LATE MEDIEVAL AND EARLY RENAISSANCE NORTHERN EUROPE FRAMING THE ERA Rogier van der Weyden and Saint Luke In the 15th century, Flanders—a region corresponding to what is today Belgium, the Netherlands, Luxembourg, and part of northern France (map 20-1)—enjoyed widespread prosperity. Successful merchants and craft guilds joined the clergy and royalty in commissioning artists to produce works for both public and private venues. Especially popular were paintings prepared using the recently per-fected medium of oil-based pigments, which soon became the favored painting medium throughout Europe. One of the early masters of oil painting was Rogier van der Weyden (ca. 1400–1464) of Tournai in present-day Belgium. Rogier made Brussels his home in 1435 and soon thereafter painted Saint Luke Drawing the Virgin (fig. 20-1), probably for the city’s artists’ guild, the Guild of Saint Luke. Luke was the patron saint of artists because legend said he had painted a portrait of the Virgin Mary (see “Early Christian Saints,” pages 246–247). Rogier’s subject was therefore perfectly suited for the head-quarters of a painters’ guild. It shows Luke (his identifying attribute, the ox, is at the right; see “The Four Evangelists,” page 331) at work in the kind of private residence that wealthy Flemish merchants of this era owned. Mary has miraculously appeared before Luke and invited him to paint her portrait as she nurses her son. The saint begins the process by making a preliminary drawing, the same process Rogier himself would have used when he began this commission. The painting thus not only honors Luke but also pays tribute to the profession of painting in Flanders (see “The Artist’s Profession in Flanders,” page 580) by documenting the preparatory work required before artists can begin painting the figures and setting. The subject also draws attention to the venerable history of portrait painting. A rare genre dur-ing the Middle Ages, portraiture became a major source of income for Flemish artists, and Rogier was one of the best portrait painters (fig. 20-12A) in Flanders. In fact, some scholars have suggested that Rogier’s Saint Luke is a self-portrait, identifying the painter with the first Christian artist and under-scoring the holy nature of painting. Saint Luke Drawing the Virgin is also emblematic of 15th-century Flemish painting in aiming to record every detail of a scene with loving fidelity to optical appearance, seen here in the rich fabrics, the patterned floor, and the landscape visible through the window. Also characteristic of Flemish art is the imbuing of many of the painting’s details with symbolic significance. For example, the carved armrest of the Virgin’s bench depicts Adam, Eve, and the serpent, reminding the viewer that Mary is the new Eve and Christ the new Adam who will redeem humanity from Adam and Eve’s Original Sin. 567 Copyright 2021 Cengage Learning. All NORTHERN EUROPE IN THE 15TH CENTURY As the 15th century opened, Rome and Avignon were still the official seats of two competing popes (see “The Great Schism,” page 423), and the Hundred Years’ War (1337–1453) between France and England still raged. The general European movement toward centralized royal governments, begun in the 12th century, continued apace, with a corresponding waning of feudalism. A ris-ing merchant class, whose success depended on individual effort and talent instead of inherited nobility, spawned a new economic system—the early stage of European capitalism. In response to the financial requirements of trade, new credit and exchange systems created a network of enterprising European cities. Trade in money accompanied trade in commodities, and the former financed industry. Both were in the hands of international banking compa-nies, such as those of Jacques Coeur in Bourges (fig. 13-31) and the Medici in Florence (see “The Medici,” page 593). In 1460, Flemish entrepreneurs established the first international commercial stock North Sea E NG L AN D London English Channel Haarlem Ghent Bruges Tournai Amsterdam Nijmegen Louvain Cologne Antwerp Brussels Creglingen Würzburg Paris F R A N C E Tours POITOU Poitiers ATLANTIC OCEAN AUVERGNE Avignon Florence Lucca PAPAL STATES S PA I N 0 0 150 150 300 kilometers Mediterranean Sea 300 miles Rome Tyrrhenian Sea Adriatic Sea OT TOMAN EMP I R E Bourges BERRY Melun Nemours Colmar Dijon Beaune Lake Geneva Geneva Venice Nancy Strasbourg Buxheim H O L Y R O M A N E M P I R E Nuremberg H U NGA RY Kraków Magdeburg PO L AN D exchange in Antwerp. In fact, the French word for stock market (bourse) comes from the name of the van der Beurse family of Bru-ges, the wealthiest city in 15th-century Flanders. Art also thrived in northern Europe during this time, under royal, ducal, church, and private patronage. Two developments in particular were of special significance: the adoption by Rogier van der Weyden (fig. 20-1) and his contemporaries of oil-based pig-ment as the preferred medium for painting, and the blossoming of printmaking as a major art form, which followed Johannes Guten-berg’s invention of moveable type and the printing press. These new media had a dramatic influence on artistic production both north and south of the Alps. THE FRENCH DUCAL COURTS In the 15th century, Flanders was not an independent state but a region under the control of the duke of Burgundy, the ruler of the fertile east-central region of France still famous for its wines (map 20-1). Duke Philip the Bold (r. 1363–1404) was one of four MAP 20-1 France, the duchy of Burgundy, and the Holy Roman Empire in 1477. Late MedievaL and earLy renaissance northern europe 1395–1425 ■ Claus Sluter carves life-size statues of biblical figures with portraitlike features, and Jacques de Baerze and Melchior Broederlam carve and paint the Retable de Champmol for Philip the Bold, duke of Burgundy ■ The Limbourg brothers expand the illusionistic capabilities of manuscript illumination for Jean, duke of Berry 1425–1450 ■ In Flanders, Robert Campin, Jan van Eyck, and Rogier van der Weyden use oil paints to record the exact surface appearance of objects, fabrics, and faces ■ ■ Flemish painters establish portraiture as a major art form German graphic artists pioneer wood-cut printing, making art affordable to the masses 1450–1475 ■ The second generation of Flemish master painters—Petrus Christus, Dieric Bouts, and Hugo van der Goes—continues to use oil paints for altarpieces featuring naturalistic repre-sentations of religious themes ■ In Germany, Johannes Gutenberg invents moveable type and prints the first Bibles on a letterpress 1475–1500 ■ In Flanders, Hans Memling specializes in paintings of the Madonna and Child and portraits of wealthy merchants ■ The Late Gothic style lingers in Ger-many in the large wood altarpieces carved by Veit Stoss and Tilman Riemenschneider ■ Martin Schongauer becomes the first Northern European master of metal engraving sons of King John II (r. 1350–1364) of France. In 1369, Philip mar-ried Margaret de Mâle, the daughter of the count of Flanders, and acquired territory in the Netherlands. Thereafter, the major source of Burgundian wealth was Bruges, the city that made Burgundy a powerful rival of France, which then, as in the Gothic age, was a much smaller kingdom geographically than the modern nation-state. Bruges initially derived its wealth from the wool trade, but soon expanded into banking, becoming the financial clearinghouse for all of northern Europe. Indeed, Bruges so dominated Flanders that the duke of Burgundy eventually chose to make the city his capital and moved his court there from Dijon. Due to the expanded territory and the prosperity of the duchy of Burgundy, Philip the Bold and his successors were probably the most powerful northern European rulers during the first three quarters of the 15th century. Although members of the French royal family, they usually supported England during the Hundred Years’ War because they relied on English raw materials for their wool industry. At times, the dukes of Burgundy controlled much of northern France, including Paris, the seat of the French monarchy. At the height of Burgundian power, the ducal lands stretched from the Rhône River to the North Sea. chartreuse de champmol The great wealth the Burgundy court acquired enabled it to become a significant patron of the arts. Burgundian dukes fully appreciated that artworks could support their dynastic and political goals as well as adorn their castles and townhouses. Philip the Bold’s grandest artistic enterprise was the Chartreuse de Champmol, near Dijon. A chartreuse (“charter house” in English) is a Carthusian monastery. The Carthusian order, founded by Saint Bruno (ca. 1030–1101) in the late 11th century at Chartreuse, near Grenoble in southeastern France, consisted of monks who devoted their lives to solitary liv-ing and prayer. Unlike monastic orders that earned income from farming and other work, the Carthusians generated no revenues. Philip’s generous endowment at Champmol was therefore the sole funding for an ambitious artistic program inspired by the French royal abbey at Saint-Denis (see “Abbot Suger and the Rebuilding of Saint-Denis,” page 383, and fig. 13-1), the burial site of the French kings. The duke’s choice for architect was Drouet de Dammartin, who had worked for his brother King Charles V (r. 1364–1380) on the Louvre (fig. 20-6), the French royal palace in Paris. In 1372, Philip appointed as chief sculptor the Netherlandish master Jean de Marville (d. 1389), who had also worked for Charles V, but at Rouen Cathedral. Emulating the royal burials at Saint-Denis, Philip decided to create at the Dijon chartreuse a ducal mausoleum that would serve both as a means of securing salvation in perpetuity for the ducal family (the monks prayed continuously for their souls) and as a dynastic symbol of Burgundian power. Claus Sluter. In 1389, following the death of Jean de Marville, Philip placed the Neth-erlandish sculptor Claus Sluter (ca. 1360–1406) of Haarlem in charge of the sculptural program (figs. 20-2 and 20-2a). Sluter had joined the Chartreuse de Champmol sculp-ture workshop as Jean’s assistant in 1385. For the portal (fig. 20-2A) of the monastery’s chapel, Sluter’s workshop produced stat-ues of the duke and his wife kneeling before the Virgin and Child. For the cloister, Sluter designed a large sculptural fountain located in a well (fig. 20-2). The well itself served as a water source for the monastery, but Sluter’s fountain did not spout water because the Carthusian commitment to silence and prayer would have precluded anything producing sound. The Well of Moses features statues of Moses and five other Old 20-2a Sluter, Chartreuse de Champmol portal, 1390–1393. 1 ft. 20-2 Claus Sluter, Well of Moses, Chartreuse de Champmol, Dijon, France, 1396–1406. Asnières limestone, painted and gilded by Jean Malouel, Moses 69 high. The Well of Moses, a symbolic fountain of life made for the duke of Bur-gundy, originally supported a sculpted Crucifixion group. Sluter’s figures recall French Gothic jamb statues, but are far more realistic. Testament prophets (David, Daniel, Isaiah, Jeremiah, and Zachariah) ringing a base that once supported a 25-foot-tall group of Christ on the cross mourned by Mary Magdalene, joined perhaps by the Vir-gin Mary and John the Evangelist. Art historians usually describe the Well of Moses as a fons vitae, a fountain of everlasting life, in which the blood of the crucified Christ, symbolized by water, flows down into a basin, and anyone who drinks from the fountain is redeemed. Sluter incorporated The six prophets have almost portraitlike features and distinct individual personalities and costumes. For example, David is an elegantly garbed Gothic king and Moses an elderly horned prophet (compare fig. 12-38) with a waist-length beard. Sluter intensely studied the natural appearance of faces and fabrics in order to sculpt the biblical figures in minute detail. Heavy draperies with voluminous folds swathe the life-size statues. Sluter succeeded in making their difficult, complex surfaces seem remarkably natural-istic. He enhanced this effect by skillfully differentiating textures, from coarse drapery to smooth flesh and silky hair. Paint, much of which has flaked off, further augmented the naturalism of the figures. (The painter was Jean Malouel [ca. 1365–1415], another Netherlandish master.) This fascination with the specific and tan-gible in the visible world became one of the chief characteristics of 15th-century Flemish art. Retable de Champmol. Philip the Bold also commissioned a major altarpiece—the Retable de Champmol (figs. 20-3 and 20-4)—for the main altar in the chapel of the Chartreuse. A collaborative project between two Flemish artists, this altarpiece consisted of a 1 ft. 20-3 Jacques de Baerze, Retable de Champmol (open), from the chapel of the Chartreuse de Champmol, Dijon, France, installed 1399. Wood, center section 59 5 3 40 × 89 3 1 40. Musée des Beaux-Arts, Dijon. Worshipers could view the interior of the Champmol altarpiece on Sundays and feast days. Jacques de Baerze carved three scenes of Jesus’s life centered on the Crucifixion, a fitting backdrop for the Eucharist. 