les politiques de lutte contre le changement climatique et la transition énergétique. L’artificialisation des sols au détriment des espaces naturels, agricoles et forestiers, a un impact sur le réchauffement car un sol artificialisé n’absorbe plus le CO2. Les conséquences sont aussi négatives pour la biodiversité, la capacité des terres agricoles à nourrir la population, les risques d’inondation et toutes les conséquences liées à l’étalement urbain. Le changement climatique entraine des conséquences importantes sur les équilibres écologiques (dérèglement météorologique, hausse du niveau et acidification des océans, menace pour la biodiversité…) et sur nos sociétés (rendement agricole, risque de pandémie, de conflits, de déplacement de populations…). 2. Les risques du C.C dans l’immobilier Le changement climatique va entrainer d’avantages de phénomènes climatique extremes : des vagues de chaleur, des précipitations et sécheresses Les logements, les villes, l’aménagement des territoires, ne sont pas toujours adaptés, ce qui créer des risques. 2.1 des logements inadaptés au CC A. Performances énergétiques des logements et précarité énergétiques mettre imagi 2.a Le parc résidentiel Français est ancien. Environ un quart des résidences principales ont été construites avant 1948 et la moitié avant 1974 : année de la première réglementation thermique (RT) pour les bâtiments neuf en France l’enjeux du plan de rénovation énergétique est de faire baissé la facture d’énergie des ménages tout en améliorant l’état du parc résidentiel. Plusieurs aides national sont disponibles pour financer des projets de rénovation Des aides spécifiques sont destinés aux rénovation permettant d’atteindre le niveau basse consommation (étiquette énergétique A ou B) ou qui permettent de sortir du statut de passoire thermique (F ou G) photo B. le confort d’été/ hiver Les règlementations se sont longtemps concentrer sur le confort d’hiver et la manière de concevoir les bâtiments afin de conserver la chaleur. Le réchauffement climatique et la multiplications de canicule et de période de fortes chaleur d’été font émerger la question du confort d’été des logements Le confort d’été correspond au faites de maintenir des températures intérieur agréable, même lors des vagues de chaleur et sans avoir recours à la climatisation, très consommatrice d’énergie et émétrice de GES C. Les ilots de chaleur urbain (ICU) Photo En France plus du quart de la population vit actuellement en zone urbaine. Les banlieux et les couronnes péri-urbaines se sont développer dans de grandes proportion En milieu urbain on observe des températures plus importantes que dans la campagnes environnante : c’est le phénomène d’ilot de chaleur urbain (ICU) Cette différence de température est particulièrement marqué la nuit, au moment ou les matériaux urbains (béton, asphalte, bitume, ciment...) libère la chaleur qu’ils ont stockés durant la journée Cette chaleur est en quelques sortes absorbée du fait de la configuration urbaine et s’échappe moins facilement qu’a la campagne. Avec le changement climatique, les températures moyennes en été et les vagues de chaleur vont augmenter et les risque aussi Les risques de l’ICU : > conditions de vie dégradé > problèmes de santé > consommation d’eau accru > problème de qualité de l’air > concentration ozone > baisse de la productivité des personnes > consommation d’énergie accru avec la climatisation La climatisation le faux bon ami : > utilise de l’énergie et amplifie le réchauffement climatique > rejette de l’air chaud à l’extérieur et amplifie la température ambiante à l’extérieur 2.2 des risques naturels lié au contexte de CC A . le risque d’inondation Le CC se traduira selon les territoires par une augmentation des précipitations extrêmes avec comme conséquences une augmentation du risques d’inondation pour des communes situé près des cours d’eau fortement influencé par des précipitations. B. Les risques près des littoraux; érosion et submersion de l’eau INSÉRER PHOTO Parmi les effets du réchauffement climatique, son impact sur le littoral, les ports et les estuaires sera particulièrement visible il se traduira avant tout par une montée du niveau de la mer Les communes des zones basses littoral vont devoirs s’adapter à cette probable submersion l’érosion côtiere provoque un recul du trait de côte; ce phénomène naturel et accélérer par le CC; la montée du niveau de la mer et une urbanisation inadaptée sur certains littoraux. 1/5 du littoral Français est concerné ainsi que 50 000 habitations d’ici 2100. La loi climat et résilience 2021 prévoie des mesures pour les zones les plus à risques C. Les risques liés au retrait gonflement des sols argileux (RGA) Photo des3 maisons Certains sous sol sont argileux, environ 10 millions de maison sont construites sur ce type de sol, soit une maison sur deux. Au grès de l’humidité et des précipitations, le sol va se gonfler d’eau, en cas de fortes pluie, et se contracter avec l’évaporation en cas de sécheresse c’est ce qu’on appel le (retrait gonflement des sols argileux) ou RGA. Avec les canicules de plus en plus nombreuses, les périodes de sécheresse, le retrait d’argile devient de plus en plus fréquent et peut provoquer des dégâts importants : fissures, les ardes, effondrement, rupture de canalisation, dislocation de dallage, distorsion de porte, de fenêtres... La reconnaissance de l’état de catastrophe naturel sur le secteur, avec publication d’un arrêté au journal officiel est souvent nécessaires pour la prise en compte du sinistre par les assurances D. Les risques liés au sécheresses l’augmentation des températures, la fréquence accru des vagues de chaleur et des sécheresses vont amplifier les risques d’incendie. Les sécheresses assèche aussi les nappes phréatiques et peuvent entrainer une pénurie d’eau potable Les politiques publiques sont mises en place pour atténuer le CC et ‘adapter à ses conséquences Lutter contre les atténuation des causes sont des politiques public Lutter contre les adaptations des conséquences sont aussi des politiques public Chapitre 2. Adaptations des territoires et de l’immobilier au C.C Pour atténuer les effets du C.C, réduire la vulnérabilité des territoires et favoriser leurs adaptations, les pouvoirs politiques mettent en place des réglementations 1. l’aménagement des territoires 1.1 limiter l’étalement urbain et l’artificialisation des sols Les causes : > attractivité des grandes villes, dynamisme économique emploi et services > insuffisance d’offre des logements par rapport à la demande, prix élevé des logements, et gout pour les maisons individuelles > aménagement du territoire, division de l’espace en grande fonction (habitat, zone industrielles et commerciale) qui implique des déplacements permis par l’usage de l’automobile Photo carte de france avec points rouge pronote l’étalement urbain désigne une augmentation de la superficie des villes lié à une extension des zones construites à leur périphérie. Cet étalement urbain est lié à l’attractivité des villes et à l’aménagement du territoire Les conséquences : > la pollution et gaz à serre > déplacement en voiture > engorgement des axes routiers > augmentation du temps consacré au déplacement > dépense en énergie > artificialisation des sols : baisse de la biodiversité, baisse de l’absorbion du co2 > imperméabilisation des sols : augmentation des risques d’inondation > grinotage des espaces naturels, agricoles et forestiers : conflits d’usage Chaque année la France perd 20 000 à 30 000 hectares d’espace naturel, agricoles et forestiers sous la pression des activités humaines. La lutte contre l’artificialisation des sols représente aujourd’hui un enjeu majeur pour limiter le réchauffement climatique, un sol artificialiser n’absorbant plus de co2 Pour lutter contre l’étalement urbain et l’artificialisation des sols : > favoriser le renouvellement urbain, c’est à dire reconstruire la ville sur elle même, recycler les friches urbaines (ce sont des espaces qui n’ont plus de fonction) réhabiliter plutôt que de démolir, et transformer les bureaux en logement, et convertir les biens à un usage réversible Artificialisation net des sols : objectifs 0, la loi climat et résilience du 22 aout 2021 a fixé un double objectif : > divisé par 2 le rythme d’artfitialisation jusqu’en 2030 (par rapport à la décènie précédente) et atteindre d’ici 2050 zéro artificialisation net c’est à dire au moins autant de surface renaturé que de surface artificialiser. Cependant cette règlementation est contester par certains élu locaux qui y voient un obstacle au développement de leurs territoires. 1.2 revitaliser et équilibré les territoires Phénomène de métropolisation et urbanisation 55% de la population mondiale vit en zone urbaine 80% pour la France La concentration de la population entraine des difficultés de logement et un étalement urbain néfaste pour l’environnement. Le rééquilibrage de l’attractivité des territoires permettrait une organisation de l’espace plus écologique et une amélioration des conditions de logement des ménages Aménager le territoire de façon plus équilibré en re-dynamisant les petites villes et les villes moyennes exemple du plan national (action coeur de ville) Le plan d’actions coeur de ville mis en place en 2018 à pour objectif de re-dynamiser les villes moyennes. Ce plan prolongé de 2023 à 2026 sous le nom (action coeur de ville) pour la transition écologique, est doté de 5 millards d’euros afin de financer des actions pour : > accompagner les villes dans leur transitions écologiques (mobilité douce; végétalisation) > conforter les services et les emploies des villes moyennes > revitaliser le centre ville en y relogeant des habitants La re-dynamisation des petites villes et villes moyennes a aussi l’avantage de remettre sur le marché résidentiel des logements vacants, et en augmenter l’attractivité du secteur de rééquilibré le marché du logement. La demande en logement des zones tendus peut se réorienter vers ces villes revitaliser ou les ménages peuvent retrouver emploi et habitation plus facilement 2. Les zones urbaines face au C.C L’atténuation du C.C et l’adaptation à ces évolutions sont deux objectifs à intégrer dans les opérations d’aménagement ou de rénovation urbaine. Quelques grands principes sont à considérer : Favoriser le rafraichissement > la végétalisation en plus d’améliorer le cadre de vie à des atouts pour diminuer l’intensité des ilôts de chaleur urbains pour atteintre cet objectif, les infrastructures urbaines peuvent aussi être repensé : choix du pavé, zone de rafraichissement accessible à toutes, actions sur la mophologie urbaine pour favoriser la ventilation urbaine Réorganiser l’espace > revoir l’organisation de la ville en intégrant une mixité des usages, en limitant l’étalement urbain permettant de diminuer les déplacements en voiture, d’améliorer la qualité de vie et de réduire les GES Film urbanisme dans la ville de colver Repenser les moyens de se déplacer en limitant l’usage des voitures, et en favorisant les transports en commun et les circulation bourses (voie piétonne, piste cyclable), on agit contre la pollution et les îlots de chaleur urbain (ICU) Le code général des collectivités territorial impose l’instauration d’une zone à faible émission (ZFE) dans les territoires en dépassement des valeurs limite de la qualité de l’air Le ZFE est une zone comportant des voix routière ou la circulation des véhicule les plus polluant est restreinte, selon des modalités spécifiques définie par la collectivité Les éco-quartiers, projet d’aménagement durable 3 Photoooooo 13 nov Le label éco-quartiers valorisent les projets d’aménagement qui intègre les enjeux et les principes du développement durable à l’échelle de la ville. Ainsi, les trois piliers du développement durable (environnemental, social et économique) se retrouvent dans les principes de l’éco-quartiers Créer en 2012 Le référenciel de labelisation a été mit a jour pour intégrer les nouvelles priorité des politiques publiques, d’ou l’objectif (0 artificialisation net) des sols, et la réglementation environnementale 2020 (RE 2020). 3 les normes de constructions prennent en compte le C.C Des normes environnementales sont mises en places dans l’immobilier neuf, celles ci concernent aussi bien les bâtiments résidentiel que tertiaires. 3.1 des réglementations thermiques (RT) au réglementations environnementales (RE) Photo 20 nov La première RT a vu le jour en 1974, à la suite du choc pétrolier, avec pour objectif de fixer des limites de consommation énergétiques pour les bâtiments résidentiel neuf. Avec le temps, ces réglementations sont devenues plus exigeante et ont couvert des champs de plus en plus vaste : > chauffage, surface vitrée, ventilation ou encore isolation « la RT 2012 » s’occupe de ça Un bâtiment à énergie positives produit plus d’énergie qu’il en consomme. c’est ce type de bâtiment qui est visé dans la réglementation 2020 (RE 2020) La RE 2020 ne contrôle plus seulement la consommation des bâtiments neufs, mais aussi leurs bilans carbone, en incluant l’analyse du cycle de vie des matériaux employés. Le confort d’été des bâtiments est également prie en compte dans cette réglementation. La RE 2020 sera progressivement de plus en plus exigeante avec 3 étapes prévues en 2024, 2027, et 2030. Les objectifs de la RE 2020 : > concevoir des bâtiments qui consomment moins et qui utilisent des énergies moins carboner (réduction des besoins en énergies, sortie des énergies fossiles et recours à des énergies renouvelables) > stimuler des constructions bas carbone qui utilisent le bois et des matériaux bio-sourcés (bois, lin, bambou, paille, liège fibre de coco...) l’analyse est faite sur l’ensemble du cycle de vie du bâtiment. > produire des bâtiments confortable en cas de fortes chaleurs Les réglementations sont des normes qui s’impose aux constructeurs 3.2 la mise en place de labels de certification Un label est une mention à poser sur un produit qui garantie son origine, sa qualité, ou le resté d’un cahier de charges. Un organisme indépendant doit vérifier le respect des conditions d’attribution du label pour que l’entreprise puisse s’en prévaloir. Même si ce n’est pas obligatoire, certains promoteur s’engage volontairement dans les démarches de certification ou de labelisation afin de mettre en évidence les qualités des programmes construit Photo 3.2 du 20 nov Chapitre 3 informations et orientation du client vers des solutions d’adaptation de son bien au CC 1 Des diagnostics obligatoire pour mieux diffuser l’information 1.1 le contenu global du dossier diagnostic technique (DDT) Le propriétaire vendeur ou bailleur doit fournir lors d’une transaction une série de diagnostic réunie dans un DDT. Le DDT est annexé au bail pour une location ou à la promesse de vente puis à l’acte définitif lors de la session d’un bien DPE Pour tous les biens Audit énergétique Si le bien est classé F ou G sur le DPE Constat de risque exposition au plomb Tous les logements construit avant 1949 Etat de l’installation électricité et gaz Si l’installation a plus de 15 ans Etat des risques Si le logement est situé en zone concerné par un risque naturel technologique ou minier Diagnostic bruit Si le bien est situé dans une zone exposition au bruit Amiante Si le permis de construire est antérieur 1997 Termites insectes Si le bien est situé dans une zone déclarée par arrêté préfectoral Diagnostic Obligations Le carnet d’information du logement CIL (date de construction, style, travaux...) centralise les informations sur les caractéristiques du logement et sur les travaux passé et accompagné les travaux d’amélioration de la performance énergétique du logement Ce carnet concerne les logements neufs dont le permis de construire ou la déclaration préalable a été déposer depuis le 1er janvier 2023 ainsi que les logements existant faisant l’objet de travaux de rénovation ayant une incidence direct sur leurs performances énergétique Le CIL est remit par le propriétaire vendeur à l’acquéreur au plus tard lors de la signature de l’acte authentique de vente 1.2 les diagnostics énergétiques DPE ET audit énergétique DPE Les annonces immobilières de vente ou de location qu’elles soient diffuser par des professionnels de l’immobilier ou des particulier, doivent faire figurer les informations suivantes : > les classement énergétiques et climatique du logement sur un échelle de A à G > si le logement est classé F ou G l’annonce doit comporter « logement à consommation énergétique excessive » > le montant des dépenses énergétiques annuel du logement pour un usage standard En cas d’absence de ce DPE sur l’annonce risque d’amende 3000€ pour une personne physique et 15 000€ pour une personne moral. Le DPE est obligatoire lors des ventes (annexé à l’avant contrat puis au contrat définitif) (et des locations annexé au bail sauf si le logement est habité moins de 4 mois par an) Programme neuf un DPE neuf est remit à l’acquéreur au plus tard le jour de la livraison du logement Depuis le 1er juillet 2021 le DPE n’est plus simplement informatif mais opposable, l’acheteur ou le locataire peut engager la responsabilité du vendeur ou du bailleur s’il constate une irrégularité à conditions que ça lui pose préjudice Etablit par un diagnostiqueur professionnel sur la base des caractéristiques physique du logement (bâti, qualité de l’isolation, type de fenêtre, système de chauffage) diagnostiqueur non certifié risque amende 1500€ Contenu du DPE : > caractéristiques du logement et ses équipements > quantité annuel d’énergie consommées ou estimées ( et dépenses de consommation) > étiquette énergie > les recommandations pour améliorer les performances énergétiques, l’évaluation de leur coût et efficacité Depuis le 1er janvier 2023 les logements dont la consommation d’énergie dépasse 450 kwh au M2 par an d’énergie final ne peuvent plus être proposés à la location ( critères de decence) cette interdiction des biens les plus énergivores sur le marché locatif concernera à terme les logements classé G à compter de 2025 les logements classé F à compter 2026 et classé E 2034 La loi climat et résilience du 22 août 2021 interdit toutes augmentation de loyer des logements du parc privé classé F et G au titre du DPE Le diagnostiqueur doit transmettre les résultats du DPE à l’agence de la transition écologique (ADEM) Il est possible de retrouver un DPE et de contrôler sa validité en se rendant sur le site de l’observatoire des DPE (mit en place par l’ademe) et en saisissant le numéro du diagnostic dans le moteur de recherche Audit énergétique Depuis le 1er avril 2023 un audit énergétique doit être réalisé en cas de vente d’un bien appartenant aux classes énergétiques F ou G l’audit énergétique est une version plus poussé du DPE le volet travaux d’opération de la performance énergétique et climatique est notamment enrichie Un autre audit est possible : audit avant travaux il permet d’avoir encore plus de précisions sur les travaux envisageable et leurs coûts mais est plus cher que l’audit énergétique 1.3 état des risques Les obligations d’information des acquéreurs et les locataires l’information des locataires et acquéreurs est obligatoire lorsque le bien est loué ou vendu et est exposé à un risque naturel, minié, technologique ou au recul du trait de côte Un ER (état des risques) doit figurer dans le DDT (dossier de diagnostic technique) annexé à la promesse ou contrat de vente/location Contrairement à d’autres diagnostics immobilier obligatoire l’IAL (information acquéreur locataire) ne nécessite pas de recourir à un professionnel agréer Le propriétaire peut remplir lui même son état des risques, des formulaires disponible en ligne Zoom sur le recul du trait de côte Impact sur les biens immobilier : Le changement climatique accentue le trait de côte la mer avance progressivement sur ls terres un quart du littoral français est concerné, la loi climat et résilience 2021 prévoit d’adapter les territoires littoraux les plus exposés à ce risque Les communes particulièrement menacées (lister par décrêt) doivent intégrer dans leurs PLU (plan local urbanisme) et PLUI (plan local urbanisme inter) une carte des zones exposées au recul du trait de côte ( ZERTC) à l’échéance de 30 et 100ans Les conséquences sur les biens qui se trouvent dans ces zones sont importantes Depuis le 1er janvier 2023 les agents immobilier doivent indiquer si le logement est situé dans une zone exposé au recul du trait de côte dans leur annonce de vente et location A peine de nulité toutes promesses de ventes tout contrat de vente ou location pourtant sur des constructions localisée dans une zone menacée doivent mentionner Un droit de préambtion s’applique sur l’intégralité sur la zone du recul de trait de côte toutes ventes est subordonnée à peine de nulité à une déclaration préalable adresser par le propriétaire à la commune ou est situé le bien. La commune peut mettre en place un bail réel d’adaptation à l’errosion au tiers pour gérer temporairement des biens acquis dans les zone menacés par le recul du trait de côte Zoom sur le RGA lorsqu’un sol est argileux il se rétracte en période sèche (retrait) et il gonfle en période pluvieuse. Ces variations de volume dans le sol créer des désordres sur les fondations comme en surface (fissure, tassement...), pouvant dans les cas les plus graves rendre la maison inhabitable pour que le propriétaire soit indemnisé par l’assurance il faut qu’un arrêté interministériel de catastrophe naturel soit rendu sur la commune concerné et que le RGA (retrait gonflement argileux) soit reconnu comme la cause déterminante du dommage. Dans l’effet les indemnisations peuvent être difficile à obtenir En cas de vente d’un terrain non bâti constructible : Une étude géo technique doit être fourni par le vendeur. De plus le projet de construction doit suivre les réglementations d’un étude géo technique de conception zone moyenne ou forte RGA « attestation RGA » obligatoire pour tous les bâtiment ne comportant pas plus de deux logement construit ou rénové suivant un permis de construire déposé après le 1er janvier 2024. l’attestation annexé au titre de propriété du bien suit ces mutations successives. Permet de bénéficier de la garantie CATNAT retrait gonflement des sols pendant 10ans à compter de la réception des travaux. À défaut, les biens seront exclu du droit à la garantie sécheresse pendant 10 ans 1.4 les diagnostics au niveau des copropriété PPPT/PPT (projet plan pluriannuel travaux/ plan pluriannuel travaux) : le PPPT propose plusieurs PPT répondant aux besoins de la copropriété travaux à réalisé pendant les 10 prochaines années,pour les copropriété de plus de 15ans obligatoire selon un calendrier qui dépend du nb de lot PPT pour les : Plus de 200 lots à partir 01/01/2023 De 51 à 800 à partir 01/01/2024 Moins de 51 lots à partir du 01/01/2025 DPE collectif : évalue la performance énergétique de l’ensemble de l’immeuble, pour une approche global et efficace, permet de planifier le PPT. Obligatoire pour les copropriété construite avant 2013 selon un calendrier qui dépend du nombre de lot Obligatoire pour les lots de : Plus de 200 et les monopropriétés à partir de 01/01/2024 De 51 à 200 à partir de 01/01/2025 Et moins de 51 à partir de 01/01/2026 DTG (diagnostic technique global) : rapport pluridisciplinaire (architecture, thermique et ingénierie financière) qui établie des scénarios hierarchisé de travaux économie d’énergie ainsi que les aides financières mobilisable. Permet un accompagnement de la copropriété dans sa démarche vers les travaux de rénovation. Obligation pour la mise en copropriété d’un immeuble de plus de 10ans ou un immeuble insalubre, sinon non obligatoire 2 l’orientation du client vers des solutions d’adaptation de son bien immobilier au CC 2.1 les interlocuteurs Pour être efficace et améliorer les performances énergétiques d’un bien, les travaux doivent être envisagés de manière global. Le plus souvent ces travaux portent sur l’isolation, la ventilation, l’optimisation du système de chauffage, remplacement des menuiseries ( fenêtre, porte) Accompagnement du client lors des opérations de travaux Chapitre 4 identification des besoins en travaux de l’immeuble Dans l’évolution actuelle des pratiques immobilières l’identification précisent des besoin en travaux d’un immeuble constitue une étape incontournable pour répondre au défi posé par le changement climatique et pour aligner les opérations immobilières avec les normes de durabilité et d’efficacité énergétique I Le diagnostic de l’état général de bâtiment C’est une démarche essentielle qui sert de fondation à tout opération de travaux Cette étape implique une inspection minutieuse de toutes les parties structurelle et non structurelles du bâtiment, de la cave au grenier on recherchera la présence d’amiante ou de plomb dans la construction Présentation générale du bâtiment : - Type de construction - Année de construction - Historique du bâtiment Structure : - Les éléments porteur verticaux (murs porteurs, pilier) - Structures porteuse ( plancher, escaliers) Équipements et finitions : - Isolation thermique et acoustique - Installation eau gaz électricité et télécommunication - Menuiseries extérieur et intérieur - Revêtement des sols - Circuit de ventilation (vmc) Il est conseillé de documenter chaque anomalies par des description précises et des supports visuel le diagnostic doit également tenir compte de la réglementation en vigueur notamment en matière de sécurité et accessibilité En vigueur - La RT 2012 pour les bâtiments existant faisant l’objet de travaux importants et toutes les constructions neuves qui visent à limiter les consommations énergétiques - La loi élan 2018 portant sur l’évolution du logement, de l’aménagement et du numérique, cette loi établi les règles sur l’amélioration de la performance énergétique et l’accessibilité ainsi que des mesures sur l’adaptation des logements à la perte d’autonomie - l’arrêté 2017 modifiant l’arrêté de 2007, relative aux caractéristiques thermiques et à la performance énergétiques des bâtiments existants, il impose que lorsqu’un maître d’ouvrage décide de remplacer, d’installer un élément d’isolation, un équipement de chauffage, de production d’eau chaude, de refroidissement, de ventilation il doit installer des produits de performances supérieurs aux caractéristiques minimale mentionné dans l’arrêter - RE 2020 concerne les constructions neuves en visant une net réduction de l’empreinte carbone et une amélioration significatives de la capacité énergétiques, cette normes encourage l’utilisation faible impact écologique et production énergie renouvelable dans le but d’atteindre les objectifs de développement durable et de répondre aux enjeux climatiques actuels II Analyse des pathologies élémentaires du bâtiment L’identification des origines et la déterminations des solutions adaptes pour les structures affecte par des désordres Fissures du a un tassement différenciel Humidité Effritement mur peinture Infiltration d’eau par la toiture Défaut étancheiter ça peut être des fissures structurelle ou superficielle III interprétation des plans du bâtiments u