20-4 Melchior Broederlam, Retable de Champmol (closed), from the chapel of the Chartreuse de Champmol, Dijon, France, installed 1399. Oil and tempera on wood, each wing 59 5 3 Arts, Dijon. 40 × 49 1 1 40. Musée des Beaux-This early example of oil painting attempts to represent the three-dimensional world on a two-dimensional surface, but the gold background and flat halos recall medieval pictorial conventions. 1 the symbolism of the fons vitae in his waterless fountain, in which the viewer must imagine Christ’s blood stream-ing down over grieving angels and the Savior’s prophetic predeces-sors. Although the models for the Old Testament figures may have been French Gothic cathedral portal statues, as was certainly the case for the Dijon chapel statues (fig. 20-2A), the inspiration for the Well of Moses prophets may have come more directly from contempora-neous mystery plays in which actors portraying prophets frequently delivered commentaries on events in Christ’s life. large sculptured shrine (fig. 20-3) by Jacques de Baerze (active ca. 1384–1399) and a pair of painted exterior panels (fig. 20-4) by Melchior Broederlam (active ca. 1387–1409). Altarpieces were a major art form north of the Alps during the late 14th and the 15th century. From their position behind the altar, they served as backdrops for the Mass, the ritual celebration of the Holy Eucharist. At the Last Supper, Christ commanded his apostles to reenact the Eucharistic meal and repeat in memory of him the communion credo, wherein he tenders his body to eat and his blood to drink (see “The Life of Jesus in Art,” pages 244–245). This act serves as the nucleus of the Mass, which involves this reenactment as well as prayer and contemplation of the word of God. Because the Mass involves not only a memorial rite but Christian doctrine as well, art has traditionally played an important role in giving visual form to complex theological concepts for the faithful. Like the narrative reliefs in medieval church portals, these altarpieces had an important teaching function, especially for the illiterate. By reinforcing Church doctrines visually, they also stimulated devotion. These altarpieces most often took the form of polyptychs—hinged multipaneled paintings or multiple carved relief panels. The hinges enabled the clergy to close the polyptych’s side wings over the central panel(s). Because artists decorated both the exterior and inte-rior of the altarpieces, this multi-image format provided the opportu-nity to construct narratives through a sequence of images. Although concrete information is lacking about when the clergy opened and closed the altarpieces, the wings probably normally remained closed but were opened on Sundays and feast days. On this schedule, view-ers could have seen both the interior and exterior—diverse imagery at various times according to the liturgical calendar. Given their placement in churches as backdrops to the Mass, it is not surprising that among the many kinds of scenes depicted on altarpieces, themes directly related to Christ’s sacrifice are com-mon. The Champmol altarpiece, or retable, for example, features sculpted passion scenes on the interior: the Crucifixion (at the cen-ter) and (at left and right respectively) the adoration of the magi and the entombment of Christ, with rows of saints on the wings, all framed by delicate pinnacles, tracery, and lancets. The carved wood narratives span the full life cycle of Jesus from his birth to his death and burial, with the figure of the Savior on the cross forming a fit-ting backdrop to the Eucharist. On the Champmol retable’s painted wings (fig. 20-4), Broeder-lam depicted the Annunciation and Visitation (on the left panel) and the presentation in the temple and flight into Egypt (on the right). Thus Broederlam’s painted images on the altarpiece’s exterior gave a fuller account of the Savior’s early life and set the stage for de Baerze’s passion scenes when the wings were folded back to reveal the sculpted narratives. The two painted wings include both landscape and inte-rior scenes. Broederlam depicted the buildings in both Romanesque and Gothic styles. Scholars have suggested that the juxtaposition of different architectural styles in the left panel is symbolic. The rotunda (round building, usually with a dome, a common antique type) refers to the Old Testament, whereas the “modern” Gothic porch with its lancet windows and tracery relates to the New Testament. In the right panel, a statue of a Greco-Roman god falls from the top of a column as the holy family approaches. These and other details announce the coming of the new order under Christ. Stylistically, Broederlam’s panels are a mixture of three-dimen-sional rendition of the landscape and buildings with a solid gold background and flat gold haloes for the holy figures, regardless of the positions of their heads. Despite these lingering medieval pictorial conventions, the altarpiece is an early example of many of the artistic developments that preoccupied European artists throughout the 15th century, especially the illusionistic depiction of three-dimensional objects and the naturalistic representation of landscape. Oil Painting. The Retable de Champmol also foreshadowed an-other significant development in 15th-century art: the widespread adoption of oil paints, which Broederlam mixed with tempera in this early example (see “Tempera and Oil Painting,” page 574). Oil paints facilitated the exactitude in rendering details so charac-teristic of Northern European painting. Although the Italian biogra-pher Giorgio Vasari (see “Giorgio Vasari’s Lives,” page 648) and other 16th-century commentators credited the Flemish master Jan van Eyck (discussed later in this chapter) with the invention of oil paint-ing, recent evidence has revealed that oil paints had been known for some time, well before Melchior Broederlam liberally used oils for Philip the Bold’s Dijon altarpiece. Flemish painters built up their pic-tures by superimposing translucent paint layers on a layer of under-painting, which in turn had been built up from a carefully planned drawing (compare Saint Luke at work in fig. 20-1) made on a panel prepared with a white ground. With the oil medium, artists could create richer colors and more subtle gradations of tone than previ-ously possible, giving their paintings the illusion of glowing light and glistening surfaces. These traits differed significantly from the high-keyed color, sharp light, and rather matte (dull) surface of tempera. The brilliant and versatile oil medium suited perfectly the formal intentions of the generation of Flemish painters after Broederlam, who aimed for sharply focused clarity of detail in their representation of objects ranging in scale from large to almost invisible. Manuscript painting During the 15th century, Northern European artists built on the achievements of Gothic painters (see “Gothic Book Production,” page 402) and produced exquisitely refined illuminated manu-scripts. Among the most significant developments in manuscript painting was a new interest in representing fully modeled figures moving freely in convincing three-dimensional settings. Increased contact with Italy, where Renaissance artists had revived the picto-rial principles of classical antiquity, may have influenced Northern painters’ interest in illusionism. Limbourg Brothers. The most innovative early-15th-century manuscript illuminators were the three Limbourg brothers—Pol, Herman, and Jean—from Nijmegen in the Netherlands. They were nephews of Jean Malouel, the court artist of Philip the Bold, who painted Sluter’s Well of Moses statues (fig. 20-2). Following in the footsteps of earlier illustrators such as Jean Pucelle (figs. 13-36 and 13-36A), the Limbourg brothers expanded the illusionistic capabili-ties of illumination. Trained in the Netherlands, the brothers moved to Paris no later than 1402, and between 1405 and their death in 1416 (probably from the plague), they worked in Paris and Bourges for Jean, duke of Berry (r. 1360–1416) and brother of Philip the Bold of Burgundy and King Charles V (r. 1364–1380) of France. Jean ruled the western French regions of Berry, Poitou, and Auvergne (map 20-1). The duke was an avid art patron and focused on collecting manuscripts, jewels, and rare artifacts. Among the more than 300 manuscripts he owned were Pucelle’s Belleville Breviary (fig. 13-36) and the Hours ofJeanne d’Evreux (fig. 13-36A) as well as Les Très Riches Heures du Duc de Berry (The Very Sumptuous Hours of the Duke of Berry; figs. 20-5 and 20-6), which he commissioned the Limbourg brothers to produce. A Book of Hours, like a breviary, was The French Ducal Courts Limbourg brothers (Pol, Herman, Jean), January, from Les Très Riches Heures du Duc de Berry, 1413–1416. Colors and ink on vellum, 8 7 80 × 5 3 80. Musée Condé, Chantilly. The pictures in Les Très Riches Heures depict characteristic activities of each month. The prominence of genre subjects reflects the increasing inte-gration of religious and secular art in the 15th century. a book used for reciting prayers (see “Medieval Books,” page 324). As prayer books, they replaced the traditional psalters (books of psalms), which were the only liturgical books in private hands until the mid-13th century. Books of Hours contained liturgical passages to be read privately at set times during the day, from matins (dawn prayers) to compline (the last of the prayers recited daily), including the “Office [prayer] of the Blessed Virgin.” An illustrated calendar containing local religious feast days usually preceded the Office of the Blessed Virgin. Penitential psalms, devotional prayers, litanies to the saints, and other prayers, including those of the Holy Cross and for the dead, followed. Books of Hours became favorite possessions of the Northern European aristocracy during the 14th and 15th centuries. These costly books eventually became available to affluent merchants and contributed to the decentralization of religious practice that was one factor in the Protestant Reformation in the early 16th century (see “Luther and the Reformation,” page 692). The full-page calendar pictures of Les Très Riches Heures are the most famous in the history of manuscript illumination. They 20-6 Limbourg brothers (Pol, Herman, Jean), October, from Les Très Riches Heures du Duc de Berry, 1413–1416. Colors and ink on vellum, 8 7 80 × 5 3 80. Musée Condé, Chantilly. The Limbourg brothers were pioneers in expanding the illusionistic capabili-ties of manuscript painting with their care in rendering architectural details and their convincing depiction of cast shadows. represent the 12 months in terms of the associated seasonal tasks, alternating scenes of nobility and peasantry, and featuring the duke’s relationship with his courtiers and peasants. Above each picture is a lunette in which the Limbourgs depicted the zodiac signs and the chariot of the sun as it makes its yearly cycle through the heavens. Beyond its function as a religious book, Les Très Riches Heures also furnishes a picture of life in the territory the duke ruled—a picture designed to flatter the Limbourgs’ patron. For example, the color-ful calendar picture for January (fig. 20-5) portrays a New Year’s reception at court. The duke appears as magnanimous host, his head circled by the fire screen, almost halolike, behind him. His chamberlain stands next to him, urging the guests forward with the words “aproche, aproche,” words that call attention to the Lim-bourgs’ success in creating the illusion of deep spatial recession. The lavish spread of food on the table and the large tapestry on the back wall augment the richness of the setting and the occasion By contrast, the illustration for October (fig. 20-6) focuses on the peasantry. Here, the Limbourg brothers depicted a sower, a man plowing on horseback, and washerwomen, along with city dwell-ers, who promenade in front of the Louvre, the French king’s resi-dence at the time, now one of the world’s great art museums. (Paris was not then the highly populated urban center it is today. Open fields surrounded the royal palace.) The peasants do not appear dis-contented as they go about their various tasks. Surely this imagery flattered the duke’s sense of himself as a compassionate master. The growing artistic interest in naturalism is evident here in the careful way the painter recorded the architectural details of the Louvre and in the convincing shadows of the people and objects (such as the archer scarecrow and the horse) in the scene. As a whole, Les Très Riches Heures reinforced the image of the duke of Berry as a devout man, cultured bibliophile (“lover of books”), sophisticated art patron, and powerful and magnanimous leader. Further, the expanded range of subject matter, especially the prominence of genre subjects in a religious book, reflected the increasing integration of religious and secular concerns in both art and life during the 15th century. Although all three Limbourg brothers worked on Les Très Riches Heures, art historians have never been able to ascertain definitively which brother painted which images. (One scholar has suggested that because the book was left unfinished at the time of the brothers’ deaths, some of the details are the work of a fourth artist, who completed the illustrations around the middle of the century.) Given the common practice of collaboration on artistic projects at this time, however, the determination of specific author-ship is not very important. Together, the Très Riches Heures illumi-nators reoriented the art of manuscript illumination to approximate more closely the art of panel painting, treating the pages of books as if they were windows onto the world of 15th-century Europe. Mary of Burgundy. The Limbourgs’ most accomplished suc-cessor at the end of the century was an anonymous illuminator known as the Master of Mary of Burgundy. Some scholars identify him as Alexander Bening (ca. 1444–1519) of Ghent, a painter in the circle of Hugo van der Goes (fig. 20-16). The two facing pages illustrated here (fig. 20-7) are the opening full-page illumination and one of the daily prayers in the private devotional Book of Hours that belonged to Mary, the last duchess of Burgundy (r. 1477–1482) and daughter of Charles the Bold. She is the elegantly dressed woman sitting in a private chapel with her pet dog on her lap, reading from a prayer book of the same size and format as the one in which her portrait appears. On a ledge to her left are her rosary beads and a tall vase with purple irises—flowers associated tempera and oil painting The generic words paint and pigment encompass a wide range of substances that artists have used through the ages. Fresco aside (see “Fresco Painting,” page 428), during the 14th century, egg tempera was the material of choice for most painters, both in Italy and northern Europe. Tempera consists of egg combined with a wet paste of ground pigment. In his influential 1437 guidebook Il libro dell’arte (The Handbook of Art; see “Imitation and Emulation in Renaissance Art,” page 606), Cennino Cennini (ca. 1370–ca. 1440) noted that artists mixed only the egg yolk with the ground pigment, but analyses of paintings from this period have revealed that some artists chose to use the entire egg. Images painted with tempera have a velvety sheen. Artists usually applied tempera to the painting surface with a light touch because thick application of the pig-ment mixture would result in premature cracking and flaking. Some artists used oil paints (powdered pigments mixed with lin-seed oil) as far back as the eighth century, but not until the early 1400s did oil painting become widespread. Melchior Broederlam (fig. 20-4), Robert Campin (fig. 20-8), and other Flemish artists were among the first to employ oils extensively, often mixing them with tempera, as Broederlam did. (Italian painters soon followed suit, underscoring that artistic exchanges across the Alps went in both directions during the Renaissance.) The discovery of better drying components in the early 15th century enhanced the setting capabilities of oils. Rather than apply these oils in the light, flecked brushstrokes that the tempera technique encouraged, artists laid down the oils in transparent layers, or glazes, over opaque or semiopaque underlayers. In this manner, painters could build up deep and subtly gradated tones through repeated glazing. Unlike works in tempera, whose surface dries quickly due to water evaporation, oils dry more uniformly and slowly, giving the artist time to rework areas. This flexibility must have been particularly appealing to artists who worked very deliberately, such as Campin, Jan van Eyck, Rogier van der Wey-den, and the other Flemish masters discussed in this chapter, as well as the Italian Leonardo da Vinci (figS. 22-2 and 22-5). Leonardo also preferred oil paint because its gradual drying process and consistency enabled him to blend the pigments, thereby creating the impressive sfu-mato (smoky) effect that contributed to his fame. Moreover, while dry-ing, oil paints smooth out, erasing any trace of the brush that applied the paint. Oil paints also produce a glowing surface, creating a rich visual effect unlike the duller sheen of tempera. Both tempera and oils can be applied to various surfaces. Through the early 16th century, wood panels served as the foundation for most paintings. Italians painted on poplar. Northern European artists used oak, lime, beech, chestnut, cherry, pine, and silver fir. Local availability of these timbers determined the choice of wood. Linen canvas became increasingly popular in the late 16th century. Although evidence sug-gests that artists did not intend permanency for their early images on canvas, the material proved particularly useful in areas such as Venice where high humidity warped wood panels and made fresco unfeasible. Furthermore, until artists began to use wood bars to stretch the can-vas to form a taut surface, canvas paintings could be rolled and were lighter and more compact and therefore more easily portable than wood panels. with the Virgin Mary. The masterful representation of rich fabrics, Mary’s transparent veil, and the still life of flowers all attest to this painter’s skill and powers of observation. Even more remarkable is the illuminator’s meticulously detailed depiction of the Gothic church seen through the window of Mary’s chapel, especially because the manuscript page is only half the size of Jan van Eyck’s Madonna in a Church (fig. 20-10A). The scene presented to the viewer through the chapel window within the page’s “window onto the world”—a brilliant conception in itself—is the realization of Mary’s prayers. The duchess has been granted a private audience with the Virgin without any interced-ing priest. She, accompanied by her ladies-in-waiting, kneels before the Virgin, who sits in front of the church altar, attended by angels and holding the Christ Child in her lap. Both holy figures turn their heads to look at the duchess. The illumination has few peers in the history of art as an image of pious devotion. FLANDERS As noted, the greatest single source of income for the Burgundian ducal court came from banking and trade activities in Flanders, ter-ritory that Philip the Bold acquired when he married the Flemish count’s daughter. Flanders was also the leading artistic center of Northern Europe in the 15th century. Master of Flémalle One of the greatest Flemish painters of the generation after Melchior Broederlam was the man known as the Master of Flémalle, whom most art historians identify as Robert Campin (ca. 1375–1444), the leading painter of Tournai, who also worked in the newly popular medium of oil painting (see “Tempera and Oil Painting,” page 574). His most famous work is the Mérode Triptych (fig. 20-8), although it has recently been suggested that the triptych (three-panel painting) is the work of more than one artist and that the wings are a later addition. The question of authorship apart, the painting is one of the many small works of this period produced for private patrons and intended for household prayer. Perhaps the most striking feature of these private devotional images is the integration of religious and secular concerns. For example, artists often presented biblical scenes as taking place in a house (compare fig. 20-1). Religion was such an integral part of Flemish life that separating the sacred from the secular was almost impossible—and undesirable. Furthermore, the presentation in religious art of famil-iar settings and objects no doubt strengthened the direct bond that the patron or viewer felt with biblical figures. The Annunciation, prophesied in Isaiah 7:14, is the subject of the central panel of Campin’s triptych. Unseen by the Virgin, a tiny figure of Christ carrying the cross of his martyrdom and of human salvation enters the room on a ray of light, a potent symbol of the Incarnation and a foreshadowing of what lies ahead for the future Mother of God and her son. The archangel Gabriel approaches Mary, who sits reading inside a well-kept Flemish home. Through the window in the background of the right wing, the viewer sees a local cityscape, as in Rogier van der Weyden’s later Saint Luke (fig. 20-1). The depicted accessories, furniture, and utensils con-firm the locale as Flanders. However, the objects represented are not merely decorative. They also function as religious symbols. The book, extinguished candle, and lilies on the table; the copper basin in the corner niche; the towels, fire screen, and bench all symbolize, in different ways, the Virgin’s purity and her divine mission. In the right panel, Joseph, apparently unaware of the angel’s arrival, has constructed two mousetraps, symbolic of the theologi-cal concept that Christ is bait set in the trap of the world to catch the Devil. The ax, saw, and rod that Campin painted in the fore-ground of Joseph’s workshop not only are tools of the carpenter’s trade but also are mentioned in Isaiah 10:15. In the left panel, the closed garden is symbolic of Mary’s purity, and the flowers Campin included relate to Mary’s virtues, especially humility. The triptych’s donor, Peter Inghelbrecht, a wealthy merchant, and his wife, Margarete Scrynmakers, kneel in the garden and witness the momentous event through an open door. Donor portraits—portraits of the individual(s) who commissioned (or “donated”) the work—became very popular in the 15th century. In this instance, in addi-tion to asking to be represented in their altarpiece, the Inghelbrechts probably specified the subject. Inghelbrecht means “angel bringer,” a reference to Gabriel’s bringing the news of Christ’s birth to Mary in the central panel. Scrynmakers means “cabinet-or shrine-makers,” and probably inspired the workshop scene in the right panel. Jan van eyck In 1425, Jan van Eyck (ca. 1395–1441), the most famous of several internationally renowned Flemish artists, became the court painter of Philip the Good, duke of Burgundy (r. 1419–1467). In 1431, he moved his studio to Bruges, where the duke maintained his official residence. Ghent Altarpiece. The year Jan arrived in Bruges, he set out to complete the Ghent Altarpiece (figs. 20-9 and 20-10), which, according to the dedicatory inscription, his older brother, Hubert van Eyck (ca. 1385–1426), had begun. Given Jan’s stature today, it is noteworthy that the inscription describes Hubert as an artist “than whom there was no greater” and Jan as “his brother, second in art.” The nearly 12-foot-tall Ghent retable is one of the largest of the 15th century. Jodocus Vyd (d. 1439), diplomat-retainer of Philip the Good, and his wife, Elisabeth Borluut (d. 1443), commissioned the polyptych as the centerpiece of the chapel Vyd built in the Ghent church originally dedicated to Saint John the Baptist (since 1540, Saint Bavo Cathedral). Vyd’s largesse and the political and social connections that the Ghent Altarpiece revealed to its audience contributed to Vyd’s appointment as the city’s burgomeister (chief magistrate; mayor) shortly after the unveiling of the work. Two of the exterior panels (fig. 20-9) depict the donors. The husband and wife, in paired niches with Gothic tracery, kneel with their hands clasped in prayer. They gaze piously at two illusionistically rendered statues (painted in grisaille—that is, solely in gray tones to imitate stone) that reflect the innovative style of Claus Sluter (figs. 20-2 and 20-2A). The sculptures represent Ghent’s patron saint, John the Baptist, and John the Evangelist, who was probably Vyd’s patron saint. The Annunciation appears on the upper register, with a care-ful representation of a Flemish town outside the painted window of the center panel (compare figs. 20-1 and 20-8). In the uppermost arched panels, Jan depicted the Old Testament prophets Zachariah and Micah, along with sibyls, Greco-Roman mythological female prophets whose writings the Church interpreted as prophecies of Christ. An interesting detail is the exchange of words between Gabriel and the Virgin. Jan painted the words of Mary’s response upside down, because they are directed to God in Heaven. When open (fig. 20-10), the altarpiece reveals a richly colored painting of human redemption through Christ. In the upper regis-ter, God the Father—wearing the pope’s triple tiara, with a worldly Flanders 575 Copyright 20-9 Hubert and Jan van Eyck, Ghent Altar-piece (closed), Saint Bavo Cathedral, Ghent, Belgium, ca. 1423–1432. Oil on wood, 119 50 × 79 60. Grandiose multipanel painted altarpieces were popular in Flemish churches. Artists decorated both the interiors and exteriors of these polyp-tychs, which often, as here, included donor portraits. 