The Gerund After Prepositions and in Certain Phrases

Listado de Palabras para Certamen de Ortografía

Punishments for certain crimes

Chapter 3. Ethics and Social Responsibility iStock.com/Shaun Learning Outcomes After studying this chapter, you will be able to . . . 3-1 Explain the determinants of a civil society 3-2 Explain the concept of ethical behavior 3-3 Describe ethical behavior in business 3-4 Discuss corporate social responsibility 3-5 Describe the arguments for and against social responsibility 3-6 Explain cause-related marketing 3-1. Determinants of a Civil Society 3-1 Explain the determinants of a civil society Have you ever stopped to think about the social glue that binds society together? That is, what factors keep people and organizations from running amok and doing harm, and what factors create order in a society like ours? The answer lies in social control, defined as any means used to maintain behavioral norms and regulate conflict. Behavioral norms are standards of proper or acceptable behavior. Social control is part of your life at every level, from your family to your local community, to the nation, to the global civilization. Several modes of social control are important to marketing: Ethics: Ethics are the moral principles or values that generally govern the conduct of an individual or a group. Ethical rules and guidelines, along with customs and traditions, provide principles of right action. Laws: Often, ethical rules and guidelines are codified into law. Laws governments create are then enforced by governmental authority. This process is how the dictum “Thou shall not steal” has become part of formal law throughout the land. Law, however, is not a perfect mechanism for ensuring good corporate and employee behavior. Laws often address only the lowest common denominator of socially acceptable behavior. In other words, just because something is legal does not mean that it is ethical. For example, Texas Pete is a hot sauce sold in grocery stores across the country. The packaging for Texas Pete features a lone star, just as the Texas state flag does, and a cowboy holding a lasso. The packaging, along with the name of the product, seems to indicate that the product is made in the state of Texas, or that it is at least made from ingredients sourced in Texas. Texas Pete, however, is produced by TW Garner Foods Company, a company headquartered in North Carolina, more than 800 miles from Texas. A class action lawsuit was filed against the company for false advertising. The lawsuit claimed that consumers were paying a premium price based on their belief that the product originated in Texas, which has a reputation for spicy food. Texas Pete does not explicitly state that the product is manufactured in Texas and actually lists TW Garner Foods’ North Carolina address on the bottle, but the name of the product and the packaging certainly suggest that it is a genuine Texas-based product and could be misleading to consumers. While this presentation is technically legal, is this ethical? What’s your opinion? Here’s another example: In every state, littering is a problem—and has been for many years. Threats of fines and even jail time are shrugged off as people toss food wrappers, plastic straws and cups, and everything else imaginable out the car window. Many companies are implementing new policies to try and curtail the negative effects of littering. For example, Starbucks in California no longer automatically gives straws and plastic cutlery to customers, but, rather, will only provide these items when customers specifically request them. Nicole Glass Photography/Shutterstock.com Formal and Informal Groups: Businesses, professional organizations (such as the American Marketing Association and the American Medical Association), and clubs (such as Shriners and Ducks Unlimited) all have codes of conduct. These codes prescribe acceptable and desired behaviors for their members. Self-Regulation: Self-regulation involves the voluntary acceptance of standards established by nongovernmental entities, such as the American Association of Advertising Agencies (AAAA) or the National Association of Manufacturers. The AAAA has a self-regulation arm that deals with deceptive advertising. Other associations have regulations relating to child labor, environmental issues, conservation, and a host of other issues. The Media: In an open, democratic society, the media play a key role in informing the public about the actions of individuals and organizations—both good and bad. Laundress, a luxury laundry detergent brand that claims to be better for you and better for the environment, came under fire after issuing a safety notice for almost all of its products. The company released the notice on its social media accounts but provided very little information about the reason for the notice. It was later revealed that the majority of the products the brand manufactured between January 2021 and September 2022 contained heightened levels of bacteria that were causing severe skin rashes and other physical ailments. Many major media outlets, including The New York Times and USA Today, published articles to inform the public of this safety notice and the product recall that eventually followed. An Active Civil Society: An informed and engaged society can help mold individual and corporate ethics, as well as socially responsible behavior. Research reveals that 56 percent of U.S. consumers stop buying from companies they believe are unethical. In the United Kingdom, 53 percent of consumers reported that they would completely stop buying from a brand accused of sourcing from unethical suppliers. manufactured between January 2021 and September 2022 contained heightened levels of bacteria that were causing severe skin rashes and other physical ailments. Many major media outlets, including The New York Times and USA Today, published articles to inform the public of this safety notice and the product recall that eventually followed. An Active Civil Society: An informed and engaged society can help mold individual and corporate ethics, as well as socially responsible behavior. Research reveals that 56 percent of U.S. consumers stop buying from companies they believe are unethical. In the United Kingdom, 53 percent of consumers reported that they would completely stop buying from a brand accused of sourcing from unethical suppliers. 3-2a. Ethical Theories People usually base their individual choice of ethical theory on their life experiences. The following are some of the ethical theories that apply to marketing. Deontology The deontological theory states that people should adhere to their obligations and duties when analyzing an ethical dilemma. This theory means that a person will follow their obligations to another individual or society because upholding one’s duty is considered ethically correct. For instance, a deontologist will always keep their promises to a friend and follow the law. A person who follows this theory will produce very consistent decisions because those decisions will be based on the individual’s set duties. Deontological theory is not necessarily concerned with the welfare of others. For example, suppose a salesperson has decided that it is their ethical duty (and very practical) to always be on time for meetings with clients. Today they are running late. How are they supposed to drive? Is the deontologist supposed to speed, breaking the law to uphold their duty to society, or is the deontologist supposed to arrive at their meeting late, breaking their duty to be on time? This scenario of conflicting obligations does not lead us to a clear, ethically correct resolution, nor does it protect the welfare of others from the deontologist’s decision. Utilitarianism The utilitarian ethical theory is founded on the ability to predict the consequences of an action. To a utilitarian, the choice that yields the greatest benefit to the most people is the ethically correct choice. One benefit of this ethical theory is that the utilitarian can compare similar predicted solutions and use a point system to determine which choice is more beneficial for more people. This point system provides a logical and rational argument for each decision and allows a person to use it on a case-by-case basis. There are two types of utilitarianism: act utilitarianism and rule utilitarianism. Act utilitarianism adheres exactly to the definition of utilitarianism as just described. In act utilitarianism, a person performs the acts that benefit the most people, regardless of personal feelings or societal constraints like laws. Rule utilitarianism, however, considers the law and is concerned with fairness. A rule utilitarian seeks to benefit the most people but through the fairest and most just means available. Therefore, added benefits of rule utilitarianism are that it values justice and doing good at the same time. As is true of all ethical theories, however, both act and rule utilitarianism contain numerous flaws. Inherent in both are the flaws associated with predicting the future. Although people can use their life experiences to attempt to predict outcomes, no human being can be certain that their predictions will come true. This uncertainty can lead to unexpected results, making the utilitarian look unethical as time passes because their choice did not benefit the most people, as they had predicted. Another assumption a utilitarian must make is that they can compare the various types of consequences against each other on a similar scale. However, comparing material gains such as money against intangible gains such as happiness is impossible because their qualities differ so greatly. Casuist The casuist ethical theory compares a current ethical dilemma with examples of similar ethical dilemmas and their outcomes. This theory allows one to determine the severity of the situation and to create the best possible solution according to others’ experiences. Usually, one will find examples that represent the extremes of the situation so that a compromise can be reached to include the wisdom gained from the previous situations. One drawback to this ethical theory is that there may not be a set of similar examples for a given ethical dilemma. Perhaps that which is controversial and ethically questionable is new and unexpected. Along the same line of thinking, this theory assumes that the results of the current ethical dilemma will be similar to the results in the examples. This assumption may not be true and would greatly hinder the effectiveness of applying this ethical theory. Moral Relativism Moral relativism is a belief in time-and-place ethics, that is, the truth of a moral judgment is relative to the judging person or group. According to a moral relativist, for example, stealing is not always wrong—if you are a parent and your child is starving, stealing a loaf of bread is ethically correct. The proper resolution to ethical dilemmas is based on weighing the competing factors at the moment and then deciding to take the lesser of the evils as the resolution. Moral relativists do not believe in absolute rules. Their beliefs center on the pressure of the moment and whether the pressure justifies the action taken. Virtue Ethics Aristotle and Plato taught that solving ethical dilemmas requires training—that individuals solve ethical dilemmas when they develop and nurture a set of virtues. A virtue is a character trait valued as being good. Aristotle taught the importance of cultivating virtue in his students and then having them solve ethical dilemmas using those virtues once they had become an integral part of his students’ being through their virtue training. Some modern philosophers have embraced this notion of virtue and have developed lists of what constitutes a virtuous businessperson. Some common virtues for businesspeople are self-discipline, friendliness, caring, courage, compassion, trust, responsibility, honesty, determination, enthusiasm, and humility. You may see other lists of virtues that are longer or shorter, but here is a good start for core business virtues. 3-3. Ethical Behavior in Business 3-3 Describe ethical behavior in business Depending on which, if any, ethical theory a businessperson has accepted and uses in their daily conduct, the action they take may vary. For example, faced with bribing a foreign official to get a critically needed contract or shutting down a factory and laying off a thousand workers, a person following a deontology strategy would not pay the bribe. Why? A deontologist always follows the law. However, a moral relativist would probably pay the bribe. While the boundaries of what is legal and what is not are often fairly clear (e.g., do not run a red light, do not steal money from a bank, and do not kill anyone), the boundaries of ethical decision making are predicated on which ethical theory one is following. The law typically relies on juries to determine if an act is legal or illegal. Society determines whether an action is ethical or unethical. In 2022, Oracle, an information technology company, was forced to pay $23 million to settle charges of violating the Foreign Corrupt Practices Act (FCPA). The U.S. Department of Justice and the Securities and Exchange Commission (SEC) allege that subsidiaries of the company in India, Turkey, and the United Arab Emirates used discount schemes and sham marketing reimbursements to finance funds that were then used to bribe foreign officials. Michael Egbert, corporate communications VP for Oracle, stated that “The conduct outlined by the SEC is contrary to our core values and clear policies, and if we identify such behavior, we will take appropriate action.” Morals are the rules people develop as a result of cultural values and norms. Culture is a socializing force that dictates what is right and wrong. Moral standards may also reflect the laws and regulations that affect social and economic behavior. Thus, morals can be considered a foundation of ethical behavior. Morals are usually characterized as good or bad. “Good” and “bad” have many different connotations. One such connotation is “effective” and “ineffective.” A good salesperson makes or exceeds the assigned quota. If the salesperson sells a new computer system or an OLED TV to a disadvantaged consumer—knowing full well that the person cannot keep up the monthly payments—is that still a good salesperson? What if the sale enables the salesperson to exceed their quota? “Good” and “bad” can also refer to “conforming” and “deviant” behaviors. A doctor who runs large ads offering discounts on open-heart surgery would be considered bad, or unprofessional, because they are not conforming to the norms of the medical profession. “Good” and “bad” also express the distinction between law-abiding and criminal behavior. And, finally, different religions define “good” and “bad” in markedly different ways. A Muslim who eats pork are considered bad by other Muslims, for example. Religion is just one of the many factors that affect a businessperson’s ethics. Academic researchers have examined how consumers react to the trade-offs between highly competent but less moral service providers and less competent but highly moral service providers. Their study found that consumers valued competence more than morality. In other words, purchasers of services want someone who can do the job right . . . even if that person might be a bit shady. For example, a house-painting company that does excellent work but has had some legal problems in the past would be preferred over a mediocre painting company that has never had complaints or legal problems. 3-3a. Morality and Business Ethics Today’s business ethics consist of a subset of major life values learned since birth. The values businesspeople use to make decisions have been acquired through family, educational, and religious institutions. Ethical values are situation specific and time oriented. Everyone must have an ethical base that applies to conduct in the business world and personal life. One approach to developing a personal set of ethics is to examine the consequences of a particular act. Who is helped or hurt? How long do the consequences last? What actions produce the greatest good for the greatest number of people? A second approach stresses the importance of rules. Rules come in the form of customs, laws, professional standards, and common sense. “Always treat others as you would like to be treated” is an example of a rule. 3-3a. Morality and Business Ethics Today’s business ethics consist of a subset of major life values learned since birth. The values businesspeople use to make decisions have been acquired through family, educational, and religious institutions. Ethical values are situation specific and time oriented. Everyone must have an ethical base that applies to conduct in the business world and personal life. One approach to developing a personal set of ethics is to examine the consequences of a particular act. Who is helped or hurt? How long do the consequences last? What actions produce the greatest good for the greatest number of people? A second approach stresses the importance of rules. Rules come in the form of customs, laws, professional standards, and common sense. “Always treat others as you would like to be treated” is an example of a rule. 3-3c. Ethical Guidelines and Training In recent years, many organizations have become more interested in ethical issues. Yet interest and action are not always the same thing. Although some companies are now appointing a Chief Ethics Officer (sometimes called a Chief Compliance Officer), this role is still not present at many companies. It is very common, however, for companies of various sizes to develop a code of ethics as a guideline to help marketing managers and other employees make better decisions. Creating ethics guidelines has several advantages as follows: A code of ethics helps employees identify what their firm recognizes as acceptable business practices. A code of ethics can be an effective internal control of behavior, which is more desirable than external controls, such as government regulation. A written code helps employees avoid confusion when determining whether their decisions are ethical. The process of formulating the code of ethics facilitates discussion among employees about what is right and wrong and ultimately leads to better decisions. Ethics training is an effective way to help employees put good ethics into practice. The Ethics & Compliance Initiative’s State of Ethics and Compliance in the Workplace Report found that 84 percent of employees who work for a company with a strong ethics and compliance program perceived their organization as having a strong ethical culture. Comparatively, only 13 percent of employees working for an organization classified as having an underdeveloped ethics and compliance program felt that their organization had a strong ethical culture. Strong ethical cultures give employees the appropriate guidance to handle situations involving potential wrongdoing and lead to lower rates of misconduct. Still, simply giving employees a long list of dos and don’ts does not really help employees navigate the gray areas or adapt to a changing world market. In Carson City, Nevada, all governmental lobbyists are required to attend a course on ethics and policy before they can meet with lawmakers. The training outlines exactly how and when lobbyists are allowed to interact with lawmakers and how to report any money they spend. A clear understanding of ethical expectations is essential to an industry like lobbying, where illicit—often illegal—actions are taken to promote individual causes. Because artificial intelligence (AI) is becoming so pervasive in marketing interactions with consumers, it must also be taught about ethical decision making. Already Microsoft, Adobe, and IBM, along with smaller firms and start-ups, are developing ethical guidelines and best practices for their AI use. Type “gymnast” into Google’s image search and the vast majority of the top results are female, as are the results for “nurse.” The term “parents” shows almost exclusively heterosexual couples. The results of these searches are driven by AI, which isn’t explicitly taught to discriminate. Rather, these prejudices are the result of the data submitted to the AI algorithm. “There is increasing concern that algorithms used by modern AI systems produce discriminatory outputs, presumably because they are trained on data in which societal biases are embedded,” notes Madalina Vlasceanu, an Assistant Professor of Psychology at New York University, whose research explores biases in internet search algorithms and the potential impact of these biased search results on society. The Most Ethical Companies Each year, Ethisphere magazine (targeted toward top management and focused on ethical leadership) examines more than 5,000 companies in 30 separate industries, seeking the world’s most ethical companies. It then lists the top 100. The magazine uses a rigorous format to identify true ethical leadership. A few of the selected winners are shown in Table 3.1. Table 3.1 Selected Winners of the World’s Most Ethical Companies Company Industry Country 3M Industrial manufacturing USA Accenture Consulting Services Ireland Aflac Accident and life insurance USA Apple Technology USA Colgate-Palmolive Consumer products USA Dell Technology USA EDP Energy and utilities Portugal General Motors Company Automotive USA Illy Food, beverages, and agriculture Italy Kao Health and beauty Japan L’Oreal Health and beauty France Mastercard Payment Services USA Natura Health and beauty Brazil Parsons Engineering and design USA Salesforce Application software USA U.S. Bank Banks USA Workday Software & Services USA Source: “The 2022 World’s Most Ethical Companies Honorees List,” https://worldsmostethicalcompanies.com/honorees/ (accessed January 30, 2023).