1 ft. 1 ft. 20-10 Hubert and Jan van Eyck, Ghent Altarpiece (open), Saint Bavo Cathedral, Ghent, Belgium, ca. 1423–1432. Oil on wood, 119 50 × 159 10. In this richly colored painting of salvation from the Original Sin of Adam and Eve, God the Father presides in majesty. The van Eyck brothers used oil paints to render every detail with loving fidelity to appearance. 576 crown at his feet and resplendent in a deep-scarlet mantle—presides in majesty. To God’s right is the Virgin, represented, as in the Gothic age and in a small Jan van Eyck diptych (two-paneled painting; fig. 20-10A), as the queen of Heaven, with a crown of 12 stars on her head. John the Baptist sits to God’s left. To either side is a choir of angels, with an angel playing an organ on the right. Adam and Eve appear in the far panels. The inscriptions in the arches above Mary and Saint John extol the Virgin’s virtue and purity and Saint John’s greatness as the forerunner of Christ (see “Early Christian Saints,” pages 246–247). The inscription above the Lord’s head translates as “This is God, all-powerful in his divine majesty; of all the best, by the gentle-ness of his goodness; the most liberal giver, because of his infinite a second opinion Giovanni Arnolfini and His Wife In 1434, Jan van Eyck depicted Giovanni Arnolfini, a Lucca financier who had established himself in Bruges as an agent of the Medici family, and his second wife in their home (fig. 20-11). Arnolfini holds the hand of his spouse, whose name is not known. That much is certain, but the purpose and meaning of the double portrait remain the subject of con-siderable debate, with a few new interpretations having been advanced just during the last several years. According to the traditional interpreta-tion of the painting, Jan recorded the couple taking their marriage vows. As in the Mérode Triptych (fig. 20-8), almost every object portrayed car-ries meaning. For example, the little dog symbolizes fidelity (the com-mon canine name Fido originated from the Latin fidere, “to trust”). The finial (crowning ornament) of the marriage bed at the right is a tiny statue of Saint Margaret, patron saint of childbirth. (The bride is not yet preg-nant, although the fashionable costume she wears makes her appear so.) From the finial hangs a whiskbroom, symbolic of domestic care. Indeed, even the placement of the two figures in the room is meaningful. The woman stands near the bed and well into the room, whereas the man stands near the open window, symbolic of the outside world. Many art historians, however, dispute this interpretation because, among other things, the room in which Arnolfini and his wife stand is a public reception area, not a bedchamber. One scholar has suggested that Arnolfini is conferring legal privileges on his wife to conduct busi-ness in his absence. Another thinks that this may be a memorial portrait of a wife who died in childbirth. In any case, an important aspect of the painting is that the artist functions as a witness to whatever event is taking place. In the back-ground, framed by the arms and joined hands of the two figures, is a convex mirror (complete with its spatial distortion, brilliantly recorded; compare fig. 22-40), in which Jan depicted not only the principals, Arnolfini and his wife, but also two persons who look into the room through the door. (Arnolfini’s raised right hand may be a gesture of greeting to the two men.) One of these must be the artist himself, as the elegant inscription above the mirror, Johannes de Eyck fuit hic (“Jan van Eyck was here”), announces that he was present. The self-portrait also underscores the painter’s self-consciousness as a professional art-ist whose role deserves to be recorded and remembered. generosity.” The step behind the crown at the Lord’s feet bears the inscription “On his head, life without death. On his brow, youth without age. On his right, joy without sadness. On his left, security without fear.” The entire altarpiece amplifies the central theme of salvation. Even though humans, personified by Adam and Eve, are sinful, they will be saved because God, in his infinite love, will sac-rifice his own son for their sake. The panels of the lower register extend the symbolism of the upper. In the center panel, saints arrive from the four corners of the earth through an opulent, flower-spangled landscape. They pro-ceed toward the altar of the Lamb and the octagonal fountain of life (compare fig. 20-2). The book of Revelation passage that recounts the adoration of the Lamb is the main reading on All Saints’ Day (November 1). The Lamb symbolizes the sacrificed son of God, whose heart bleeds into a chalice, while into the fountain spills the “pure river of water of life, clear as crystal, proceeding out of the throne of God and of the Lamb” (Rev. 22:1). On the right, the 1 ft. 20-11 Jan van Eyck, Giovanni Arnolfini and His Wife, 1434. Oil on wood, 29 90 × 19 10 1 20. National Gallery, London. Jan van Eyck played a major role in establishing portraiture as an important Flemish art form. In this portrait of an Italian financier and his wife, he also portrayed himself in the convex mirror on the rear wall. Flanders Framed paintings Until the mid-20th century, when painters began to affix canvas to simple wood stretcher bars to provide a taut painting surface devoid of orna-mentation, artists considered the frame an integral part of the painting. Frames served a number of functions, some visual, others conceptual. For paintings such as large-scale altarpieces that were part of a larger environment, frames often served to integrate the painting with its sur-roundings. Frames could also be used to reinforce the illusionistic nature of the painted image. For example, the Italian painter Giovanni Bellini, in his San Zaccaria Altarpiece (fig. 22-29), duplicated the carved pilasters of the architectural frame in the painting itself, thereby enhancing the illusion of space and giving the painted figures an enhanced physical presence. In the Ghent Altarpiece, the frame seems to cast shadows on the floor between the angel and Mary in the Annunciation scene (fig. 20-9, top). More commonly, artists used frames specifically to dis-tance the viewer from the (often otherworldly) scene by calling attention to the separation of the image from the viewer’s space. Most 15th-and 16th-century paintings included elaborate frames that the artists themselves helped design and construct. Extant con-tracts reveal that the frame could account for as much as half of the cost of an altarpiece. Frequently, the commissions called for painted or gilded frames, adding to the expense. For small works, artists some-times affixed the frames to the panels before painting, so that the frame was a point of reference as they worked. Occasionally, a single piece of wood served as both panel and frame, and the artist (or, in practice, an assistant) carved the painting surface from the wood, leaving the edges as a frame. Larger images with elaborate frames, such as altarpieces, required the services of a professional woodcarver or stonemason. The painter worked closely with the individual constructing the frame to ensure its appropriateness for the image(s) produced. Unfortunately, over time, many frames have been removed from their paintings. For instance, in 1566 church officials dismantled the Ghent Altarpiece and detached its elaborately carved frame in order to protect the sacred work from Protestant iconoclasts (see “Art and the Reformation,” page 692). As ill luck would have it, when the panels were reinstalled in 1587, no one could find the frame. Sadly, the absence of many of the original frames of old paintings deprives viewers today of the painter’s complete artistic vision. Conversely, when the original frames exist, they sometimes provide essential information, such as the 1 in. 20-12 Jan van Eyck, Man in a Red Turban, 1433. Oil on wood, 19 11 80 × 10 1 40. National Gallery, London. Man in a Red Turban is the first known Western painted portrait in a thousand years in which the sitter looks directly at the viewer. The inscribed frame suggests that it is a self-portrait of Jan van Eyck. subject, name of the painter, and date. For example, the inscriptions on the frame of Jan van Eyck’s Man in a Red Turban (fig. 20-12) state that he painted it on October 21, 1433, and the inclusion of “As I can” and omission of the sitter’s name suggest that the painting is a self-portrait. 12 apostles and a group of martyrs in red robes advance. On the left appear prophets. In the right background come the virgin martyrs, and in the left background the holy confessors approach. On the lower wings, hermits, pilgrims, knights, and judges enter from left and right. They symbolize the four cardinal virtues: Temperance, Prudence, Fortitude, and Justice, respectively. The altarpiece cele-brates the whole Christian cycle from the fall of man to the redemp-tion, presenting the Church triumphant in heavenly Jerusalem. Jan used oil paints to render the entire altarpiece in shim-mering colors that defy reproduction. No small detail escaped the painter. With pristine specificity, he revealed the beauty of the most insignificant object. He depicted the soft texture of hair, the glitter of gold in the heavy brocades, the luster of pearls, and the flash-ing of gems, all with loving fidelity to appearance. This kind of meticulous attention to recording details became a hallmark of Flemish panel painting in the 15th century. Giovanni Arnolfini. Emerging capitalism led to prosperity in Europe’s booming urban centers and fueled in turn the growing bourgeois market for art objects, particularly in Bruges, Antwerp, and, later, Amsterdam. The increased wealth of the merchant class contributed to an expanded market for secular art in addition to religious artworks. It is noteworthy, for example, that both the Mérode Triptych and the Ghent Altarpiece—certainly to be catego-rized as “religious art”—include painted portraits of their donors. These paintings marked a significant revival of portraiture, a genre that had languished since antiquity. Private commissions for por-traits as independent artworks began to multiply as both artists and 578 patrons became interested in the reality (both physical and psycho-logical) that portraits could reveal. In the 15th century, Flemish patrons eagerly embraced the opportunity to have their likenesses painted. The elite wanted to memorialize themselves in their dynastic lines and to establish their identities, ranks, and stations with images far more concrete than heraldic coats of arms. Portraits also served to represent state offi-cials at events they could not attend. Royalty, nobility, and the very rich would sometimes send artists to paint the likeness of a pro-spective bride or groom. For example, when young King Charles VI (r. 1380–1422) of France sought a bride, he dispatched a painter to three different royal courts to make portraits of the candidates. But prosperous merchants also commissioned portraits for their homes. An early example of secular portraiture is Jan van Eyck’s dif-ficult-to-interpret depiction of the banker Giovanni Arnolfini (see “Giovanni Arnolfini and His Wife,” page 577). Man in a Red Turban. Whatever the intended meaning of Giovanni Arnolfini and His Wife, the painting is representative of the growing importance of secular portraiture as an income-producing artistic genre in 15th-century Flanders. In Man in a Red Turban (fig. 20-12), the man whom Jan van Eyck portrayed looks directly at the viewer. This is the first