1. Barangay Health Worker (BHW) Program Republic Act No. 7883 What is it? * A community-based health initiative. * Trains local volunteers to provide primary healthcare services and health education at the barangay level. Green Modern Professional Environmental Awareness Presentation.pdf Why is it needed? * Helps communities with limited healthcare access. * Connects families with health centers and healthcare providers. * Brings basic healthcare closer to residents. Green Modern Professional Environmental Awareness Presentation.pdf Who implements it? * Department of Health (DOH) * Local Government Units (LGUs) * Local Health Boards Green Modern Professional Environmental Awareness Presentation.pdf Who benefits? * Barangay Health Workers * Underserved communities * Families and community members Green Modern Professional Environmental Awareness Presentation.pdf Importance / benefits * Makes basic healthcare more accessible. * Provides health education. * Helps identify health problems early. * Improves connections between residents and healthcare providers. Green Modern Professional Environmental Awareness Presentation.pdf Roles of BHWs * Provide basic health services. * Give health information and education. * Monitor community health. * Assist in disease prevention. * Encourage residents to seek proper healthcare. Green Modern Professional Environmental Awareness Presentation.pdf Penalties/fines: Not specified in the presentation. ⸻ 2. Magna Carta of Women Republic Act No. 9710 What is it? * A comprehensive Philippine human-rights law. * Signed on August 14, 2009. * Seeks to eliminate discrimination against women by recognizing, protecting, fulfilling, and promoting women’s human rights and fundamental freedoms, especially for marginalized women. magna carta of women.pdf Why was it implemented? 1. Fulfill international commitments * Helps the Philippines meet obligations under CEDAW. * Makes protection of women’s rights a domestic legal responsibility. 2. Address gender inequality * Requires government agencies to integrate women’s needs into planning. * Requires at least 5% of annual budgets for Gender and Development (GAD) programs. 3. Protect marginalized women * Includes farmers, fisherfolk, informal workers, indigenous groups, etc. * Provides rights involving land ownership, agricultural resources, social protection, and representation. magna carta of women.pdf Penalties * ₱10,000–₱50,000 fine for certain violations. * Serious violations: 1–6 months imprisonment. * Government officials who fail to enforce/protect women’s rights can face: * Formal warnings * Suspension without pay * Loss of employment magna carta of women.pdf Effects on community health * Barangays should have a VAW Desk providing crisis intervention, legal support, and psychosocial care. * Improves women’s access to public healthcare, maternal care, and family planning. * Provides up to 2 months paid special leave after gynecological surgeries. * Requires women’s representation in local development and health-planning bodies. magna carta of women.pdf Importance * Makes gender equality a legal responsibility of government. * Protects marginalized women and gives them access to resources, opportunities, and legal protection. Recommended improvements * Increase public awareness. * Strengthen enforcement and penalties. * Train barangay officials. * Hold officials accountable when complaints aren’t properly handled. ⸻ 3. Food Safety Act of 2013 Republic Act No. 10611 What is it? * Protects people from unsafe, contaminated, or harmful food. * Covers food safety from farm to fork, from production until food reaches consumers. * Strengthens food regulations and promotes proper food-handling practices. GROUP 6 FOOD SAFETY ACT.pdf Why is it needed? Without proper food-safety regulation, people can be exposed to foodborne illnesses and poisoning, including diseases such as: * Botulism * Hepatitis A * Listeriosis GROUP 6 FOOD SAFETY ACT.pdf Purpose * Protect consumer health. * Make sure local food supplies are properly checked. * Facilitate market access for safe food products. GROUP 6 FOOD SAFETY ACT.pdf Government agencies * FDA: processed/pre-packaged food. * DOH/LGUs: sanitation and food-service establishments. * DA: food safety in primary production such as crops, livestock, and fisheries. GROUP 6 FOOD SAFETY ACT.pdf Penalties First conviction * ₱50,000–₱100,000 fine * Suspension of authorization for 1 month Second conviction * ₱100,000–₱200,000 fine * Suspension for 3 months Third conviction * ₱200,000–₱300,000 fine * Suspension for 6 months If slight physical injury occurs * ₱200,000–₱300,000 fine * 6-month suspension * Offender also pays hospitalization and rehabilitation costs. GROUP 6 FOOD SAFETY ACT.pdf If serious/less serious physical injury occurs * ₱200,000–₱300,000 fine * 1-year suspension * Hospitalization and rehabilitation costs must also be paid. If death occurs * 6 months and 1 day to 6 years and 1 day imprisonment * ₱300,000–₱500,000 fine * Permanent revocation of authorization to operate the food business. GROUP 6 FOOD SAFETY ACT.pdf Recommended improvements * More frequent food inspections. * Better food-safety education in schools. * Food-safety campaigns and seminars. * Encourage people to follow food-safety practices. GROUP 6 FOOD SAFETY ACT.pdf ⸻ 4. Consumer Act of the Philippines Republic Act No. 7394 What is it? * Primary national law protecting consumer interests. * Protects product safety. * Establishes fair standards for businesses. * Signed April 13, 1992. Green Monochromatic Simple The Minimalist Presentation Template.pdf Main objectives * Protect consumers from hazardous/substandard products. * Ban deceptive, unfair, and unconscionable sales practices. * Provide clear product information. * Give consumers legal remedies when harmed. Green Monochromatic Simple The Minimalist Presentation Template.pdf Why was it needed? * Protect consumers from unsafe products. * Prevent unfair business practices. * Prevent misleading information. * Promote consumers’ health, safety, and economic interests. * Protect the right to information, safety, and fair treatment. Green Monochromatic Simple The Minimalist Presentation Template.pdf Positive effects * Protects against unsafe/substandard products. * Requires clear labeling, descriptions, ingredients, and expiration dates. * Bans false advertising and deceptive packaging. * Gives consumers ways to seek refunds, replacements, or damages. Green Monochromatic Simple The Minimalist Presentation Template.pdf Possible negative effects * Compliance costs can increase product prices. * Strict licensing/certification can be difficult for small businesses. * Fraudulent or exaggerated consumer claims can financially burden honest businesses. Green Monochromatic Simple The Minimalist Presentation Template.pdf Penalties * Selling banned/unsafe products: ₱1,000–₱10,000 fine, 2 months–1 year imprisonment, or both. * Certain medicine/medical-device violations: ₱5,000–₱10,000 fine, 1–5 years imprisonment, or both. * Warranty violations: ₱1,000–₱50,000 fine or 1–5 years imprisonment, or both. * Certain labeling/packaging violations: ₱500–₱20,000 fine, 3 months–2 years imprisonment, or both. Green Monochromatic Simple The Minimalist Presentation Template.pdf Government agencies * DTI: consumer products and unfair/deceptive trade practices. * DOH: food, drugs, cosmetics, medical devices. * DA: agricultural/fresh-food safety and labeling. Green Monochromatic Simple The Minimalist Presentation Template.pdf Improvements * Stronger protection against online scams and fake advertisements. * More consumer education about scams, false advertising, and safe products. Green Monochromatic Simple The Minimalist Presentation Template.pdf ⸻ 5. Safe Spaces Act Republic Act No. 11313, “Bawal Bastos Law” What is it? * Protects individuals from gender-based sexual harassment in: * Public spaces * Workplaces * Schools * Online environments. Health .pdf Passed * April 17, 2019 What is gender-based sexual harassment? Unwanted/unwelcome sexual acts, comments, gestures, or behavior directed at someone because of sex, gender, sexual orientation, gender identity, or gender expression. Health .pdf Examples * Catcalling/wolf-whistling * Unwanted sexual remarks * Sexist, homophobic, or transphobic slurs * Persistent unwanted invitations * Stalking * Unwanted sexual messages * Certain sharing of photos/videos without consent. Health .pdf Why is it important? * Promotes safety, respect, dignity, and equality. * Recognizes that harassment can happen in public spaces, schools, workplaces, and online. Community effects * Creates safer communities. * Raises awareness. * Encourages respect for boundaries. * Provides reporting mechanisms. * Requires schools/LGUs to take action. * Provides support and protection for victims. Health .pdf Penalties Catcalling/verbal harassment * 1st offense: ₱1,000 + community service + Gender Sensitivity Seminar * 2nd offense: 6–10 days arrest OR ₱3,000 fine * 3rd offense: 11–30 days arrest + ₱10,000 fine Stalking * ₱30,000 fine or arrest for first offense, with higher penalties for repeat offenses. Online sexual harassment * ₱100,000–₱500,000 fine and/or imprisonment. Health .pdf Improvements * More awareness campaigns. * Clear reporting procedures. * Easier access to complaint desks/hotlines. * Regular gender-sensitivity seminars. * More training for teachers, barangay officials, and enforcers. * Better complaint documentation/follow-up. Health .pdf ⸻ 6. Expanded Program on Immunization EPI What is it? * A public-health program designed to protect people, especially children, from vaccine-preventable diseases through recommended vaccines. Expanded Program on Immunization.pdf History * Global EPI launched by WHO in 1974. * Developed into the Essential Programme on Immunization, covering vaccination throughout life. Expanded Program on Immunization.pdf Philippines * Implemented through the DOH National Immunization Program (NIP) with LGUs and health facilities. Expanded Program on Immunization.pdf Why was it established? Many infectious diseases caused: * Illness * Disability * Death, especially among children. Vaccination provides immunity before exposure and helps prevent outbreaks. Expanded Program on Immunization.pdf Main objectives * Protect infants, children, pregnant women, and other priority groups. * Increase immunization coverage. * Give vaccines at recommended ages/intervals. * Prevent outbreaks. * Reduce illness, disability, and deaths. * Reach communities with limited healthcare access. Expanded Program on Immunization.pdf Diseases mentioned * Tuberculosis * Hepatitis B * Diphtheria * Pertussis * Tetanus * Polio * Measles * Mumps * Rubella * Hib disease * Pneumococcal disease * HPV-related diseases. Expanded Program on Immunization.pdf How it works * Vaccines train the immune system to recognize specific pathogens. * High vaccination coverage reduces disease transmission and can help protect people who cannot receive certain vaccines or don’t develop adequate immunity. Expanded Program on Immunization.pdf Challenges * Limited healthcare access. * Vaccine hesitancy/misinformation. * Missed or delayed appointments. * Supply/logistical problems. * Health-system barriers. * Emergencies/disruptions. Improvements * Improve access in remote areas. * Community/mobile vaccination. * Catch-up vaccination. * Better vaccine supply, transportation, and cold-chain management. * Train/support healthcare workers. * Better immunization records. * Accurate health education. * Counter misinformation. * Stronger disease surveillance and outbreak response. Penalties: Not specified because this is a health program rather than a presentation focused on criminal sanctions. ⸻ 7. Responsible Parenthood and Reproductive Health Act Republic Act No. 10354 What is it? * Establishes a national system for healthcare, education, and support concerning: * Pregnancy * Childbirth * Family planning * Sexual health. PE - Group 7.pdf What does it cover? * Maternal and newborn care. * Family-planning methods. * Health education. * Access to healthcare facilities/professionals. * Adolescent health guidance. PE - Group 7.pdf Why was it signed? * Address health and population concerns. * Improve access to healthcare and information. * Reduce preventable deaths related to pregnancy/childbirth. * Help families make informed decisions about having children. * Address poor and marginalized communities. * Establish government responsibilities for these services. PE - Group 7.pdf Penalties Under Section 24, the presentation lists: * ₱10,000–₱100,000 fine * 1–6 months imprisonment * Some public-official violations may result in suspension or removal from office. * Other violations have specific penalties. PE - Group 7.pdf Effects on community health * Better care before/after childbirth. * Better newborn and child healthcare. * Greater access to family planning. * Adolescent health guidance. * Additional support for people who struggle to access healthcare. PE - Group 7.pdf Why it matters * Pregnancy/childbirth can involve serious health risks. * Lack of healthcare access can worsen those risks. * Unplanned pregnancies can create additional challenges. * Misinformation can lead to poor decisions. * Poor and remote communities may have fewer healthcare options. PE - Group 7.pdf Improvements * Expand services in remote areas. * Strengthen monitoring. * Update educational materials. * Increase healthcare-worker training, especially in underserved areas. PE - Group 7.pdf ⸻ 8. National Health Insurance Program NHIP / RA 7875, expanded through RA 11223 What is it? * Government initiative intended to provide universal health-insurance coverage and financial protection against medical costs. * Enacted in 1995 under RA 7875. * Coverage was expanded through the Universal Health Care Act (RA 11223), including automatic enrollment of Filipino citizens at birth. Soft Pink Elegant Scrapbook Creative Portfolio Presentation.pdf Why was it implemented? * Make healthcare financially accessible. * Help people who cannot afford healthcare. * Provide government subsidies for indigent members. * Achieve universal health-insurance coverage. * Promote equality in healthcare access. * Share the financial burden of healthcare. Who is involved? * DOH: policy coordination/guidance and healthcare regulation. * PhilHealth: main implementer/administrator, including membership, contributions, benefits, claims, and provider accreditation. * LGUs: local implementation, enrollment support, subsidies, and access. * DSWD: helps identify indigent/vulnerable Filipinos who may qualify. Positive effects * Increased access to healthcare. * Reduces financial burden from medical emergencies. * Encourages preventive healthcare. * Particularly helps people with limited ability to pay. Problems/issues * Benefits may not cover all healthcare expenses. * Unequal healthcare access between regions. * Claims and administrative problems can cause delays or denials. Recommended improvements * Reduce out-of-pocket expenses. * Expand healthcare access, especially rural clinics. * Expand preventive care such as screenings, vaccinations, checkups, and health education. * Improve electronic claims processing. Penalties: Not specified in this presentation. ⸻ 9. Ecological Solid Waste Management Act Republic Act No. 9003 What is it? * Environmental law focused on proper solid-waste management. Why was it needed? * Non-biodegradable waste polluted waterways and marine ecosystems. * Clogged drainage contributed to localized flooding. * Rapid urbanization and single-use packaging created huge amounts of waste that local systems struggled to handle. Group 4 RA 9003.pdf When established? * Passed by Congress: December 20, 2000 * Approved: January 26, 2001 Group 4 RA 9003.pdf Who is involved? * Provinces/MMDA * Cities/municipalities * Barangays * NGOs * Manufacturers/recyclers * Private contractors * Households and businesses. Group 4 RA 9003.pdf Implementation * Multi-level governance. * Mandatory waste segregation at source. * Materials Recovery Facilities (MRFs). * Closure of open/unmanaged dumpsites. * Penalties for prohibited acts. Group 4 RA 9003.pdf Penalties Violation Penalty Littering/dumping ₱300–₱1,000 + 1–15 days community service Improper collection/transport or open burning ₱300–₱1,000 + 1–15 days jail Non-segregated collection, squatting in dumpsites, dumping in flood-prone areas, unauthorized recycling removal ₱1,000–₱3,000 + 15 days–6 months jail Mixing recyclables, operating open dumps, non-eco packaging/importing non-eco packaging ₱500,000 + 5–10% income Importing toxic waste/unauthorized disposal ₱10,000–₱200,000 + 30 days–3 years jail Illegal waste facility/building near dumpsites/landfill on aquifer or watershed ₱100,000–₱1 million + 1–6 years jail EPR noncompliance ₱5 million–₱20 million + possible permit suspension These sanctions are listed in the presentation. Group 4 RA 9003.pdf Positive effects * Cleaner and safer surroundings. * Better air quality. * Green jobs/income. * Stronger barangay leadership. * Better waste-management habits. Group 4 RA 9003.pdf Negative effects * Higher costs for households/LGUs. * Inconvenience from segregation. * Improper disposal if facilities aren’t adequate. * Strain on local governments. * Dumpsite closures can create short-term problems. Group 4 RA 9003.pdf Recommendations * Enforce Extended Producer Responsibility. * Make manufacturers/distributors responsible for post-consumer plastic packaging. * Fund and require functioning barangay MRFs for composting and recycling. Group 4 RA 9003.pdf ⸻ 10. Philippine Clean Air Act Republic Act No. 8749 What is it? * Law intended to protect human health and the environment by controlling/reducing air pollution from: * Vehicles * Factories * Other pollution sources. Group 3.pdf Why is it needed? * Reduces air pollution. * Protects public health. * Sets rules for pollution from vehicles, factories, and other sources. * Gives people the right to breathe clean air. Group 3.pdf Sources of air pollution mentioned * Burning fossil fuels. * Automobiles. * Agricultural activities. * Factories and industries. * Mining activities. Effects * Air pollution can damage human health. * Industrial emissions degrade air quality. * Mining dust/chemicals can affect workers and nearby communities. How to improve air quality * Use renewable energy. * Limit fossil-fuel use. * Adopt sustainable habits. * Strengthen vehicle-emission regulations. * Control nitrogen oxides and fine particles. * Use technologies that reduce brake-related particles. The presentation says TAMIC® can reduce brake particles by 70–90%. Group 3.pdf Penalties The presentation divides violations into categories. Motor-vehicle violations * ₱10,000–₱100,000 per day of violation. * 6 months–1 year imprisonment. * Business operations may be suspended or closed. Gross violations * ₱100,000–₱1,000,000 per day. * 6–10 years imprisonment. * Business may be permanently closed. * Government officials may be dismissed or disqualified from office. The presentation describes gross violations as including things such as multiple violations within a year, ignoring DENR closure orders, or causing serious environmental damage. ⸻ Law / Program Key number BHW Program RA 7883 Magna Carta of Women RA 9710 Magna Carta GAD budget 5% Magna Carta fines ₱10k–₱50k Magna Carta imprisonment 1–6 months Food Safety Act RA 10611 Food Safety 1st conviction ₱50k–₱100k + 1 month suspension Food Safety 2nd ₱100k–₱200k + 3 months suspension Food Safety 3rd ₱200k–₱300k + 6 months suspension Food Safety death 6 months + 1 day to 6 years + 1 day Food Safety death fine ₱300k–₱500k Consumer Act RA 7394 Consumer unsafe products ₱1k–₱10k / 2 months–1 year Consumer medicine/device violations ₱5k–₱10k / 1–5 years Safe Spaces Act RA 11313 Safe Spaces 1st catcalling ₱1k + community service + seminar Safe Spaces 2nd 6–10 days or ₱3k Safe Spaces 3rd 11–30 days + ₱10k Safe Spaces online harassment ₱100k–₱500k +/or imprisonment EPI Global launch 1974 RH Law RA 10354 RH Law penalties ₱10k–₱100k / 1–6 months NHIP RA 7875 UHC expansion RA 11223 Ecological Solid Waste Act RA 9003 RA 9003 littering ₱300–₱1k + 1–15 days community service RA 9003 toxic waste ₱10k–₱200k + 30 days–3 years RA 9003 major violations ₱100k–₱1M + 1–6 years RA 9003 EPR noncompliance ₱5M–₱20M Clean Air Act RA 8749 Clean Air motor violations ₱10k–₱100k/day + 6 months–1 year Clean Air gross violations ₱100k–₱1M/day + 6–10 years

Vocabulary Match (Each word can only be used once) Tolerant IP Address Internet protocol User Datagram Protocol(UDP) Protocol Path Bandwidth Computing Device Computing SystemComputing Network DataStream Packet Meta Packet Redundancy Transmission Control Protocol(TCP) Router Fault Tolerance Hi, Elijah. When you submit this form, the owner will see your name and email address. 1.Information passed through the internet in packets (2 Points) 2.Data added to packets to help route them through the network and reassemble the original message. (2 Points) 3.The maximum amount of data that can be sent in a fixed amount of time, usually measured in bits per second. (2 Points) 4.The series of connections between computing devices on a network starting with a sender and ending with a receiver (2 Points) 5.A group of interconnected computing devices capable of sending or receiving data. Path. (2 Points) 6.A chunk of data sent over a network. (2 Points) 7.A protocol for sending packets that does error-checking to ensure all packets are received and properly ordered (2 Points) 8.A protocol for sending packets quickly with minimal error-checking and no resending of dropped packets (2 Points) 9.A type of computer that forwards data across a network (2 Points) 10.The inclusion of extra components so that a system can continue to work even if individual components fail, for example by having more than one path between any two connected devices in a network. (2 Points) 11.Can continue to function even in the event of individual component failures. This is important because elements of complex systems like a computer network fail at unexpected times, often in groups. (2 Points) 12.An agreed-upon set of rules that specify the behavior of some system (2 Points) 13.The unique number assigned to each device on the Internet (2 Points) 14.A protocol for sending data across the Internet that assigns unique numbers (IP addresses) to each connected device (2 Points) 15.A machine that can run a program, including computers, tablets, servers, routers, and smart sensors (2 Points) 16.What is a group of computing devices and programs working together for a common purpose (2 Points) 17.Who helped creater the internet (2 Points) Vint Cerf and Bob Kahn The President Bill Gates Google 18.What protocol is used for transmitting web pages over the Internet (2 Points) Internet Protocal HyperText Transfer Protocol File Transfer Protocal Bandwidth 19.DNS stands for (2 Points) Domain Name Service Domain Nervous System Domain Neff Service Domain Name System 20.Differing access to computing devices and the Internet, based on socioeconomic, geographic, or demographic characteristics (2 Points) Internet Dilemma Digital Divide Net Neutrality Internet Censorship 21.What is the attempt to control or suppress what can be accessed, published, or viewed on the Internet by certain people. This can be used to protect people (i.e. to not allow access to child pornography) but can also be used to limit free speech. (2 Points) Internet Dilemma Digital Divide Net Neutrality Internet Censorship 22.While technology is increasingly integrated into daily life, there are still many who lack access to the Internet or digital technology. In rural areas there are challenges building networks to connect geographically sparse populations, but even in cities some groups or areas have relatively less access to the Internet or knowledge of how to use it. (2 Points) Internet Dilemma Digital Divide Net Neutrality Internet Censorship 23.Internet users love services like streaming movies, video chatting, or online gaming. All of this content needs to travel over the Internet, however, and the companies that build and maintain networks are complaining about the increased demands being placed on their networks (2 Points) Internet Dilemma Digital Divide Net Neutrality Internet Censorship 24.What are Packets made up of ? (2 Points) Binary Sequences of X's and O's Binary Sequences of 1's and 0's ASCII Numbers Flippy Do Pro 25.How does an Ip Address relate to a home address? Choose all that apply example 174.256.45.156 (2 Points) House number Street street Country 26.What does ARPANET stand for ? (2 Points) Agency Rest Platform and Network Solutions Aerial Research Probes Network Defense at Work Project Advanced Research Project Agency Network 27.The series of connections between computing devices on a network starting with a sender and ending with a receiver. (2 Points) Bandwidth Path Computing Network Computing Device 28.The maximum amount of data that can be sent in a fixed amount of time, usually measured in bits per second. (2 Points) Bandwidth Path Computing Network Computing Device 29.A machine that can run a program, including computers, tablets, servers, routers, and smart sensors (2 Points) Bandwidth Computing Device Computing Network Computing System 30.Pick the two statements that are true about the Internet Protocol (IP): (2 Points) Each device or computer on the Internet is assigned a unique IP address. IP is a secret protocol shared between the sender and receiver. In order to communicate two devices on the Internet must have the same IP address. IP is the shared way that all devices and computers label their messages with the sender and receiver's addresses. 31.The Internet was developed as a result of an experiment the Defense Department. (2 Points) True False 32.A Protocol is a well known set of rules and standards used to communicate between machines with trouble. (2 Points) True False 33.IPv4 was designed in 1973 and widely adopted in the early 80's and provided for more than _______________________ connected to the internet (2 Points) 80 million special devices 1 billion unique devices 4 billion unique devices 8 trillion devices 34.IPv6 use 340 Undecillion unique address to expand the network, that enough for (2 Points) Every grain of sand on earth to have an IP address every person in the USA A&T MIDDLE COLLEGE students Every person in the world 35.The Internet is not made up of many independent networks. (2 Points) True False 36.An Internet Service Provider is a company that provides Internet access to organizations and home users. (2 Points) True False 37.What level does not belong to the IP Address hierarchy? (2 Points) Country Region Mainframe Device 38.The DNS looks up domain names and gets the associated IP address. wich is used to connect your computer to the internet. (2 Points) True False 39.What is a correct IP Address? (2 Points) 174.129.14.120 www.code.org youtube/watch Amazon.com 40.DNS servers are connected in a distributed hierarchy and divided into zones, splitting up the responsibility for the major domains. (2 Points) True False 41.Which is not a major domain zones ? (2 Points) .org .net .dnc .net 42.Which of the following best describes the protocols used on the Internet? (2 Points) The protocols of the Internet are secret to maintain the privacy and security of people using them The protocols of the Internet are open and used by all devices connected to the network Each device connected to the Internet will use a protocol designed by the company that manufactured it The protocols of the Internet are designed by government agencies to ensure they remain free to use 43.Mr. Still purchases a new smartphone and is immediately able to use it to send a photo over the Internet to a friend who lives in a different country. Which of the following is NOT necessary to make this possible? (2 Points) Both devices are using the same shared and open protocols The data of the image is routed through a sequence of directly connected devices before arriving at its destination A single direct connection is established between any two devices connected to the Internet 3 Both devices are directly connected to at least one part of the Internet 44.Which of the following is true of how packets are sent through the Internet? (2 Points) Packet metadata is only included on important packets to indicate they should get access to faster paths through the network Packet metadata is used to route and reassemble information travelling through the Internet Information sent through the internet is only encapsulated in packets if the message is too large to be sent as a datastream Information sent through the internet is split into two packets, one which contains the message and another which contains the metadata 45.Emilee is watching an online video. The video is being sent to her laptop by a server over the Internet which splits the video into packets and sends them in the order they appear in the video. Which of the following is true about how the packets will arrive at her computer? (2 Points) The packets will always be received in the order that they were sent Either every packet will reach her computer or none of them will. Packets that arrive out of order will be sent back to the server The packets may arrive out of order 46.Which of the following best describes the purpose of an IP address? (2 Points) IP addresses provide a unique number for identifying devices that send and receive information on the Internet IP addresses assist in the reconstruction of a message that has been divided into many packets IP addresses indicate the location where an internet-connected computing device was manufactured IP addresses indicate how many times an individual packet has been requested by a router 47. Which of the following Internet protocols is MOST important in reassembling packets and requesting missing packets to form complete messages? (2 Points) Transmission Control Protocol Internet Protocal HyperText Transfer Protocol (HTTP) Used DATA PROTOCOL 48. Two devices are connected to the Internet and communicating with one another. A squirrel chews through one of the wires in the network that is currently being used by the devices to communicate. The network immediately begins using a different path through the network and communication continues as normal. (2 Points) scalability fault-tolerance protocol pathing 49.An Internet Service Provider (ISP) is a company that builds the routers and wired connections that allow individuals to access the Internet. An ISP is considering adding additional redundant connections to its network. Which of the following best describes why the company would choose to do so? (2 Points) It costs less to design a network that is redundant Redundant networks are more reliable Adding additional connections reduces the fault-tolerance of the network The protocols of the Internet only work on networks that are redundant 50.Which of the following can't we trust together to successively deliver informational at scale and reliability. (2 Points) HTTP &DNS TCP/IP & ROUTING INS & UDP WIRE, CABLES & WIFI

Abbreviations for certain body areas

What useful evidence is available to learn about the costume practices of each civilization studied? What are some of the “problems” of certain sources

1. Exploration & Native Americans Christopher Columbus Italian explorer who sailed for Spain in 1492. Wanted to find a western route to Asia. Reached the Caribbean instead. His voyages began sustained European contact with the Americas. Led to European colonization and the Columbian Exchange. Conquistadores Spanish explorers/conquerors who sought gold, land, and converts. Helped Spain conquer large Native American empires. Often used military force and alliances with rival Native groups. Mayas, Incas, Aztecs Major civilizations in the Americas before European conquest. Aztecs: centered in Mexico; conquered by Cortés. Incas: centered in the Andes/South America; conquered by Pizarro. Mayas: Central America; famous for cities, writing, mathematics, and astronomy. Hernando Cortés Spanish conquistador. Conquered the Aztec Empire in 1519–1521. Defeated Montezuma/Moctezuma II and captured Tenochtitlán. Francisco Pizarro Spanish conquistador who conquered the Inca Empire. Operated in present-day Peru. Montezuma Aztec ruler when Cortés arrived. Also called Moctezuma II. His empire was eventually conquered by Cortés and his allies. Hernando de Soto Spanish explorer who explored the southeastern part of what became the United States. His expedition encountered Native peoples and reached the Mississippi River. Francisco de Coronado Spanish explorer who explored the American Southwest and Great Plains. Searched for the legendary Seven Cities of Gold. Jacques Cartier French explorer who explored the St. Lawrence River. His voyages helped France establish claims in North America. John Cabot Italian explorer sailing for England. Explored the North Atlantic coast of North America in 1497. Helped England establish a claim to North American territory. Prince Henry the Navigator Portuguese prince who supported exploration. Helped Portugal develop navigation and sailing technology. Portuguese exploration contributed to the development of the Atlantic slave trade. ⸻ 2. Spanish, French & English Colonization Joint-stock company A company where investors pool money to fund a business. Why important: English colonies such as Virginia were partly financed through joint-stock companies. Virginia Company English joint-stock company. Founded Jamestown in 1607. Investors hoped to make money from the colony. Jamestown First permanent English settlement in North America, 1607. Located in Virginia. Suffered from disease, starvation, conflict, and poor leadership. Tobacco eventually helped make the colony profitable. Tidewater Coastal area of Virginia and surrounding colonies. Early English settlements were concentrated here. Piedmont Inland region between the Tidewater/coastal plain and Appalachian Mountains. Settlement expanded into this area as colonies grew. Coureurs de bois French “runners of the woods.” French colonists/traders who lived and traveled among Native Americans. Participated heavily in the fur trade. Samuel de Champlain French explorer. Founded Quebec in 1608. Known as the “Father of New France.” Developed alliances with Native Americans. ⸻ 3. Roanoke & Early Virginia Sir Walter Raleigh English supporter of colonization. Sponsored the attempted settlement at Roanoke. Roanoke English colony established in the 1580s. Eventually disappeared. Called the “Lost Colony.” John Smith Leader at Jamestown. Helped organize the settlement and enforce discipline. Famous for his relationship with Pocahontas, although later accounts are disputed. “Starving Time” Winter of 1609–1610 at Jamestown. Colonists experienced extreme hunger, disease, and death. Demonstrated how difficult early colonization was. John Rolfe Helped make Virginia economically successful by growing tobacco. Married Pocahontas. Tobacco became Virginia’s major cash crop. Headright system Colonists received land for bringing people to Virginia. Encouraged immigration. Helped create large plantations and contributed to social/economic inequality. Freeman A colonist who possessed certain political rights, including the ability to participate in government. Political rights were generally limited to certain white male colonists. House of Burgesses Created in Virginia in 1619. First representative legislative assembly in the English colonies. Important development in colonial self-government. 1618 reforms of the Virginia Company The Virginia Company changed its policies to attract settlers and make Virginia successful. Included: More representative government. Greater incentives for settlers. Expansion of land ownership. Greater economic opportunity. Result: Virginia became more attractive to settlers. ⸻ 4. Puritans & Religion John Calvin Protestant religious thinker. Developed Calvinism. Believed in predestination. Predestination The belief that God has already determined who will be saved. Puritanism Protestant movement that wanted to reform the Church of England. Puritans believed the English church still contained too many Catholic practices. Separatists Puritans who believed the Church of England could not be reformed. Wanted to separate completely from it. The Pilgrims were Separatists. Non-Separatist Puritans Wanted to reform the Church of England rather than leave it completely. Many settled Massachusetts Bay. Pilgrims Separatist Puritans. Settled at Plymouth in 1620. Signed the Mayflower Compact. Mayflower Compact Agreement signed by Plymouth settlers. Established self-government based on majority rule. Important early example of colonial self-government. Plymouth Colony founded by Pilgrims in 1620. Later became part of Massachusetts. William Bradford Pilgrim leader and governor of Plymouth. Helped maintain the colony. Wrote about Plymouth’s early history. Massachusetts Bay Colony Founded by Puritans in 1630. Much larger than Plymouth. Centered around Boston. Governed according to Puritan religious beliefs. John Winthrop Governor of Massachusetts Bay. Described Massachusetts as a “city upon a hill.” “City upon a hill” Winthrop’s idea that Massachusetts should serve as an example of a successful Christian society to the world. Covenant A religious agreement between God and a community. Puritans believed their communities had a special covenant with God. “Visible saints” Puritans who demonstrated that they had received God’s grace and were considered members of the church. “Invisible saints” Those believed to have God’s grace/salvation, even though humans could not truly know who was saved. “Saving grace” The belief that God’s grace could lead a person to salvation. ⸻ 5. New England Religious Conflicts Anne Hutchinson Puritan woman who challenged Massachusetts religious leaders. Believed faith/grace was more important than following religious rules. Put on trial and banished from Massachusetts. Shows the limits of religious tolerance in Massachusetts. Roger Williams Founded Rhode Island. Believed in: Religious freedom Separation of church and government Fairer treatment of Native Americans Banished from Massachusetts. Fundamental Orders of Connecticut 1639. Established a representative government in Connecticut. Often considered one of the first written constitutions in America. King Philip’s War 1675–1676. Major conflict between New England colonists and Native Americans led by Metacom, whom colonists called King Philip. Resulted in enormous destruction and loss of Native American land and power. Toleration Act of 1649 Maryland law granting religious toleration to Christians. Intended especially to protect Catholics. Important early example of religious toleration, although it was limited. ⸻ 6. Massachusetts Education Massachusetts Education Act of 1647 Required towns to establish schools when they reached certain population sizes. Why? Puritans wanted people to be able to read the Bible. Important: Shows how strongly education and religion were connected in Puritan society. ⸻ 7. Colonial Regions New England Colonies Examples: Massachusetts Plymouth Connecticut Rhode Island New Hampshire Important characteristics Religious motivations Puritan influence Small farms Town-centered communities Fishing Shipbuilding Lumber Commerce Less suitable climate for large cash-crop plantations ⸻ Middle Colonies Examples: New York Pennsylvania New Jersey Delaware Important characteristics Religious diversity More ethnic diversity Fertile farmland Grain production Large ports Trade Cities such as New York and Philadelphia ⸻ Southern Colonies Examples: Virginia Maryland North Carolina South Carolina Georgia Important characteristics Plantation agriculture Tobacco, rice, indigo Slavery Large landowners Warm climate Greater social/economic inequality ⸻ 8. Types of Colonies Corporate colony Colony controlled by a company. Example: Virginia originally operated under the Virginia Company. Royal colony Controlled directly by the English king. Governor appointed by the king. Proprietary colony Granted by the king to an individual or group. Proprietor had significant control. Example: Pennsylvania → William Penn Charter of Liberties Early New York document providing certain rights and outlining representative government. Associated with efforts to establish political participation in the colony. ⸻ 9. William Penn & Quakers William Penn Quaker. Founded Pennsylvania. Wanted a colony based on religious tolerance. Had relatively peaceful relationships with Native Americans. Quakers / Society of Friends Protestant religious group. Believed in spiritual equality. Rejected many traditional church structures. Supported religious tolerance. Women had greater religious participation than in many other colonial communities. George Calvert Also known as Lord Baltimore. Catholic Englishman. Received land that became Maryland. Wanted a place where Catholics could practice their religion more freely. ⸻ 10. Georgia James Oglethorpe Founded Georgia in 1732. Intended Georgia partly as a buffer against Spanish Florida. Also wanted to create opportunities for poor English people. ⸻ 11. Pennsylvania & New York Patroonship Dutch system in New Netherland. Large land grants were given to wealthy individuals called patroons. Encouraged large estates. Quitrent A fee/rent paid to a proprietor for use of land. Common in proprietary colonies. ⸻ 12. Bacon’s Rebellion Bacon’s Rebellion 1676 Virginia. Nathaniel Bacon led settlers against Native Americans and Virginia’s government. Bacon’s followers believed Governor Berkeley was not protecting frontier settlers. Why important? Exposed class tensions between wealthy planters and poorer colonists. Afterward, Virginia increasingly relied on enslaved Africans instead of indentured servants. ⸻ 13. Colonial Social Classes Indentured servants Europeans who agreed to work for a certain number of years in exchange for passage to America. After their contract ended, they could become free. Freedom dues Things given to indentured servants when their contract ended. Could include: Clothing Tools Land or supplies Redemptioners European immigrants who agreed to work for a period of time after arriving in America to pay off transportation costs. ⸻ 14. Slavery Chattel slavery System in which enslaved people were treated legally as property. Slavery became hereditary. Enslaved people had extremely limited/no legal freedom. Middle Passage Forced voyage of enslaved Africans across the Atlantic to the Americas. Part of the triangular trade. Conditions were extremely overcrowded and deadly. Slave codes Laws restricting the rights and freedoms of enslaved people. They often: Prevented movement. Restricted education. Restricted assembly. Defined enslaved people as property. Made slavery hereditary. ⸻ 15. Stono Rebellion Stono Rebellion 1739, South Carolina. Enslaved Africans rebelled and attempted to escape toward Spanish Florida. Colonial authorities eventually suppressed the rebellion. Why important? Led to even stricter slave laws. ⸻ 16. Triangular Trade A trading system connecting Europe, Africa, and the Americas. Simplified: Europe → Africa Manufactured goods Africa → Americas Enslaved Africans Americas → Europe Sugar Tobacco Rice Other raw materials ⸻ 17. Mercantilism Economic theory used by European empires. Basic idea: Colonies exist to benefit the mother country. England wanted colonies to: Supply raw materials. Buy English manufactured goods. Increase England’s wealth. Strengthen England’s economy. ⸻ 18. Navigation Acts English laws regulating colonial trade. They required much colonial trade to: Use English ships. Pass through English-controlled channels. Benefit England. Goal: strengthen mercantilism. ⸻ 19. Molasses Act 1733 Taxed foreign molasses imported into British colonies. Designed to protect British sugar producers in the Caribbean. Colonists often avoided or resisted the tax through smuggling. Woolens Act Restricted colonial production/trade of woolen goods. Intended to protect English manufacturers. Hat Act Restricted colonial production/export of hats. Another example of Britain controlling colonial manufacturing. Iron Act Encouraged production of certain raw iron products in the colonies but restricted production of finished iron goods. Britain wanted colonies to supply raw materials while buying manufactured products from Britain. BIG IDEA: These laws show mercantilism and British attempts to control colonial economies. ⸻ 20. Dominion of New England Dominion of New England Created by King James II in 1686. Combined several New England colonies under one government. Why? Increase royal control. Enforce Navigation Acts. Reduce colonial self-government. Sir Edmund Andros Royal governor of the Dominion of New England. Strongly enforced royal policies. Very unpopular with many colonists. ⸻ 21. Glorious Revolution Glorious Revolution — 1688 English people and Parliament removed James II. William and Mary became monarchs. Increased the power of Parliament. Colonial effect: Colonists overthrew the Dominion of New England government. Sir Edmund Andros was removed. Colonists regained some self-government. ⸻ 22. Political Deference Political deference The belief that ordinary people should respect and defer to wealthy, powerful, or socially prominent leaders. Colonial society was often hierarchical. ⸻ 23. Lower House of the Legislature The elected part of a colonial legislature representing ordinary property-owning colonists. Examples: House of Burgesses Colonial assemblies Important: These assemblies helped establish the tradition of representative government. ⸻ 24. The Great Awakening Great Awakening Religious revival movement in the 1730s–1740s. Preachers emphasized: Personal faith Emotional religious experiences Salvation Individual relationships with God It challenged established churches and religious authorities. Jonathan Edwards Famous Great Awakening preacher. Known for the sermon: “Sinners in the Hands of an Angry God.” Emphasized God’s power and the need for conversion. George Whitefield Extremely popular traveling preacher. Preached throughout the colonies. Helped spread the Great Awakening. Old Lights People who supported traditional, established religious practices. New Lights People who supported the emotional revival-style religion of the Great Awakening. Baptists Protestant group that grew during the Great Awakening. Emphasized personal faith and baptism. Helped increase religious diversity. ⸻ 25. John Peter Zenger John Peter Zenger New York printer/journalist. Put on trial for criticizing the colonial governor. His lawyer argued that truthful statements should not be considered libel. Why important? His trial became an important symbol associated with freedom of the press. ⸻ 26. Maryland & Carolina Fundamental Constitutions of Carolina Document associated with governing Carolina. Created a hierarchical political/social structure. Helped establish an aristocratic plantation society. Slavery became increasingly important in Carolina. Established churches A government-supported official church. In some colonies, taxes helped support the established church. Important contrast: Established churches = government + religion connected. Rhode Island/Pennsylvania = greater religious freedom. ⸻ 27. Great Migration Great Migration, 1630–1643 Large migration of English Puritans to Massachusetts Bay and other New England colonies. Why? Religious motivations Political/religious conflict in England Desire to build Puritan communities Important: This was different from the much later Great Migration of African Americans during the 20th century. ⸻ 28. Enclosure Movement Enclosure Movement In England, landowners enclosed common lands and combined small fields into larger private farms. Effect: Some small farmers lost access to land. Increased movement of people toward cities and overseas colonies. Helped contribute to English migration to America. ⸻ 29. “City Upon a Hill” vs. Religious Tolerance Know this contrast for APUSH: Massachusetts Bay → Puritan religious society → Limited religious tolerance Rhode Island → Roger Williams → Religious freedom Pennsylvania → William Penn → Quakerism + religious tolerance Maryland → Catholic refuge → Toleration Act of 1649 ⸻ ⭐ The MOST IMPORTANT Connections to Know These are the connections your teacher is likely looking for in APUSH questions. Tobacco → Virginia John Rolfe → tobacco → profitable Virginia → plantations → labor demand → indentured servants → slavery Bacon’s Rebellion → slavery Bacon’s Rebellion → class conflict → elites become more suspicious of poor white workers → increased reliance on African slavery Puritans → Massachusetts Puritans → Great Migration → Massachusetts Bay → John Winthrop → “city upon a hill” Separatists → Plymouth Separatists → Pilgrims → Mayflower → Plymouth → Mayflower Compact Religious disagreement → Rhode Island Anne Hutchinson/Roger Williams → conflict with Massachusetts → Rhode Island → religious freedom Quakers → Pennsylvania William Penn → Quakers → Pennsylvania → religious tolerance Mercantilism → Navigation Acts Mercantilism → Britain wants colonies to benefit England → Navigation Acts → trade restrictions Great Awakening → religious change Great Awakening → emotional religion → New Lights → challenges established churches → increased religious diversity Slavery → plantation economy Cash crops → labor demand → African slavery → slave codes → racial hierarchy