known Western painted portrait in a thousand years where the sitter does so. The level, composed gaze, directed from a true three-quarter head pose, must have impressed observers deeply. The painter created the illu-sion that from whatever angle a viewer observes the face, the eyes return that gaze. Jan, with his considerable observational skill and controlled painting style, injected a heightened sense of specificity into this portrait by including beard stubble, veins in the bloodshot left eye, and weathered, aged skin. Although a definitive identifica-tion of the sitter has yet to be made, most art historians consider Man in a Red Turban a self-portrait, which Jan painted by looking at his image in a mirror (as he depicted himself in the mirror in the Arnolfinis’ home; fig. 20-11). The inscriptions on the frame (see “Framed Paintings,” page 578) reinforce this identification. Across the top, Jan wrote “As I can” in Flemish using Greek letters. One suggestion is that this portrait was a demonstration piece intended for prospective clients, who could compare the painting with the painter and judge what he “could do” in terms of recording a faith-ful likeness. Across the bottom appear the date and a statement in Latin: “Jan van Eyck made me.” The use of both Greek and Latin suggests that the artist viewed himself as both a learned man and a worthy successor to the fabled painters of antiquity. rogier van der Weyden When Jan van Eyck began work on the Ghent Altarpiece, Rogier van der Weyden (fig. 20-1) was an assistant in the work-shop of Robert Campin (fig. 20-8), but the younger Tournai painter’s fame soon eclipsed Campin’s and eventually rivaled Jan’s. Rogier’s renown rested on his skill in recording indi-vidual features and character in his portraits (fig. 20-12a) and especially on the dynamic compositions of his narrative works, which stress human action and drama. He concen-trated on Christian themes, especially those episodes in the life of Jesus that elicited pow-erful emotions—for example, the Crucifixion and Pietà (the Vir-gin Mary cradling the dead body of her son)—moving observers deeply by vividly portraying the sufferings of Christ. 20-12a Van der Weyden, Portrait of a Lady, ca. 1460. Deposition. One of Rogier’s early masterworks is Deposition (fig. 20-13), the center panel of a triptych commissioned by the archers’ guild of Louvain for the church of Notre-Dame hors-les-murs (Church of Our Lady—the Virgin—outside the [town] walls). Rogier acknowledged the patrons of this large painting by incorpo-rating the crossbow (the guild’s symbol) into the decorative trac-ery in the corners. Instead of creating a deep landscape setting, as Jan van Eyck might have, Rogier compressed the figures and action onto a shallow stage with a golden back wall, imitat-ing the large sculptured shrines so popular in the 15th century, of which Jacques de Baerze’s Retable de Champ-mol (fig. 20-3) is one of many Nether-landish examples (compare figs. 20-21 and 20-22). The device admirably served his purpose of expressing max-imum action within a limited space 20-13 Rogier van der Weyden, Deposition, center panel of a triptych from Notre-Dame hors-les-murs, Louvain, Belgium, ca. 1435–1442. Oil on wood, 79 2 5 del Prado, Madrid. 80 × 89 7 1 1 ft. 80. Museo Deposition resembles a relief carving in which the biblical figures act out a drama of passionate sorrow as if on a shallow theatrical stage. The painting makes an unforgettable emotional impression. and dramatically confronting the viewer, but the setting of the Cru-cifixion in a box is unrealistic, as is the size of the cross, the arms of which are not wide enough for Jesus’s hands to have been nailed to them. The painting, with the artist’s crisp drawing and precise mod-eling of forms, resembles a stratified relief carving, and the viewer may wonder if this is a painting of the biblical event or a painting of a shrine representing the event. In any case, a series of lateral undu-lating movements gives the group a compositional unity, a formal cohesion that Rogier strengthened by depicting the sorrowful anguish that many of the figures share. Present are the Virgin, sev-eral of her half-sisters, Joseph of Arimathea, Nicodemus, Saint John the Evangelist, and Mary Magdalene. The similar poses of Christ and his mother further unify the composition, evoke the shape of the crossbows in the corner tracery, and reflect the belief that Mary suffered the same pain at the Crucifixion as her son. ART AND SOCIETY the artist’s profession in Flanders As they did in Italy (see “Artistic Training,” page 434), guilds controlled artistic production in Flanders. To pursue a craft, individuals had to belong to the guild representing that craft. Painters, for example, sought admission to the Guild of Saint Luke, the patron saint of painters because Luke made a portrait of the Virgin Mary (fig. 20-1). The patron saint of the metalworkers’ guild was Saint Eligius (fig. 20-14), who was a goldsmith before devoting himself to the Church and eventually becom-ing bishop of Tournai. The path to eventual membership in the guild began, for men, at an early age, when the father apprenticed his son in boyhood to a mas-ter, with whom the young aspiring painter lived. The master taught the fundamentals of his craft—how to make implements, prepare panels with gesso (plaster mixed with a binding material), and mix colors, oils, and varnishes. Once the youth mastered these procedures and learned to work in the master’s traditional manner, he usually spent several years working as a journeyman in various cities, observing and absorbing ideas from other masters. He then was eligible to become a master and could apply for admission to the guild. Fees could be very high, espe-cially if an artist was not a citizen of the same city, as was the case, for example, when Petrus Christus of Baerle purchased citizenship in Bruges in order to join that city’s painters’ guild. Sometimes, an art-ist seeking admission to a guild would marry the widow of a member. (A woman could inherit her husband’s workshop, but could not run it.) Guild membership was essential for establishing an artist’s reputation and for obtaining commissions. The guild inspected paintings to evalu-ate workmanship and ensure that its members used quality materials. It also secured adequate payment for its artists’ labor. Women had far fewer opportunities than men to train as artists, in large part because of social and moral constraints that forbade women to reside as apprentices in the homes of male masters. Moreover, from the 16th century, when academic training courses supplemented and then replaced guild training, until the 20th century, women would not as a rule expect or be permitted instruction in figure painting, because it involved dissection of cadavers and study of the nude male model. Flemish women interested in pursuing art as a career—for example, Caterina van Hemessen (fig. 23-16)—most often received tutoring from fathers and husbands who were professionals and whom the women assisted in all the technical procedures of the craft. Despite these Rogier’s extraordinary ability to represent flesh and fabric rivaled Jan van Eyck’s, and few painters, not even Jan, have equaled him in rendering passionate sorrow as it vibrates through a figure or distorts a tearstained face. Rogier’s depictions of the agony of loss in Deposition and of the terror of the damned in Last Judgment (fig. 20-13a) are among the most moving and unforgettable images in religious art. It was probably Rogier whom Michelangelo had in mind when, according to the Portuguese painter Francisco de Hol-landa (1517–1584), the Italian master observed, “Flemish paint-ing [will] please the devout better than any painting of Italy, which will never cause him to shed a tear, whereas that of Flanders will cause him to shed many.”1 20-13a Van der Weyden, Last Judgment, ca. 1443–1451. 1 ft. 20-14 Petrus Christus, A Goldsmith in His Shop, 1449. Oil on wood, 39 30 × 29 100. Metropolitan Museum of Art, New York (Robert Lehman Collection, 1975). Once thought to depict Eligius, the patron saint of goldsmiths, Christus’s painting, made for the Bruges goldsmiths’ guild, is more likely a genre scene of a couple shopping for a wedding ring. obstacles, membership records of the art guilds of Bruges and other cities reveal that a substantial number of Flemish women were able to establish themselves as artists during the 15th century. That they suc-ceeded in negotiating the difficult path to acceptance as professionals is a testament to both their tenacity and their artistic skill. 580 Later Flemish painters Robert Campin, Jan van Eyck, and Rogier van der Weyden were the leading figures of the first generation of “Northern Renaissance” painters. (Art historians usually transfer to Northern Europe, with less validity than in its original usage, the term Renaissance, coined to describe the conscious revival of classical art in Italy.) The second generation of Flemish masters, active during the latter half of the 15th century, had much in common with their illustrious predeces-sors, especially a preference for using oil paints to create naturalistic representations, often, although not always, of traditional Christian subjects for installation in churches. Petrus Christus. One work of uncertain Christian content is A Goldsmith in His Shop (fig. 20-14) by Petrus Christus (ca. 1410–1472), who settled in Bruges in 1444. According to the traditional interpretation, A Goldsmith in His Shop portrays Saint Eligius (who was initially a master goldsmith before committing his life to God) sitting in his stall, showing an elegantly attired couple a selection of rings. The bride’s betrothal girdle lies on the table as a symbol of chastity, and the woman reaches for the ring the goldsmith weighs. The artist’s inclusion of a crystal container for Eucharistic wafers (on the lower shelf to the right of Saint Eligius) and the scales (a ref-erence to the Last Judgment) supports a religious interpretation of this painting and continues the Flemish tradition of imbuing every-day objects with symbolic significance. A halo once encircled the goldsmith’s head, seemingly confirming the religious nature of this scene. Scientists have determined, however, that the halo was a later addition by another artist, and restorers have removed it. Most scholars now think that the painting, although not devoid of religious content, should be seen as a vocational painting of the type often produced for installation in Flemish guild chapels. Although the couple’s presence suggests a marriage portrait, the patrons were probably not the couple portrayed but rather the goldsmiths’ guild in Bruges. Saint Eligius was the patron saint of gold-and silver-smiths, blacksmiths, and metalworkers, all of whom shared a chapel in a building adjacent to their meetinghouse. The reconsecration of this chapel took place in 1449, the same date as the Christus paint-ing. Therefore, it seems probable that the artist painted A Goldsmith in His Shop, which illustrates an economic transaction and focuses on the goldsmith’s profession, specifically for the guild chapel. A guild chapel is also the likely original setting of Rogier van der Weyden’s Saint Luke Drawing the Virgin (fig. 20-1). As noted, in the 15th century, in addition to their primary function as “trade unions,” guilds played an increasingly important role in community life and often became major patrons of art in their cities (see “The Artist’s Profession in Flanders,” page 580). Christus went to great lengths to produce a historically cred-ible image. For example, the variety of objects depicted in the paint-ing serves as advertisement for the goldsmiths’ guild. Included are the goldsmiths’ raw materials (precious stones, beads, crystal, coral, and seed pearls) scattered among finished products (rings, buckles, and brooches). The pewter vessels on the upper shelves are dona-tion pitchers, which town leaders gave to distinguished guests. All these meticulously painted objects not only attest to the centrality and importance of goldsmiths to both the secular and sacred com-munities but also enhance the naturalism of the painting. The con-vex mirror in the foreground showing another couple and a street with houses serves to extend the painting’s space into the viewer’s space, further creating the illusion of reality, as in Jan van Eyck’s Arnolfini portrait (fig. 20-11). Dieric Bouts. In Last Supper (fig. 20-15), Dieric Bouts (ca. 1415–1475) of Haarlem chose a different means of suggesting 1 ft. 20-15 Dieric Bouts, Altarpiece of the