✈️ AVTN 110 — AVIATION BASICS STUDY GUIDE 1. FAA — Federal Aviation Administration What does the FAA do? * Promotes aviation safety. * Creates safety standards for civil aviation. * Regulates pilots, aircraft, flight operations, and training. Important terms * FARs = Federal Aviation Regulations * Rules for aviation. * CFR = Code of Federal Regulations * Collection of U.S. government rules. * Title 14 = Aeronautics and Space * Covers civil aviation. Remember: FAA = Safety + Rules ⸻ 2. 14 CFR Title 14 — Aeronautics and Space Important parts: * Part 61 → Pilot certification * Part 91 → General flight rules * Part 135 → Commercial/corporate operations * Part 141 → Flight schools with FAA-approved programs Easy memory: 61 = Pilot 91 = Rules 135 = Corporate/Charter 141 = Flight School ⸻ 3. NOTAMs NOTAM = Notice to Airmen NOTAMs give pilots important, time-sensitive information. Examples: * Runway closed * Taxiway closed * Obstructions * Airshows * Special events Remember: NOTAM = Something important has changed. ⸻ 4. Pilot Certifications Private Pilot * Personal or recreational flying. * Cannot normally accept payment for flying. * Can command an aircraft under VFR. VFR = Visual Flight Rules Commercial Pilot * Allows you to earn money for flying. * Without an instrument rating, there are restrictions on flying for hire. ATP — Airline Transport Pilot * Highest level of pilot certificate. * Needed to serve as PIC/SIC in airline operations. * Generally requires 1,500 hours. * Minimum age is 23. PIC Pilot in Command SIC Second in Command Restricted ATP * Can allow someone to serve as SIC at scheduled airlines. * Based on certain education and flight-experience requirements. * Minimum age is 21. ⸻ 5. Extra Pilot Ratings Instrument Rating Allows you to fly in a wider range of weather conditions using instruments. IFR = Instrument Flight Rules Commercial Rating Allows you to receive compensation for flying. MEI Multi-Engine Instructor Important for many flying jobs. CFI Certified Flight Instructor Teaches people how to fly. CFII Certified Flight Instructor — Instrument Teaches instrument flying. Seaplane Rating Allows you to fly seaplanes. ⸻ 6. Flight Instructor What does a flight instructor do? The instructor is responsible for training the student in the knowledge and skills needed to become a safe pilot. A CFI must: * Have enough flying experience. * Pass knowledge tests. * Pass practical tests. * Demonstrate teaching ability. Remember: CFI = Teaches you to fly ⸻ 7. What Is a Flying Lesson Like? 1. Weather Check Check weather to see if conditions are safe. 2. Instructor Briefing Talk with your instructor about what you will practice. 3. Preflight Inspection Use a checklist to inspect the airplane. 4. Flight Practice old skills and learn new maneuvers. 5. After Flight * Instructor evaluates the lesson. * Logbook is filled out. * Instructor endorses the logbook when needed. Easy memory: Weather → Brief → Inspect → Fly → Log ⸻ 8. Part 61 vs Part 141 Part 61 * More flexible. * Often smaller/“mom & pop” flight schools. * Certified instructors. * Curriculum is not regulated by FAA in the same way as Part 141. * Training is focused on meeting the required test standards. * More personalized to each student. Part 141 * Highly regulated by FAA. * Has an approved curriculum. * Flight AND ground training are regulated. * More paperwork. * Certified CFIs. * Has a regulated maintenance program. * Academic units can reduce the required flight hours for certain certificates. * Can be eligible for GI Bill benefits. Easy memory: Part 61 = Flexible Part 141 = Structured + FAA regulated ⸻ 9. Four Forces of Flight There are 4 forces: ✈️ Thrust Forward force Produced by the: * Propeller * Powerplant/engine 🛑 Drag Backward force Caused by resistance/disruption of airflow around: * Wings * Fuselage * Other aircraft parts ⬇️ Weight Downward force The combined load of the aircraft, including: * Crew * Fuel * Cargo/baggage ⬆️ Lift Upward force Produced by air acting on the wing. SUPER EASY: Thrust → Forward Drag → Backward Lift → Up Weight → Down ⸻ 10. Aviation Career Opportunities Possible aviation careers/areas: * ✈️ Airlines * 🛫 Airports * 🛩️ Flight Departments * 🏢 Part 91 / Part 135 corporate flying * 🚁 Unmanned Aircraft Systems (UAS) * 🚀 Advanced Air Mobility (AAM) * ⛽ Fixed Base Operators (FBOs) * 🎖️ Military * 👮 Law Enforcement ⸻ 11. NATO Phonetic Alphabet You need to know these:

There’s a certain Slant of light

Like my friend Kylie read this to me "**Civil Disobedience** By Henry David Thoreau 1849 I heartily accept the motto, "That government is best which governs least"; and I should like to see it acted up to more rapidly and systematically. Carried out, it finally amounts to this, which also I believe- "That government is best which governs not at all"; and when men are prepared for it, that will be the kind of government which they will have. Government is at best but an expedient; but most governments are usually, and all governments are sometimes, inexpedient. The objections which have been brought against a standing army, and they are many and weighty, and deserve to prevail, may also at last be brought against a standing government. The standing army is only an arm of the standing government. The government itself, which is only the mode which the people have chosen to execute their will, is equally liable to be abused and perverted before the people can act through it. Witness the present Mexican war, the work of comparatively a few individuals using the standing government as their tool; for, in the outset, the people would not have consented to this measure. This American government- what is it but a tradition, though a recent one, endeavoring to transmit itself unimpaired to posterity, but each instant losing some of its integrity? It has not the vitality and force of a single living man; for a single man can bend it to his will. It is a sort of wooden gun to the people themselves. But it is not the less necessary for this; for the people must have some complicated machinery or other, and hear its din, to satisfy that idea of government which they have. Governments show thus how successfully men can be imposed on, even impose on themselves, for their own advantage. It is excellent, we must all allow. Yet this government never of itself furthered any enterprise, but by the alacrity with which it got out of its way. It does not keep the country free. It does not settle the West. It does not educate. The character inherent in the American people has done all that has been accomplished; and it would have done somewhat more, if the government had not sometimes got in its way. For government is an expedient by which men would fain succeed in letting one another alone; and, as has been said, when it is most expedient, the governed are most let alone by it. Trade and commerce, if they were not made of india-rubber, would never manage to bounce over the obstacles which legislators are continually putting in their way; and, if one were to judge these men wholly by the effects of their actions and not partly by their intentions, they would deserve to be classed and punished with those mischievous persons who put obstructions on the railroads. But, to speak practically and as a citizen, unlike those who call themselves no- government men, I ask for, not at once no government, but at once a better government. Let every man make known what kind of government would command his respect, and that will be one step toward obtaining it. After all, the practical reason why, when the power is once in the hands of the people, a majority are permitted, and for a long period continue, to rule is not because they are most likely to be in the right, nor because this seems fairest to the minority, but because they are physically the strongest. But a government in which the majority rule in all cases cannot be based on justice, even as far as men understand it. Can there not be a government in which majorities do not virtually decide right and wrong, but conscience?- in which majorities decide only those questions to which the rule of expediency is applicable? Must the citizen ever for a moment, or in the least degree, resign his conscience to the legislation? Why has every man a conscience, then? I think that we should be men first, and subjects afterward. It is not desirable to cultivate a respect for the law, so much as for the right. The only obligation which I have a right to assume is to do at any time what I think right. It is truly enough said that a corporation has no conscience; but a corporation of conscientious men is a corporation with a conscience. Law never made men a whit more just; and, by means of their respect for it, even the well-disposed are daily made the agents of injustice. A common and natural result of an undue respect for law is, that you may see a file of soldiers, colonel, captain, corporal, privates, powder- monkeys, and all, marching in admirable order over hill and dale to the wars, against their wills, ay, against their common sense and consciences, which makes it very steep marching indeed, and produces a palpitation of the heart. They have no doubt that it is a damnable business in which they are concerned; they are all peaceably inclined. Now, what are they? Men at all? or small movable forts and magazines, at the service of some unscrupulous man in power? Visit the Navy-Yard, and behold a marine, such a man as an American government can make, or such as it can make a man with its black arts- a mere shadow and reminiscence of humanity, a man laid out alive and standing, and already, as one may say, buried under arms with funeral accompaniments, though it may be, "Not a drum was heard, not a funeral note, As his corse to the rampart we hurried; Not a soldier discharged his farewell shot O'er the grave where our hero we buried." The mass of men serve the state thus, not as men mainly, but as machines, with their bodies. They are the standing army, and the militia, jailers, constables, posse comitatus, etc. In most cases there is no free exercise whatever of the judgment or of the moral sense; but they put themselves on a level with wood and earth and stones; and wooden men can perhaps be manufactured that will serve the purpose as well. Such command no more respect than men of straw or a lump of dirt. They have the same sort of worth only as horses and dogs. Yet such as these even are commonly esteemed good citizens. Others- as most legislators, politicians, lawyers, ministers, and office-holders- serve the state chiefly with their heads; and, as they rarely make any moral distinctions, they are as likely to serve the devil, without intending it, as God. A very few- as heroes, patriots, martyrs, reformers in the great sense, and men- serve the state with their consciences also, and so necessarily resist it for the most part; and they are commonly treated as enemies by it. A wise man will only be useful as a man, and will not submit to be "clay," and "stop a hole to keep the wind away," but leave that office to his dust at least: "I am too high-born to be propertied, To be a secondary at control, Or useful serving-man and instrument To any sovereign state throughout the world." He who gives himself entirely to his fellow-men appears to them useless and selfish; but he who gives himself partially to them is pronounced a benefactor and philanthropist. How does it become a man to behave toward this American government today? I answer, that he cannot without disgrace be associated with it. I cannot for an instant recognize that political organization as my government which is the slave's government also. All men recognize the right of revolution; that is, the right to refuse allegiance to, and to resist, the government, when its tyranny or its inefficiency are great and unendurable. But almost all say that such is not the case now. But such was the case, they think, in the Revolution Of '75. If one were to tell me that this was a bad government because it taxed certain foreign commodities brought to its ports, it is most probable that I should not make an ado about it, for I can do without them. All machines have their friction; and possibly this does enough good to counterbalance the evil. At any rate, it is a great evil to make a stir about it. But when the friction comes to have its machine, and oppression and robbery are organized, I say, let us not have such a machine any longer. In other words, when a sixth of the population of a nation which has undertaken to be the refuge of liberty are slaves, and a whole country is unjustly overrun and conquered by a foreign army, and subjected to military law, I think that it is not too soon for honest men to rebel and revolutionize. What makes this duty the more urgent is the fact that the country so overrun is not our own, but ours is the invading army. Paley, a common authority with many on moral questions, in his chapter on the "Duty of Submission to Civil Government," resolves all civil obligation into expediency; and he proceeds to say that "so long as the interest of the whole society requires it, that is, so long as the established government cannot be resisted or changed without public inconveniency, it is the will of God... that the established government be obeyed- and no longer. This principle being admitted, the justice of every particular case of resistance is reduced to a computation of the quantity of the danger and grievance on the one side, and of the probability and expense of redressing it on the other." Of this, he says, every man shall judge for himself. But Paley appears never to have contemplated those cases to which the rule of expediency does not apply, in which a people, as well as an individual, must do justice, cost what it may. If I have unjustly wrested a plank from a drowning man, I must restore it to him though I drown myself. This, according to Paley, would be inconvenient. But he that would save his life, in such a case, shall lose it. This people must cease to hold slaves, and to make war on Mexico, though it cost them their existence as a people. In their practice, nations agree with Paley; but does any one think that Massachusetts does exactly what is right at the present crisis? "A drab of state, a cloth-o'-silver slut, To have her train borne up, and her soul trail in the dirt." Practically speaking, the opponents to a reform in Massachusetts are not a hundred thousand politicians at the South, but a hundred thousand merchants and farmers here, who are more interested in commerce and agriculture than they are in humanity, and are not prepared to do justice to the slave and to Mexico, cost what it may. I quarrel not with far-off foes, but with those who, near at home, cooperate with, and do the bidding of those far away, and without whom the latter would be harmless. We are accustomed to say, that the mass of men are unprepared; but improvement is slow, because the few are not materially wiser or better than the many. It is not so important that many should be as good as you, as that there be some absolute goodness somewhere; for that will leaven the whole lump. There are thousands who are in opinion opposed to slavery and to the war, who yet in effect do nothing to put an end to them; who, esteeming themselves children of Washington and Franklin, sit down with their hands in their pockets, and say that they know not what to do, and do nothing; who even postpone the question of freedom to the question of free trade, and quietly read the prices-current along with the latest advices from Mexico, after dinner, and, it may be, fall asleep over them both. What is the price-current of an honest man and patriot today? They hesitate, and they regret, and sometimes they petition; but they do nothing in earnest and with effect. They will wait, well disposed, for others to remedy the evil, that they may no longer have it to regret. At most, they give only a cheap vote, and a feeble countenance and God-speed, to the right, as it goes by them. There are nine hundred and ninety-nine patrons of virtue to one virtuous man. But it is easier to deal with the real possessor of a thing than with the temporary guardian of it. All voting is a sort of gaming, like checkers or backgammon, with a slight moral tinge to it, a playing with right and wrong, with moral questions; and betting naturally accompanies it. The character of the voters is not staked. I cast my vote, perchance, as I think right; but I am not vitally concerned that that right should prevail. I am willing to leave it to the majority. Its obligation, therefore, never exceeds that of expediency. Even voting for the right is doing nothing for it. It is only expressing to men feebly your desire that it should prevail. A wise man will not leave the right to the mercy of chance, nor wish it to prevail through the power of the majority. There is but little virtue in the action of masses of men. When the majority shall at length vote for the abolition of slavery, it will be because they are indifferent to slavery, or because there is but little slavery left to be abolished by their vote. They will then be the only slaves. Only his vote can hasten the abolition of slavery who asserts his own freedom by his vote. I hear of a convention to be held at Baltimore, or elsewhere, for the selection of a candidate for the Presidency, made up chiefly of editors, and men who are politicians by profession; but I think, what is it to any independent, intelligent, and respectable man what decision they may come to? Shall we not have the advantage of his wisdom and honesty, nevertheless? Can we not count upon some independent votes? Are there not many individuals in the country who do not attend conventions? But no: I find that the respectable man, so called, has immediately drifted from his position, and despairs of his country, when his country has more reason to despair of him. He forthwith adopts one of the candidates thus selected as the only available one, thus proving that he is himself available for any purposes of the demagogue. His vote is of no more worth than that of any unprincipled foreigner or hireling native, who may have been bought. O for a man who is a man, and, as my neighbor says, has a bone in his back which you cannot pass your hand through! Our statistics are at fault: the population has been returned too large. How many men are there to a square thousand miles in this country? Hardly one. Does not America offer any inducement for men to settle here? The American has dwindled into an Odd Fellow-one who may be known by the development of his organ of gregariousness, and a manifest lack of intellect and cheerful self-reliance; whose first and chief concern, on coming into the world, is to see that the almshouses are in good repair; and, before yet he has lawfully donned the virile garb, to collect a fund for the support of the widows and orphans that may be; who, in short, ventures to live only by the aid of the Mutual Insurance company, which has promised to bury him decently. It is not a man's duty, as a matter of course, to devote himself to the eradication of any, even the most enormous, wrong; he may still properly have other concerns to engage him; but it is his duty, at least, to wash his hands of it, and, if he gives it no thought longer, not to give it practically his support. If I devote myself to other pursuits and contemplations, I must first see, at least, that I do not pursue them sitting upon another man's shoulders. I must get off him first, that he may pursue his contemplations too. See what gross inconsistency is tolerated. I have heard some of my townsmen say, "I should like to have them order me out to help put down an insurrection of the slaves, or to march to Mexico;- see if I would go"; and yet these very men have each, directly by their allegiance, and so indirectly, at least, by their money, furnished a substitute. The soldier is applauded who refuses to serve in an unjust war by those who do not refuse to sustain the unjust government which makes the war; is applauded by those whose own act and authority he disregards and sets at naught; as if the state were penitent to that degree that it differed one to scourge it while it sinned, but not to that degree that it left off sinning for a moment. Thus, under the name of Order and Civil Government, we are all made at last to pay homage to and support our own meanness. After the first blush of sin comes its indifference; and from immoral it becomes, as it were, unmoral, and not quite unnecessary to that life which we have made. The broadest and most prevalent error requires the most disinterested virtue to sustain it. The slight reproach to which the virtue of patriotism is commonly liable, the noble are most likely to incur. Those who, while they disapprove of the character and measures of a government, yield to it their allegiance and support are undoubtedly its most conscientious supporters, and so frequently the most serious obstacles to reform. Some are petitioning the State to dissolve the Union, to disregard the requisitions of the President. Why do they not dissolve it themselves- the union between themselves and the State- and refuse to pay their quota into its treasury? Do not they stand in the same relation to the State that the State does to the Union? And have not the same reasons prevented the State from resisting the Union which have prevented them from resisting the State? How can a man be satisfied to entertain an opinion merely, and enjoy it? Is there any enjoyment in it, if his opinion is that he is aggrieved? If you are cheated out of a single dollar by your neighbor, you do not rest satisfied with knowing that you are cheated, or with saying that you are cheated, or even with petitioning him to pay you your due; but you take effectual steps at once to obtain the full amount, and see that you are never cheated again. Action from principle, the perception and the performance of right, changes things and relations; it is essentially revolutionary, and does not consist wholly with anything which was. It not only divides States and churches, it divides families; ay, it divides the individual, separating the diabolical in him from the divine. Unjust laws exist: shall we be content to obey them, or shall we endeavor to amend them, and obey them until we have succeeded, or shall we transgress them at once? Men generally, under such a government as this, think that they ought to wait until they have persuaded the majority to alter them. They think that, if they should resist, the remedy would be worse than the evil. But it is the fault of the government itself that the remedy is worse than the evil. It makes it worse. Why is it not more apt to anticipate and provide for reform? Why does it not cherish its wise minority? Why does it cry and resist before it is hurt? Why does it not encourage its citizens to be on the alert to point out its faults, and do better than it would have them? Why does it always crucify Christ, and excommunicate Copernicus and Luther, and pronounce Washington and Franklin rebels? One would think, that a deliberate and practical denial of its authority was the only offence never contemplated by government; else, why has it not assigned its definite, its suitable and proportionate, penalty? If a man who has no property refuses but once to earn nine shillings for the State, he is put in prison for a period unlimited by any law that I know, and determined only by the discretion of those who placed him there; but if he should steal ninety times nine shillings from the State, he is soon permitted to go at large again. If the injustice is part of the necessary friction of the machine of government, let it go, let it go: perchance it will wear smooth- certainly the machine will wear out. If the injustice has a spring, or a pulley, or a rope, or a crank, exclusively for itself, then perhaps you may consider whether the remedy will not be worse than the evil; but if it is of such a nature that it requires you to be the agent of injustice to another, then, I say, break the law. Let your life be a counter-friction to stop the machine. What I have to do is to see, at any rate, that I do not lend myself to the wrong which I condemn. As for adopting the ways which the State has provided for remedying the evil, I know not of such ways. They take too much time, and a man's life will be gone. I have other affairs to attend to. I came into this world, not chiefly to make this a good place to live in, but to live in it, be it good or bad. A man has not everything to do, but something; and because he cannot do everything, it is not necessary that he should do something wrong. It is not my business to be petitioning the Governor or the Legislature any more than it is theirs to petition me; and if they should not bear my petition, what should I do then? But in this case the State has provided no way: its very Constitution is the evil. This may seem to be harsh and stubborn and unconciliatory; but it is to treat with the utmost kindness and consideration the only spirit that can appreciate or deserves it. So is an change for the better, like birth and death, which convulse the body. I do not hesitate to say, that those who call themselves Abolitionists should at once effectually withdraw their support, both in person and property, from the government of Massachusetts, and not wait till they constitute a majority of one, before they suffer the right to prevail through them. I think that it is enough if they have God on their side, without waiting for that other one. Moreover, any man more right than his neighbors constitutes a majority of one already. I meet this American government, or its representative, the State government, directly, and face to face, once a year- no more- in the person of its tax- gatherer; this is the only mode in which a man situated as I am necessarily meets it; and it then says distinctly, Recognize me; and the simplest, the most effectual, and, in the present posture of affairs, the indispensablest mode of treating with it on this head, of expressing your little satisfaction with and love for it, is to deny it then. My civil neighbor, the tax-gatherer, is the very man I have to deal with- for it is, after all, with men and not with parchment that I quarrel- and he has voluntarily chosen to be an agent of the government. How shall he ever know well what he is and does as an officer of the government, or as a man, until he is obliged to consider whether he shall treat me, his neighbor, for whom he has respect, as a neighbor and well-disposed man, or as a maniac and disturber of the peace, and see if he can get over this obstruction to his neighborliness without a ruder and more impetuous thought or speech corresponding with his action. I know this well, that if one thousand, if one hundred, if ten men whom I could name- if ten honest men only- ay, if one HONEST man, in this State of Massachusetts, ceasing to hold slaves, were actually to withdraw from this copartnership, and be locked up in the county jail therefor, it would be the abolition of slavery in America. For it matters not how small the beginning may seem to be: what is once well done is done forever. But we love better to talk about it: that we say is our mission, Reform keeps many scores of newspapers in its service, but not one man. If my esteemed neighbor, the State's ambassador, who will devote his days to the settlement of the question of human rights in the Council Chamber, instead of being threatened with the prisons of Carolina, were to sit down the prisoner of Massachusetts, that State which is so anxious to foist the sin of slavery upon her sister- though at present she can discover only an act of inhospitality to be the ground of a quarrel with her- the Legislature would not wholly waive the subject the following winter. Under a government which imprisons any unjustly, the true place for a just man is also a prison. The proper place today, the only place which Massachusetts has provided for her freer and less desponding spirits, is in her prisons, to be put out and locked out of the State by her own act, as they have already put themselves out by their principles. It is there that the fugitive slave, and the Mexican prisoner on parole, and the Indian come to plead the wrongs of his race should find them; on that separate, but more free and honorable, ground, where the State places those who are not with her, but against her- the only house in a slave State in which a free man can abide with honor. If any think that their influence would be lost there, and their voices no longer afflict the ear of the State, that they would not be as an enemy within its walls, they do not know by how much truth is stronger than error, nor how much more eloquently and effectively he can combat injustice who has experienced a little in his own person. Cast your whole vote, not a strip of paper merely, but your whole influence. A minority is powerless while it conforms to the majority; it is not even a minority then; but it is irresistible when it clogs by its whole weight. If the alternative is to keep all just men in prison, or give up war and slavery, the State will not hesitate which to choose. If a thousand men were not to pay their tax-bills this year, that would not be a violent and bloody measure, as it would be to pay them, and enable the State to commit violence and shed innocent blood. This is, in fact, the definition of a peaceable revolution, if any such is possible. If the tax-gatherer, or any other public officer, asks me, as one has done, "But what shall I do?" my answer is, "If you really wish to do anything, resign your office." When the subject has refused allegiance, and the officer has resigned his office, then the