Holy Sacrament, Saint Peter’s, Louvain, Belgium, 1464–1468. Oil on wood, center panel (Last Supper) 69 × 59. The Last Supper, the central panel of this altarpiece, is one of the earliest Northern Renaissance paintings to employ Italian linear perspective. Included are portraits of the work’s Flemish patrons. spatial recession. The painting is the central panel of the Altarpiece of the Holy Sacrament, which the Confraternity of the Holy Sacra-ment in Louvain commissioned in 1464. Four years later, Bouts became the city’s offi-cial painter and was asked to produce a series of panels—including Wrongful Beheading of the Count (fig. 20-15a) and Justice of Otto III (fig. 20-15B)—for Louvain’s town hall. Bouts’s Last Supper is one of the earliest Northern Renaissance paintings to employ linear perspective and a vanishing point to create the illusion of depth. All of the central room’s orthogonals (converging diagonal lines imagined to be behind and perpendicular to the picture plane) lead to the vanishing point in the center of the mantelpiece above Jesus’s head. The small side room, however, has its own vanishing point, and neither it nor the vanishing point of the main room falls on the horizon of the landscape (the horizon line) seen through the windows, as in Italian Renaissance paintings composed according 20-15B BoutS, Justice of Otto III, ca. 1470–1473. to the strict rules of linear perspective (see “Linear Perspective,” page 599). In Last Supper, Bouts did not depict the biblical narrative itself but instead presented Jesus in the role of a priest performing the liturgical ritual of the consecration of the Eucharistic wafer. By dividing the apostles into two asymmetrical groups with no one sitting at the middle of the near side of the table, Bouts focused attention on the Savior and the food platter and wine chalice at the table’s center. Bouts’s Last Supper contrasts strongly with other depictions of the same subject, which often represented Jesus’s prediction of Judas’s betrayal or his comforting of John. The Confraternity of the Holy Sacrament dedicated itself to the worship of the Eucharist, and the smaller panels on the altarpiece’s wings depict Old Testament prefigurations of the Eucharist—for example, at the top right, the gathering of manna in the desert and, at bottom left, Jews celebrating Passover (the occasion for Jesus’s final meal). Bouts also added four servants (two looking through the window-like opening in the rear wall and two standing) not mentioned in the New Testament account, all dressed in Flemish attire. These are portraits of the four members of the confraternity who contracted Bouts to paint the altarpiece, continuing the Flemish tradition of inserting into representations of biblical events portraits of the painting’s patrons, first noted in the Mérode Triptych (fig. 20-8), where the Inghelbrechts are also looking into the room from out-side; that is, they are not participants in but witnesses of the biblical event. Hugo van der Goes. By the mid-15th century, Flemish art had achieved renown throughout Europe. The Portinari Altarpiece (fig. 20-16), for example, is a large-scale Flemish work in a family chapel in Florence, Italy. The artist who received the commission was Hugo van der Goes (ca. 1440–1482), who joined the painters’ guild of Ghent as a master in 1467 and served as the guild’s dean from 1473 to 1475. Hugo painted the triptych in Flanders for Tom-maso Portinari, an Italian shipowner and agent in Bruges for the powerful Medici bank of Florence. The altarpiece was Portinari’s gift to the church of Sant’Egidio, and he appears on the wings with his family and their patron saints, who are much larger than the donors. The main panel, Adoration of the Shepherds, depicts a sub-ject based on the 14th-century vision of a Swedish saint in which Mary, instead of cradling her newborn son, kneels solemnly to join Joseph, the angels, and the shepherds in adoring the infant Savior, who lies on the ground and glows with divine light. In order to situate the main actors at the center of the panel, Hugo tilted the ground, a compositional device he may have derived from the tilted stage floors of 15th-century mystery plays. Three shepherds enter 1 ft. 20-16 Hugo van der Goes, Adoration of the Shepherds (Portinari Altarpiece, open), from Sant’Egidio, Florence, Italy, ca. 1473–1478. Tempera and oil on wood, center panel 89 3 1 20 × 109, each wing 89 3 1 20 × 49 7 1 20. Galleria degli Uffizi, Florence. This altarpiece is a rare instance of the awarding of a major commission in Italy to a Flemish painter. The Florentines admired Hugo’s realistic details and brilliant portrayal of human character from the right rear. Hugo represented them in attitudes of wonder, piety, and gaping curiosity. Their lined faces, work-worn hands, and uncouth dress and manner indicate that they are common folk, very different than the three magi who will soon come to adore the newborn Jesus. The architecture and a continuous Northern European land-scape unify the three panels. (The bare trees of the setting estab-lish that it is winter, the season of Christ’s birth.) Symbols surface throughout the altarpiece. Iris and columbine flowers are emblems of the sorrows of the Virgin. The angels represent the 15 joys of Mary. A sheaf of wheat stands for Bethlehem (the “house of bread” in Hebrew), a reference to the Eucharist. The harp of David, embla-zoned over the building’s portal in the middle distance (just to the right of the Virgin’s head), signifies the ancestry of Christ. To stress the meaning and significance of the illustrated event, Hugo revived medieval pictorial devices. Small scenes shown in the background of the altarpiece represent (from left to right) the journey of Mary and Joseph to Bethlehem, the annunciation to the shepherds, and the arrival of the magi. Hugo’s variation in the scale of his figures to differentiate them by their importance to the central event also reflects older traditions. Still, he put a vigorous, penetrating realism to work in a new direction, characterizing human beings according to their social level while showing their common humanity. After Portinari placed the altarpiece in his family’s chapel in the Florentine church of Sant’Egidio, it created a considerable stir among Italian artists. Although the painting may have seemed unstructured to the Italians and the employing of hierarchy of scale old fashioned, Hugo’s masterful technique and what the Floren-tines deemed incredible realism in representing drapery, flowers, animals, and, above all, human character and emotion made a deep impression on them. At least one Florentine artist, Domenico Ghir-landaio (figs. 21-26 and 21-27), paid tribute to the Flemish master by using Hugo’s most striking motif, the adoring shepherds, in one of his own Nativity paintings. Hans Memling. Hugo’s contemporary, Hans Memling (ca. 1430–1494), may have trained as a painter in Rogier van der Weyden’s studio. He became a citizen of Bruges in 1465 and received numer-ous commissions from the city’s wealthy merchants, Flemish and foreign alike. He specialized in portraits of his patrons (one of whom was Tommaso Portinari; fig. 20-18A) and images of the Madonna. Memling’s many paintings of the Virgin portray young, slight, pretty princesses, each holding a doll-like infant Jesus. The center panel of the Saint John Altarpiece is Virgin with Saints and Angels (fig. 20-17). The patrons of this altarpiece—two brothers and two sisters of the order of the Hospital of Saint John in Bru-ges—appear on the exterior side panels (not illustrated). In the main panel, two angels, one playing a musical instrument and the other holding a book, flank the Virgin. To the sides of Mary’s throne stand Saints John the Baptist on the left and John the Evangelist on the right. Seated in the foreground are Saints Catherine and Barbara. This gathering celebrates the mystic marriage of Saint Catherine of Alexandria, one of many virgin saints believed to have entered into a spiritual marriage with Christ. As one of the most revered virgins of Christ, Saint Catherine provided a model of devotion that resonated with women viewers (especially nuns). The altarpiece exudes an opu-lence that results from the rich colors, the meticulously depicted tap-estries and brocades, and the serenity of the figures. The composition 1 ft. 20-17 Hans Memling, Virgin with Saints and Angels, center panel of the Saint John Altarpiece, Hospitaal Sint Jan, Bruges, Belgium, 1479. Oil on wood, center panel 59 7 3 40 × 59 7 3 40, each wing 59 7 3 40 × 29 7 1 80. Memling specialized in images of the Madonna. His Saint John Altarpiece exudes an opulence that results from the sparkling and luminous oil colors and the realistic depiction of rich tapestries and brocades 20-18 Hans Memling, Diptych of Martin van Nieuwenhove, 1487. Oil on wood, each panel 19 5 3 Bruges. 80 × 19 10. Memlingmuseum, In this diptych, the Virgin and Child pay a visit to the home of 23-year-old Martin van Nieuwenhove. A round convex mirror reflects the three figures and unites the two halves of the diptych spatially. is balanced and serene, the color sparkling and luminous, and the execution of the highest technical quality. Memling combined portraiture and Madonna imagery again in a much less ambitious—and more typical—work (fig. 20-18) that he painted for Martin van Nieuwenhove (1464–1500). The smaller scale of the private commission and its much more intimate character underscore the different approaches that painters regu-larly took when producing artworks for different kinds of patrons and for public versus private settings. Martin van Nieuwenhove was a member of an important Bruges family that held various posts in the civic government. He himself served as burgomeister of Bruges in 1497. The painting takes the form of a diptych, with the patron portrayed on the right wing praying to the Madonna and Child on the left wing, a format invented by Rogier van der Weyden. Accord-ing to inscriptions on the frames, van Nieuwenhove commissioned the work in 1487 when he was 23 years old. He died only 13 years later, 3 years after becoming mayor. The format of the van Nieuwenhove diptych follows the pat-tern that Memling used earlier for his wedding triptych Tom-maso Portinari and Maria Baroncelli (fig. 20-18a) but with only a single (male) portrait. (The lost central section of the Portinari triptych probably closely resembled the van Nieu-wenhove Madonna and Child.) Memling’s portrayals of Mary and Jesus consistently feature a tender characterization of the young Virgin and her nude infant son. Here, however, Memling set both the Madonna and her patron in the interior of a well-appointed Flemish home featuring stained-glass windows. The window to the left of the Virgin’s head bears van Nieuwenhove’s coat of arms. The window behind the donor depicts his patron saint, Martin of Tours. These precisely recorded details identify the home as van Nieuwenhove’s (the Minnewater Bridge in Bru-ges is visible through the open window), and the Madonna and Child have honored him by coming to his private residence. Even Saint Luke had to go to the Virgin’s home to paint her portrait (fig. 20-1), but the conceit is a familiar one in Flemish painting. An early example is the Annunciation taking place in the home of Peter Inghelbrecht in Robert Campin’s Mérode Triptych (fig. 20-8). In the Memling portrait diptych, the Christ Child sits on the same ledge as the donor’s open prayer book. Also uniting the two wings of the diptych is the round con-vex mirror behind the Vir-20-18a MeMling, Tommaso Porti-nari and Maria Baroncelli, ca. 1470. gin’s right shoulder in which the viewer sees the reflection of the Virgin’s back and van Nieuwenhove as well as the rest of the room (compare figs. 20-11 and 20-14). 