revolution is accomplished. But even suppose blood should flow. Is there not a sort of blood shed when the conscience is wounded? Through this wound a man's real manhood and immortality flow out, and he bleeds to an everlasting death. I see this blood flowing now. I have contemplated the imprisonment of the offender, rather than the seizure of his goods- though both will serve the same purpose- because they who assert the purest right, and consequently are most dangerous to a corrupt State, commonly have not spent much time in accumulating property. To such the State renders comparatively small service, and a slight tax is wont to appear exorbitant, particularly if they are obliged to earn it by special labor with their hands. If there were one who lived wholly without the use of money, the State itself would hesitate to demand it of him. But the rich man- not to make any invidious comparison- is always sold to the institution which makes him rich. Absolutely speaking, the more money, the less virtue; for money comes between a man and his objects, and obtains them for him; and it was certainly no great virtue to obtain it. It puts to rest many questions which he would otherwise be taxed to answer; while the only new question which it puts is the hard but superfluous one, how to spend it. Thus his moral ground is taken from under his feet. The opportunities of living are diminished in proportion as what are called the "means" are increased. The best thing a man can do for his culture when he is rich is to endeavor to carry out those schemes which he entertained when he was poor. Christ answered the Herodians according to their condition. "Show me the tribute-money," said he;- and one took a penny out of his pocket;- if you use money which has the image of Caesar on it, and which he has made current and valuable, that is, if you are men of the State, and gladly enjoy the advantages of Caesar's government, then pay him back some of his own when he demands it. "Render therefore to Caesar that which is Caesar's, and to God those things which are God's"- leaving them no wiser than before as to which was which; for they did not wish to know. When I converse with the freest of my neighbors, I perceive that, whatever they may say about the magnitude and seriousness of the question, and their regard for the public tranquillity, the long and the short of the matter is, that they cannot spare the protection of the existing government, and they dread the consequences to their property and families of disobedience to it. For my own part, I should not like to think that I ever rely on the protection of the State. But, if I deny the authority of the State when it presents its tax-bill, it will soon take and waste all my property, and so harass me and my children without end. This is hard. This makes it impossible for a man to live honestly, and at the same time comfortably, in outward respects. It will not be worth the while to accumulate property; that would be sure to go again. You must hire or squat somewhere, and raise but a small crop, and eat that soon. You must live within yourself, and depend upon yourself always tucked up and ready for a start, and not have many affairs. A man may grow rich in Turkey even, if he will be in all respects a good subject of the Turkish government. Confucius said: "If a state is governed by the principles of reason, poverty and misery are subjects of shame; if a state is not governed by the principles of reason, riches and honors are the subjects of shame." No: until I want the protection of Massachusetts to be extended to me in some distant Southern port, where my liberty is endangered, or until I am bent solely on building up an estate at home by peaceful enterprise, I can afford to refuse allegiance to Massachusetts, and her right to my property and life. It costs me less in every sense to incur the penalty of disobedience to the State than it would to obey. I should feel as if I were worth less in that case. Some years ago, the State met me in behalf of the Church, and commanded me to pay a certain sum toward the support of a clergyman whose preaching my father attended, but never I myself. "Pay," it said, "or be locked up in the jail." I declined to pay. But, unfortunately, another man saw fit to pay it. I did not see why the schoolmaster should be taxed to support the priest, and not the priest the schoolmaster; for I was not the State's schoolmaster, but I supported myself by voluntary subscription. I did not see why the lyceum should not present its tax-bill, and have the State to back its demand, as well as the Church. However, at the request of the selectmen, I condescended to make some such statement as this in writing:- "Know all men by these presents, that I, Henry Thoreau, do not wish to be regarded as a member of any incorporated society which I have not joined." This I gave to the town clerk; and he has it. The State, having thus learned that I did not wish to be regarded as a member of that church, has never made a like demand on me since; though it said that it must adhere to its original presumption that time. If I had known how to name them, I should then have signed off in detail from all the societies which I never signed on to; but I did not know where to find a complete list. I have paid no poll-tax for six years. I was put into a jail once on this account, for one night; and, as I stood considering the walls of solid stone, two or three feet thick, the door of wood and iron, a foot thick, and the iron grating which strained the light, I could not help being struck with the foolishness of that institution which treated me as if I were mere flesh and blood and bones, to be locked up. I wondered that it should have concluded at length that this was the best use it could put me to, and had never thought to avail itself of my services in some way. I saw that, if there was a wall of stone between me and my townsmen, there was a still more difficult one to climb or break through before they could get to be as free as I was. I did not for a moment feel confined, and the walls seemed a great waste of stone and mortar. I felt as if I alone of all my townsmen had paid my tax. They plainly did not know how to treat me, but behaved like persons who are underbred. In every threat and in every compliment there was a blunder; for they thought that my chief desire was to stand the other side of that stone wall. I could not but smile to see how industriously they locked the door on my meditations, which followed them out again without let or hindrance, and they were really all that was dangerous. As they could not reach me, they had resolved to punish my body; just as boys, if they cannot come at some person against whom they have a spite, will abuse his dog. I saw that the State was half-witted, that it was timid as a lone woman with her silver spoons, and that it did not know its friends from its foes, and I lost all my remaining respect for it, and pitied it. Thus the State never intentionally confronts a man's sense, intellectual or moral, but only his body, his senses. It is not armed with superior wit or honesty, but with superior physical strength. I was not born to be forced. I will breathe after my own fashion. Let us see who is the strongest. What force has a multitude? They only can force me who obey a higher law than I. They force me to become like themselves. I do not hear of men being forced to have this way or that by masses of men. What sort of life were that to live? When I meet a government which says to me, "Your money or your life," why should I be in haste to give it my money? It may be in a great strait, and not know what to do: I cannot help that. It must help itself; do as I do. It is not worth the while to snivel about it. I am not responsible for the successful working of the machinery of society. I am not the son of the engineer. I perceive that, when an acorn and a chestnut fall side by side, the one does not remain inert to make way for the other, but both obey their own laws, and spring and grow and flourish as best they can, till one, perchance, overshadows and destroys the other. If a plant cannot live according to its nature, it dies; and so a man. The night in prison was novel and interesting enough. The prisoners in their shirt-sleeves were enjoying a chat and the evening air in the doorway, when I entered. But the jailer said, "Come, boys, it is time to lock up"; and so they dispersed, and I heard the sound of their steps returning into the hollow apartments. My room-mate was introduced to me by the jailer as "a first-rate fellow and a clever man." When the door was locked, he showed me where to hang my hat, and how he managed matters there. The rooms were whitewashed once a month; and this one, at least, was the whitest, most simply furnished, and probably the neatest apartment in the town. He naturally wanted to know where I came from, and what brought me there; and, when I had told him, I asked him in my turn how he came there, presuming him to be an honest man, of course; and, as the world goes, I believe he was. "Why," said he, "they accuse me of burning a barn; but I never did it." As near as I could discover, he had probably gone to bed in a barn when drunk, and smoked his pipe there; and so a barn was burnt. He had the reputation of being a clever man, had been there some three months waiting for his trial to come on, and would have to wait as much longer; but he was quite domesticated and contented, since he got his board for nothing, and thought that he was well treated. He occupied one window, and I the other; and I saw that if one stayed there long, his principal business would be to look out the window. I had soon read all the tracts that were left there, and examined where former prisoners had broken out, and where a grate had been sawed off, and heard the history of the various occupants of that room; for I found that even here there was a history and a gossip which never circulated beyond the walls of the jail. Probably this is the only house in the town where verses are composed, which are afterward printed in a circular form, but not published. I was shown quite a long list of verses which were composed by some young men who had been detected in an attempt to escape, who avenged themselves by singing them. I pumped my fellow-prisoner as dry as I could, for fear I should never see him again; but at length he showed me which was my bed, and left me to blow out the lamp. It was like travelling into a far country, such as I had never expected to behold, to lie there for one night. It seemed to me that I never had heard the town clock strike before, nor the evening sounds of the village; for we slept with the windows open, which were inside the grating. It was to see my native village in the light of the Middle Ages, and our Concord was turned into a Rhine stream, and visions of knights and castles passed before me. They were the voices of old burghers that I heard in the streets. I was an involuntary spectator and auditor of whatever was done and said in the kitchen of the adjacent village inn- a wholly new and rare experience to me. It was a closer view of my native town. I was fairly inside of it. I never had seen its institutions before. This is one of its peculiar institutions; for it is a shire town. I began to comprehend what its inhabitants were about. In the morning, our breakfasts were put through the hole in the door, in small oblong-square tin pans, made to fit, and holding a pint of chocolate, with brown bread, and an iron spoon. When they called for the vessels again, I was green enough to return what bread I had left; but my comrade seized it, and said that I should lay that up for lunch or dinner. Soon after he was let out to work at haying in a neighboring field, whither he went every day, and would not be back till noon; so he bade me good-day, saying that he doubted if he should see me again. When I came out of prison- for some one interfered, and paid that tax- I did not perceive that great changes had taken place on the common, such as he observed who went in a youth and emerged a tottering and gray-headed man; and yet a change had to my eyes come over the scene- the town, and State, and country- greater than any that mere time could effect. I saw yet more distinctly the State in which I lived. I saw to what extent the people among whom I lived could be trusted as good neighbors and friends; that their friendship was for summer weather only; that they did not greatly propose to do right; that they were a distinct race from me by their prejudices and superstitions, as the Chinamen and Malays are; that in their sacrifices to humanity they ran no risks, not even to their property; that after all they were not so noble but they treated the thief as he had treated them, and hoped, by a certain outward observance and a few prayers, and by walking in a particular straight though useless path from time to time, to save their souls. This may be to judge my neighbors harshly; for I believe that many of them are not aware that they have such an institution as the jail in their village. It was formerly the custom in our village, when a poor debtor came out of jail, for his acquaintances to salute him, looking through their fingers, which were crossed to represent the grating of a jail window, "How do ye do?" My neighbors did not thus salute me, but first looked at me, and then at one another, as if I had returned from a long journey. I was put into jail as I was going to the shoemaker's to get a shoe which was mended. When I was let out the next morning, I proceeded to finish my errand, and, having put on my mended shoe, joined a huckleberry party, who were impatient to put themselves under my conduct; and in half an hour- for the horse was soon tackled- was in the midst of a huckleberry field, on one of our highest hills, two miles off, and then the State was nowhere to be seen. This is the whole history of "My Prisons." I have never declined paying the highway tax, because I am as desirous of being a good neighbor as I am of being a bad subject; and as for supporting schools, I am doing my part to educate my fellow-countrymen now. It is for no particular item in the tax-bill that I refuse to pay it. I simply wish to refuse allegiance to the State, to withdraw and stand aloof from it effectually. I do not care to trace the course of my dollar, if I could, till it buys a man or a musket to shoot one with- the dollar is innocent- but I am concerned to trace the effects of my allegiance. In fact, I quietly declare war with the State, after my fashion, though I will still make what use and get what advantage of her I can, as is usual in such cases. If others pay the tax which is demanded of me, from a sympathy with the State, they do but what they have already done in their own case, or rather they abet injustice to a greater extent than the State requires. If they pay the tax from a mistaken interest in the individual taxed, to save his property, or prevent his going to jail, it is because they have not considered wisely how far they let their private feelings interfere with the public good. This, then, is my position at present. But one cannot be too much on his guard in such a case, lest his action be biased by obstinacy or an undue regard for the opinions of men. Let him see that he does only what belongs to himself and to the hour. I think sometimes, Why, this people mean well, they are only ignorant; they would do better if they knew how: why give your neighbors this pain to treat you as they are not inclined to? But I think again, This is no reason why I should do as they do, or permit others to suffer much greater pain of a different kind. Again, I sometimes say to myself, When many millions of men, without heat, without ill will, without personal feeling of any kind, demand of you a few shillings only, without the possibility, such is their constitution, of retracting or altering their present demand, and without the possibility, on your side, of appeal to any other millions, why expose yourself to this overwhelming brute force? You do not resist cold and hunger, the winds and the waves, thus obstinately; you quietly submit to a thousand similar necessities. You do not put your head into the fire. But just in proportion as I regard this as not wholly a brute force, but partly a human force, and consider that I have relations to those millions as to so many millions of men, and not of mere brute or inanimate things, I see that appeal is possible, first and instantaneously, from them to the Maker of them, and, secondly, from them to themselves. But if I put my head deliberately into the fire, there is no appeal to fire or to the Maker of fire, and I have only myself to blame. If I could convince myself that I have any right to be satisfied with men as they are, and to treat them accordingly, and not according, in some respects, to my requisitions and expectations of what they and I ought to be, then, like a good Mussulman and fatalist, I should endeavor to be satisfied with things as they are, and say it is the will of God. And, above all, there is this difference between resisting this and a purely brute or natural force, that I can resist this with some effect; but I cannot expect, like Orpheus, to change the nature of the rocks and trees and beasts. I do not wish to quarrel with any man or nation. I do not wish to split hairs, to make fine distinctions, or set myself up as better than my neighbors. I seek rather, I may say, even an excuse for conforming to the laws of the land. I am but too ready to conform to them. Indeed, I have reason to suspect myself on this head; and each year, as the tax-gatherer comes round, I find myself disposed to review the acts and position of the general and State governments, and the spirit of the people, to discover a pretext for conformity. "We must affect our country as our parents, And if at any time we alienate Our love or industry from doing it honor, We must respect effects and teach the soul Matter of conscience and religion, And not desire of rule or benefit." I believe that the State will soon be able to take all my work of this sort out of my hands, and then I shall be no better a patriot than my fellow-countrymen. Seen from a lower point of view, the Constitution, with all its faults, is very good; the law and the courts are very respectable; even this State and this American government are, in many respects, very admirable, and rare things, to be thankful for, such as a great many have described them; but seen from a point of view a little higher, they are what I have described them; seen from a higher still, and the highest, who shall say what they are, or that they are worth looking at or thinking of at all? However, the government does not concern me much, and I shall bestow the fewest possible thoughts on it. It is not many moments that I live under a government, even in this world. If a man is thought-free, fancy-free, imagination-free, that which is not never for a long time appearing to be to him, unwise rulers or reformers cannot fatally interrupt him. I know that most men think differently from myself; but those whose lives are by profession devoted to the study of these or kindred subjects content me as little as any. Statesmen and legislators, standing so completely within the institution, never distinctly and nakedly behold it. They speak of moving society, but have no resting-place without it. They may be men of a certain experience and discrimination, and have no doubt invented ingenious and even useful systems, for which we sincerely thank them; but all their wit and usefulness lie within certain not very wide limits. They are wont to forget that the world is not governed by policy and expediency. Webster never goes behind government, and so cannot speak with authority about it. His words are wisdom to those legislators who contemplate no essential reform in the existing government; but for thinkers, and those who legislate for all time, he never once glances at the subject. I know of those whose serene and wise speculations on this theme would soon reveal the limits of his mind's range and hospitality. Yet, compared with the cheap professions of most reformers, and the still cheaper wisdom and eloquence of politicians in general, his are almost the only sensible and valuable words, and we thank Heaven for him. Comparatively, he is always strong, original, and, above all, practical. Still, his quality is not wisdom, but prudence. The lawyer's truth is not Truth, but consistency or a consistent expediency. Truth is always in harmony with herself, and is not concerned chiefly to reveal the justice that may consist with wrong-doing. He well deserves to be called, as he has been called, the Defender of the Constitution. There are really no blows to be given by him but defensive ones. He is not a leader, but a follower. His leaders are the men of '87- "I have never made an effort," he says, "and never propose to make an effort; I have never countenanced an effort, and never mean to countenance an effort, to disturb the arrangement as originally made, by which the various States came into the Union." Still thinking of the sanction which the Constitution gives to slavery, he says, "Because it was a part of the original compact- let it stand." Notwithstanding his special acuteness and ability, he is unable to take a fact out of its merely political relations, and behold it as it lies absolutely to be disposed of by the intellect- what, for instance, it behooves a man to do here in America today with regard to slavery- but ventures, or is driven, to make some such desperate answer as the following, while professing to speak absolutely, and as a private man- from which what new and singular code of social duties might be inferred? "The manner," says he, "in which the governments of those States where slavery exists are to regulate it is for their own consideration, under their responsibility to their constituents, to the general laws of propriety, humanity, and justice, and to God. Associations formed elsewhere, springing from a feeling of humanity, or any other cause, have nothing whatever to do with it. They have never received any encouragement from me, and they never will." They who know of no purer sources of truth, who have traced up its stream no higher, stand, and wisely stand, by the Bible and the Constitution, and drink at it there with reverence and humility; but they who behold where it comes trickling into this lake or that pool, gird up their loins once more, and continue their pilgrimage toward its fountain-head. No man with a genius for legislation has appeared in America. They are rare in the history of the world. There are orators, politicians, and eloquent men, by the thousand; but the speaker has not yet opened his mouth to speak who is capable of settling the much-vexed questions of the day. We love eloquence for its own sake, and not for any truth which it may utter, or any heroism it may inspire. Our legislators have not yet learned the comparative value of free trade and of freedom, of union, and of rectitude, to a nation. They have no genius or talent for comparatively humble questions of taxation and finance, commerce and manufactures and agriculture. If we were left solely to the wordy wit of legislators in Congress for our guidance, uncorrected by the seasonable experience and the effectual complaints of the people, America would not long retain her rank among the nations. For eighteen hundred years, though perchance I have no right to say it, the New Testament has been written; yet where is the legislator who has wisdom and practical talent enough to avail himself of the light which it sheds on the science of legislation? The authority of government, even such as I am willing to submit to- for I will cheerfully obey those who know and can do better than I, and in many things even those who neither know nor can do so well- is still an impure one: to be strictly just, it must have the sanction and consent of the governed. It can have no pure right over my person and property but what I concede to it. The progress from an absolute to a limited monarchy, from a limited monarchy to a democracy, is a progress toward a true respect for the individual. Even the Chinese philosopher was wise enough to regard the individual as the basis of the empire. Is a democracy, such as we know it, the last improvement possible in government? Is it not possible to take a step further towards recognizing and organizing the rights of man? There will never be a really free and enlightened State until the State comes to recognize the individual as a higher and independent power, from which all its own power and authority are derived, and treats him accordingly. I please myself with imagining a State at least which can afford to be just to all men, and to treat the individual with respect as a neighbor; which even would not think it inconsistent with its own repose if a few were to live aloof from it, not meddling with it, nor embraced by it, who fulfilled all the duties of neighbors and fellow-men. A State which bore this kind of fruit, and suffered it to drop off as fast as it ripened, would prepare the way for a still more perfect and glorious State, which also I have imagined, but not yet anywhere seen. THE END"

📚 Advanced Vocabulary — Notes 1–20 1. Abundant — plentiful; a lot 2. Accurate — correct; exact 3. Admire — respect someone/something 4. Adverse — harmful; negative 5. Agile — quick and able to move easily 6. Alleviate — reduce; make less serious 7. Ambiguous — unclear; can have different meanings 8. Amiable — friendly and pleasant 9. Ample — enough; more than enough 10. Anecdote — a short story about an event 11. Anticipate — expect something to happen 12. Apparent — obvious; easy to see 13. Apprehend — understand 14. Arduous — very difficult; requiring effort 15. Articulate — express ideas clearly 16. Assert — state something confidently 17. Astute — clever; able to understand things quickly 18. Authentic — real; genuine 19. Avid — very enthusiastic about something 20. Benevolent — kind; wanting to help others 21–40 21. Bliss — great happiness 22. Boast — talk proudly about yourself 23. Bold — brave; confident 24. Brief — short 25. Candid — honest and direct 26. Capable — skilled; able to do something 27. Cautious — careful to avoid danger or mistakes 28. Cease — stop 29. Clarify — make something easier to understand 30. Coherent — logical and easy to understand 31. Compassion — kindness toward someone who is suffering 32. Competent — able; having the necessary skills 33. Comprehend — understand 34. Concise — brief but clear 35. Confident — self-assured; believing in yourself 36. Conquer — defeat; overcome 37. Conscious — aware 38. Consistent — regular; staying the same 39. Constructive — helpful; intended to improve something 40. Contemplate — think deeply about something 41–60 41. Convince — persuade someone to believe/do something 42. Courageous — brave 43. Credible — believable; trustworthy 44. Crucial — extremely important 45. Cultivate — develop or improve 46. Curious — eager to know or learn 47. Dazzling — extremely bright or impressive 48. Decisive — firm; able to make decisions 49. Dedicate — devote time/effort to something 50. Deliberate — careful and intentional 51. Delight — great pleasure or happiness 52. Dense — thick; closely packed 53. Depict — describe or show 54. Deteriorate — become worse 55. Diligent — hardworking and careful 56. Discreet — careful; not attracting attention 57. Distinct — clearly different 58. Diverse — varied; including different types 59. Dynamic — energetic; active 60. Eager — very excited or ready to do something 61–80 61. Eloquent — fluent and persuasive in speaking/writing 62. Elusive — difficult to find, catch, or understand 63. Embark — begin something new 64. Eminent — famous and respected 65. Empathy — understanding another person’s feelings 66. Endure — bear; tolerate something difficult 67. Enhance — improve 68. Enormous — extremely large 69. Enthusiastic — very excited/interested 70. Essential — absolutely necessary 71. Ethical — morally right 72. Evaluate — judge the quality/value of something 73. Evident — clear; obvious 74. Exceptional — unusually good; outstanding 75. Exaggerate — make something seem bigger/more important than it really is 76. Exquisite — extremely beautiful 77. Extensive — large or wide-ranging 78. Fabricate — invent or make up 79. Fascinate — interest someone greatly 80. Feasible — possible; practical 81–100 81. Fierce — strong; aggressive 82. Flourish — grow or develop well 83. Fortunate — lucky 84. Fragile — delicate; easily damaged 85. Frequent — happening often 86. Fundamental — basic; essential 87. Generous — willing to give or share 88. Genuine — real; sincere 89. Glorious — magnificent; wonderful 90. Grateful — thankful 91. Harmonious — peaceful; working well together 92. Hesitate — pause because you are unsure 93. Humble — modest; not thinking you are better than others 94. Ideal — perfect or most suitable 95. Identical — exactly the same 96. Illustrate — explain or show with an example 97. Immense — extremely large 98. Imminent — about to happen 99. Impart — give or communicate information 100. Imply — suggest without saying directly 101–120 101. Impressive — remarkable; causing admiration 102. Incline — tend toward something; be likely to 103. Incredible — amazing; difficult to believe 104. Indicate — show or point out 105. Indifferent — uninterested; not caring 106. Industrious — hardworking 107. Inevitable — unavoidable; certain to happen 108. Influence — affect someone or something 109. Ingenious — clever and creative 110. Innocent — not guilty 111. Inspire — motivate someone 112. Intense — very strong 113. Interpret — explain the meaning of something 114. Intricate — complicated; having many details 115. Intuitive — understood naturally without needing much explanation 116. Irrelevant — not related to the topic 117. Judicious — wise; showing good judgment 118. Keen — eager; very interested 119. Legitimate — lawful; valid 120. Liberal — open-minded; accepting different ideas 🧠 Mini study trick Pour chaque mot, essaie de mémoriser 3 choses : Word → Simple meaning → Example Example: Alleviate → reduce → Medicine can alleviate pain.

amino acid structure, 3 letter, 1 letter and their pH and pKa (pKa for certain groups)

Origins and Insertions of certain muscles