584 FRANCE In contrast to the prosperity and peace that Flanders enjoyed dur-ing the 15th century, in France the Hundred Years’ War crippled economic enterprise and prevented political stability. The anarchy of war and the weakness of the kings gave rise to a group of duch-ies, each with significant power and the resources to commission major artworks. The strongest and wealthiest of these has already been examined—the duchy of Burgundy, which controlled Flanders, as well as the duchy of Berry in France. The French dukes of Bour-bon and Nemours as well as members of the French royal court were also important art patrons. In addition to illustrated books, such as the Très Riches Heures du Duc de Berry (figs. 20-5 and 20-6), inde-pendent paintings were popular in France, as in Flanders, for private devotional use. The preferred medium was oil paint on wood panels. Jean Fouquet. Among the French artists whose paintings were in high demand was Jean Fouquet (ca. 1425–1478). Fouquet’s workshop was in Tours, and he received important commissions from King Charles VII (r. 1422–1461, the patron and client of Jacques Coeur; fig. 13-31) and from the duke of Nemours and other elite members of the French aristocracy. Fouquet painted a diptych (fig. 20-19) for Étienne Chevalier, who, despite his lowly birth as the son of one of Charles VII’s secretaries, rose to become royal treasurer in 1452. In the left panel of the Melun Diptych (named for its original location in Melun Cathedral), Chevalier appears with his patron saint, Saint Stephen (Étienne in French). Appropriately, Fouquet’s donor portrait of Chevalier depicts his prominent patron as devout—kneeling, with hands clasped in prayer. The represen-tation of the pious donor with his standing saint recalls Flemish art, as do the three-quarter stances and the realism of Chevalier’s portrait. The artist portrayed Saint Stephen, whose head also has a portraitlike quality, holding the stone symbolizing his martyrdom (death by stoning) atop a volume of the holy scriptures, thereby ensuring that viewers can properly identify the saint. Fouquet ren-dered the entire image in meticulous detail and included a highly ornamented architectural setting. In its original diptych form (the two panels are now in differ-ent museums), the viewer would follow the gaze of Chevalier and Saint Stephen over to the right panel, which depicts the Virgin Mary and Christ Child in a most unusual way—with marblelike flesh, sur-rounded by red and blue cherubs (chubby winged child angels). The juxtaposition of these two images enabled the patron to bear wit-ness to the sacred. The integration of sacred and secular (especially the political or personal), prevalent in other Northern Renaissance artworks, also emerges here, which complicates the reading of this diptych. Agnès Sorel (1421–1450), the mistress of Charles VII, was Fouquet’s model for the Virgin Mary, whose left breast is exposed, presumably to nurse the infant Jesus, but she does not look at her son or the viewer. (Mary as nursing mother is a not uncommon way of representing the Virgin in Northern Europe; compare fig. 20-1.) Chevalier commissioned this painting after Sorel’s death, probably by poisoning while pregnant with the king’s child. Thus, in addition to the religious interpretation of this diptych, there is surely a personal 1 ft. 1 ft. 20-19 Jean Fouquet, Melun Diptych, ca. 1452. Left wing: Étienne Chevalier and Saint Stephen. Oil on wood, 39 1 Gemäldegalerie, Staatliche Museen zu Berlin, Berlin. Right wing: Virgin and Child. Oil on wood, 39 11 Museum voor Schone Kunsten, Antwerp. 40 × 29 9 1 20 × 29 9 1 20. 20. Koninklijk Fouquet’s meticulous representation of a pious kneeling donor with a standing patron saint recalls Flemish painting, as do the three-quarter stances and the realism of the donor’s portrait head 20-20 Konrad Witz, Miraculous Draft of Fish, exterior wing of Altarpiece of Saint Peter, from the Chapel of Notre-Dame des Maccabées, Cathedral of Saint Peter, Geneva, Switzerland, 1444. Oil on wood, 49 30 × 59 10. Musée d’Art et d’Histoire, Geneva. Konrad Witz set this biblical story on Lake Geneva. The painting is one of the first 15th-century works depicting a specific locale and is noteworthy for the painter’s skill in rendering water effects. 1 ft. and political narrative here as well, made all the more complex given that Sorel gave birth to three of the king’s daughters, but never a son. HOLY ROMAN EMPIRE Because the Holy Roman Empire (whose core was Germany) did not participate in the drawn-out saga of the Hundred Years’ War, its economy remained stable and prosperous. Without a domi-nant court to commission artworks, wealthy merchants and clergy became the primary German art patrons during the 15th century. panel painting The art of the early Northern Renaissance in the Holy Roman Empire displays a pronounced stylistic diversity. Some artists fol-lowed developments in Flemish painting, and large-scale altar-pieces featuring naturalistically painted biblical themes were familiar sights in German churches. Konrad Witz. Among the most notable 15th-century German altarpieces is the Altarpiece of Saint Peter, painted by Konrad Witz (ca. 1400–1446) for the chapel of Notre-Dame des Maccabées in the Cathedral of Saint Peter in Geneva. Signed by “Magister Con-radus of Basel” and dated 1444, the altarpiece is a triptych featuring Witz’s paintings on both the exterior and interior. Miraculous Draft of Fish (fig. 20-20) appears on one of the exterior wings. The other (not illustrated) depicts the release of Saint Peter from prison. The central panel is lost. On the interior wings, Witz painted scenes of the adoration of the magi and of Saint Peter’s presentation of the donor (Bishop François de Mies) to the Virgin and Child. Miraculous Draft of Fish shows Peter, the first pope, unsuccessfully trying to emulate Christ walking on water. The choice of this episode from among oth-ers in Peter’s life (see “Early Christian Saints,” pages 246–247) may be a commentary on the part of Witz’s patron, the Geneva cardinal, on the limited power of the pope in Rome. The painting is particularly significant because of the land-scape’s prominence. Witz showed his considerable skill in the recording of water effects—the shimmering sky on the slowly mov-ing lake surface, the mirrored reflections of the figures in the boat, and the transparency of the shallow water in the foreground. He observed and represented the landscape so carefully that art histo-rians have been able to determine the exact location shown. Witz presented a view of the shores of Lake Geneva, with the town of Geneva on the right and Le Môle Mountain in the dis-tance behind Christ’s head. This painting is one of the first 15th-century works depict-ing a specific, identifiable site. The work of other leading German painters of the mid-15th century—for exam-ple, Stefan Lochner (ca. 1400–1451)—retained medieval features to a much greater degree, as is immediately evident in a comparison between Witz’s landscape and Lochner’s Madonna in the Rose Gar-den (fig. 20-20a). 586 CHAPTER 20 Late Medieval and Early Renaissance Northern Europe Copyright 2021 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 20-20a lochner, Madonna in the Rose Garden, ca. 1435–1440. sculpture As in Flanders (fig. 20-3), in the Holy Roman Empire many of the leading 15th-century artists specialized in carving large wood retables. These grandiose sculpted altarpieces reveal the lingering power of the Late Gothic style. Veit Stoss. The sculptor Veit Stoss (ca. 1447–1533) trained in the Upper Rhine region, possibly in Strasbourg, but settled in Kraków (in present-day Poland) in 1477. In that year, he began work on a monumental altarpiece for the church of Saint Mary in Kraków, paid for by the city’s citizens. In the central boxlike shrine is Death and Assumption of the Virgin (fig. 20-21), peopled by huge carved, painted, and gilded figures, some 9 feet high. On both the outer and inner faces of the wings, Stoss portrayed scenes from the lives of Christ and Mary. The altar forcefully expresses the intense piety of Gothic culture in its late phase, when artists used every figural and ornamental motif in the repertoire of Gothic art to heighten the emotion and glorify sacred events. In the center panel of the Kraków altarpiece, Christ’s disciples congregate around the Virgin, who collapses, dying. One of them supports her, while another wrings his hands in grief. Above, Mary rises to Heaven with the resurrected Christ. Stoss posed others in attitudes of woe and psychic shock, striving for realism in every minute detail. He engulfed the figures in restless, twisting, and curving swaths of drapery whose broken and writhing lines unite the whole tableau in a vision of agitated emotion. The artist’s massing of sharp, broken, and pierced forms that dart flamelike through the composition—at once unifying and animating it—recalls the design principles of Late Gothic architecture (fig. 13-28). Indeed, in the Kraków altar-piece, Stoss merged sculpture and architecture, enhancing their union with paint and gilding. The Kraków altarpiece gives modern viewers the opportunity to appreciate the polychromy that was standard in ancient and medieval sculpture in both wood and stone. Examples such as this one are unfortunately rare. The vast majority of preserved statues and reliefs from antiquity and the Middle Ages give a false impres-sion of their original appearance (compare figs. 3-13A and 5-63A) because the paint has disappeared. 10 ft. 20-21 Veit Stoss, Death and Assumption of the Virgin, center panel of the Altarpiece of the Virgin Mary (with wings open), Church of Saint Mary, Kraków, Poland, 1477–1489. Painted and gilded lime-wood, central panel 239 90 high. In this huge painted and gilded sculptured wood altarpiece, Stoss used every figural and ornamental element from the vocabulary of Gothic art to heighten the emotion and glorify the sacred event. 20-22 Tilman Riemenschneider, Assumption of the Virgin (Creglingen Altarpiece), Herrgottskirche, Creglingen, Germany, ca. 1495–1505. Lime-wood, 309 20 high. Riemenschneider specialized in carving large unpainted wood retables. His works feature intricate Gothic trac-ery and religious figures whose bodies are almost lost within their swirling garments. into fluid motion by employing an endless and restless line running through the garments of the figures. The draperies float and flow around bodies lost within them, serving not as descrip-tions but as design elements that tie the figures to one another and to the framework. A look of psychic strain, a facial expression common in Riemenschneider’s work, heightens the spiritu-ality of the figures, immaterial and weightless as they appear. Graphic arts 10 ft. A new age blossomed in the 15th century with a sudden technological advance that had wide-spread effects—the invention by Johannes Gutenberg (ca. 1400–1468) of moveable type around 1450 and the development of the print-ing press. Printing had been known in China centuries before, but had never fostered, as it did in 15th-century Europe, a revolution in written communication and in the generation and man-agement of information. Printing provided new and challenging media for artists, and the earli-est form was the woodcut. Artists produced inex-pensive woodcuts such as the Buxheim Saint Christopher (fig. 20-22a) before the development of moveable-type print-ing. But when the im-proved economy and a rise in literacy necessi-tated the production of illustrated books on a grand scale, artists met the challenge of bringing the woodcut picture onto the same letterpress text pages (see “How to Illustrate Printed Books,” page 589). 20-22a Buxheim Saint Christopher, 1423(?). Martin Schongauer. The woodcut medium hardly had matured when printmakers intro-duced the technique of engraving (see “Engrav-Tilman Riemenschneider. Assumption of the Virgin is also the center panel of the Creglingen Altarpiece (fig. 20-22), carved by Tilman Riemenschneider (ca. 1460–1531) of Würzburg for a parish church in Creglingen, Germany. Riemenschneider incor-porated intricate Gothic forms, especially in the 30-foot-tall altar-piece’s elaborate canopy, but unlike Stoss, he did not paint the figures or the background, relying instead purely on sculptural form. The Würzburg master succeeded in setting the whole design ing and Etching,” page 590). Begun in the 1430s and well developed by 1450, engraving proved much more flexible than woodcut. Predictably, in the second half of the century, engraving began to replace the woodcut process for making both book illustrations and widely popular single prints. Not surprisingly, many of the earli-est engravers were professional goldsmiths, who easily applied their training in incising designs into gold and silver jewelry to the new art form. how to illustrate printed Books With the invention of moveable type in the 15th century and the new widespread availability of paper from commercial mills, the art of print-making developed rapidly in Europe. A print is an artwork created by transferring a design on a metal plate or a wood or stone block to a sheet of paper. Prints are usually produced in multiple impressions. The set of prints that an artist creates from a single block or plate is called an edition. Like the manufacturing of books on a press, the printmaking process involves the transfer of ink from a printing surface to paper. This can be accomplished in several ways. The oldest and simplest is the relief method—carving the design into a surface, usually a soft wood, such as pear. Relief print-ing requires artists to conceptualize their images in reverse—that is, they must draw mirror images of the intended design on the wood block. They then remove the surface areas around the drawn lines using a gouging instrument. Thus when the printmaker inks the ridges that correspond to the original (reversed) drawing, the hollow areas remain dry, and a correctly oriented image results when the artist presses the printing block against paper. Because artists produce woodcuts through a subtractive process (removing parts of the mate-rial), it is difficult to create very thin, fluid, and closely spaced lines. Moreover, if the ridges are too thin, they will break during printing. As a result, woodcut prints (for example, figS. I-9, 20-22A, and 20-23) tend to exhibit stark contrasts between the dark lines and the blank background. During the later 15th century, publishers realized that the wood-cut was the ideal medium for solving the problem of illustrating their new printed books. The new technology quickly led to the demise of the manuscript illuminator as well as the scribe, both of whom had been essential for the production of illustrated books through the late Middle Ages, whether they were monks working in monastic scriptoria or lay professionals employed in the for-profit workshops of Paris and other cities. The most ambitious early effort to produce low-cost mass-produced printed books was the so-called Nuremberg Chronicle, a history of the world produced in Nuremberg by anton koBerger (ca. 1445–1513), with more than 650 illustrations furnished by the workshop of Michael WolgeMut (1434–1519). The hand-colored page illustrated here (fig. 20-23) represents Madeburga (modern Magde-burg, Germany). The blunt, simple lines of the woodcut technique give a detailed perspective of Magdeburg, its harbor and shipping, its walls and towers, its churches and municipal buildings, and a statue-topped columnar monument. Despite the numerous architectural structures, this illustration is not an accurate depiction of the city but the prod-uct of the artist’s fanciful imagination. Wolgemut often used the same image to illustrate different cities, even those with very little in common—for example, Verona, Italy, and Damascus, Syria. This depiction of Magdeburg is a generic view of a late medieval German town, not a portrait of a specific place. Regardless, the Nuremberg Chronicle is a monument to a new craft, which expanded in concert with the art of the printed book. 20-23 Michael Wolgemut and workshop, Madeburga, page from the Nurem-berg Chronicle, 1493. Woodcut, 19 6 1 80 × 29 15 80. Printed by Anton Koberger. The Nuremberg Chronicle is an early example of wood-cut illustrations in printed books. The more than 650 pictures include detailed views of towns, but they are generic rather than specific portrayals. 1 engraving and etching In contrast to the production of relief prints, in the intaglio method of printmaking, the artist incises (cuts) the lines on a metal plate, often copper, rather than cuts away the area around the lines, as the relief printer does. The image can be created on the plate manually (engrav-ing or drypoint; for example, fig. 20-24) using a tool (a burin or stylus) or chemically (etching; for example, fig. 25-16). In the etching process, an acid bath eats into the exposed parts of the plate where the artist has drawn through an acid-resistant coating. When the artist inks the surface of the intaglio plate and wipes it clean, the ink is forced into the incisions. Then the artist runs the plate and paper through a roller press, and the paper absorbs the remaining ink, creating the print. Because the artist “draws” the image onto the plate, intaglio prints differ in char-acter from relief prints, such as woodcuts. Engravings, drypoints, and etchings generally present a wider variety of linear effects, as is imme-diately evident in a comparison of the roughly contemporaneous wood-cut (fig. 20-23) by Michael Wolgemut and an engraving (fig. 20-24) by Martin Schongauer. Intaglio prints also often reveal to a greater extent evidence of the artist’s touch, the result of the hand’s changing pressure and shifting directions. The paper and inks that artists use also affect the finished look of the printed image. During the 15th and 16th centuries, European print-makers used papers produced from cotton and linen rags that paper-makers mashed with water into a pulp. The papermakers then applied a thin layer of this pulp to a wire screen and let it dry to create the paper. As contact with Asia increased, printmakers made greater use of what was called Japan paper (of mulberry fibers) and China paper. Artists, then as now, could select from a wide variety of inks. The type and pro-portion of the ink ingredients affect the consistency, color, and oiliness of inks, which various papers absorb differently. Paper is lightweight, and the portability of prints has been an important factor in their appeal to artists. The opportunity to produce numerous impressions from the same print surface also made printmak-ing attractive to 15th-and 16th-century artists. In addition, prints can be sold at much lower prices than paintings or sculptures. Consequently, prints reached a far wider audience than did one-of-a-kind artworks. The number and quality of existing 15th-and 16th-century European prints attest to the importance of the new print medium. 20-24 Martin Schongauer, Saint Anthony Tormented by Demons, ca. 1480. Engraving, 19 1 40 × 90. Fondazione Magnani Rocca, Corte di Mamiano. Schongauer was the most skilled of the early masters of metal engraving. By using a burin to incise lines in a copper plate, he was able to create a marvelous variety of tonal values and textures. 1 in. Martin Schongauer (ca. 1430–1491) of Colmar, a painter and the son of a goldsmith, was the most skilled and subtle North-ern European master of metal engraving. His Saint Anthony Tor-mented by Demons (fig. 20-24) shows both the versatility of the medium and the artist’s mastery of it. The stoic saint is caught in a revolving thornbush of spiky demons, who claw and tear at him furiously. With unsurpassed skill and subtlety, Schongauer incised lines of varying thickness and density into a metal plate and cre-ated marvelous distinctions of tonal values and textures—from smooth skin to rough cloth, from the furry and feathery to the hairy and scaly. The use of cross-hatching (sets of engraved lines at right angles) to describe forms, which Schongauer probably devel-oped, became standard among German graphic artists. The Italians preferred parallel hatching (fig. 21-29) and rarely adopted cross-hatching, which, in keeping with the general Northern Renaissance approach to art, tends to describe the surfaces of things rather than their underlying structures. Schongauer probably engraved Saint Anthony around 1480. By then, the political geography of Europe had changed dramatically. Charles the Bold, who had assumed the title of duke of Burgundy in 1467, died in 1477, bringing to an end the Burgundian dream of forming a strong middle kingdom between France and the Holy Roman Empire. After Charles’s death at the battle of Nancy, the French monarchy reabsorbed the southern Burgundian lands, and the Netherlands passed to the Holy Roman Empire by virtue of the dynastic marriage of Charles’s daughter, Mary of Burgundy (fig. 20-7), to Maximilian of Habsburg, inaugurating a new political and artistic era in Northern Europe, examined in Chapter 23. The next two chapters, however, explore Italian developments in painting, sculpture, and architecture during the 15th and 16th centuries. 590 French ducal courts ■ The most powerful rulers north of the Alps during the first three quarters of the 15th century were the dukes of Burgundy. They controlled Flanders, which derived its wealth from wool and banking, and were great art patrons. Duke Philip the Bold (r. 1363–1404) endowed the Carthusian monastery at Champmol, near Dijon, which became a ducal mausoleum. The head of Philip’s sculptural workshop was Claus Sluter, whose Well of Moses features innovative statues of prophets with portraitlike features and realistic costumes. ■ In the 15th century, Northern European artists popularized the use of oil paints on wood panels. By superimposing translucent glazes, painters could create richer colors than possible using tempera or fresco. One of the earliest examples of oil painting is Melchior Broederlam’s wings of the Retable de Champmol, painted for Philip the Bold. Carved wood narrative reliefs by Jacques de Baerze fill the retable’s interior. ■ The Limbourg brothers expanded the illusionistic capabilities of manuscript illumination in the Book of Hours they produced for Jean, duke of Berry (r. 1360–1416) and brother of King Charles V (r. 1364–1380). Their full-page calendar pictures alternately represent the nobility and the peasantry, always in seasonal, naturalistic settings with realistically painted figures. Flanders ■ A major art form in Flemish churches and private homes alike was the altarpiece with folding wings. In Robert Campin’s Mérode Triptych, the Annunciation takes place in a Flemish home. As is typical of “Northern Renaissance” art, the everyday objects in the triptych have symbolic significance. The largest altarpiece of the era is the Ghent Altarpiece, begun by Hubert van Eyck and completed by his brother Jan. ■ Jan van Eyck, Rogier van der Weyden, and others established portraiture as an important art form in 15th-century Flanders. Their subjects were successful businessmen, both Flemish and foreign, and occasionally themselves. Jan portrayed himself wearing a red turban, and Rogier represented himself in the guise of Saint Luke drawing the Virgin. ■ Among the other major Flemish painters were Petrus Christus and Hans Memling of Bruges, Dieric Bouts of Louvain, and Hugo van der Goes of Ghent, all of whom produced both altarpieces for churches and portraits for the homes of wealthy merchants. van Eyck, Ghent Altarpiece, ca. 1423–1432 de Baerze, Retable de Champmol, 1399 Limbourg brothers, Les Très Riches Heures du Duc de Berry, 1413–1416 France and the holy roman empire ■ During the 15th century, the Hundred Years’ War crippled the French economy, but dukes and mem-bers of the royal court still commissioned some notable artworks. French court art—for example, Jean Fouquet’s Melun Diptych—owes a large debt to Flemish painting in style and technique as well as in the integration of sacred and secular themes. ■ The Late Gothic style remained popular in 15th-century Germany for large carved wood retables fea-turing highly emotive figures amid Gothic tracery. The leading sculptors were Veit Stoss and Tilman Riemenschneider. ■ The major German innovation of the 15th century was the development of the printing press, which publishers soon used to produce books with woodcut illustrations. Woodcuts are relief prints in which the artist carves out the areas around the lines to be printed. ■ German artists, such as Martin Schongauer, were the earliest masters of engraving. The intaglio technique enables a wider variety of linear effects because the artist incises the image directly onto a metal plate. Nuremberg Chronicle, 1493 Fouquet 21-1a Inspired by a poem by Angelo Poliziano, Botticelli painted Birth of Venus for the Medici between 1484 and 1486. At the left, Zephyrus, carrying Chloris, blows Venus on a cockleshell to Cyprus.  21-1b Botticelli’s revival of the theme of the female nude, largely absent from medieval art, was consistent with the Quattrocento view that beholding physical beauty prompts the contemplation of spiritual beauty. 1 ft. 21-1 Sandro Botticelli, Birth of Venus, ca. 1484–1486. Tempera on canvas, 59 90 × 99 20. Galleria degli Uffizi, Florence.  21-1c Awaiting the newborn goddess of love on her sacred island is the nymph Pomona, who runs to meet Venus with a brocaded mantle. Her draperies undulate loosely in the gentle gusts of wind. Copyright

Arbete och pengar, åk 5

Synthese - Penser la mort

Contexte de l'ouvrage (Penser la mort)

skimming vs penetration pricing - exam 3

HGGSP - Thème 1 : Penser la démocratie directe et représentative

Philo- Penser avec méthode

1. Comment penser le droit ?

Earth Science: Plate Tectonics, Pangea, and Mountain Building

# 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.

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