spark writing 11.10.2026

SPAC 110

18 Adlosterone Antagonists (potassium sparing) Diuretics

# 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.

SPAC 215 Quiz 4

Modul 5 – Apache Spark Core & RDDs

Modul 7 – Spark Streaming & Structured Streaming

Modul 6 – Spark SQL, Catalyst Optimizer & Tungsten

Modul 6 – Spark Prestandajustering & Adaptive Query Execution (AQE)

allocating scarce healthcare resources

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

art that sparks debate

ART APPRECIATION: HUMANITIES, ASSUMPTIONS, AND THE NATURE OF ARTS Art Appreciation helps us understand the meaning, purpose, and value of art. It explores the relationship between the humanities and the arts, the common beliefs people have about art, and the different ways art can be understood and interpreted. I. Humanities and Their Relationship to the Arts A. What Are the Humanities? Humanities are fields of study that focus on human beings, experiences, ideas, values, beliefs, creativity, and culture. The word humanities is associated with the Latin term humanitas, which refers to qualities and learning related to being human. The humanities help us understand human life by exploring questions such as: What does it mean to be human? Why do people create? What do people consider beautiful? How do people express their emotions and beliefs? How does culture influence people’s thinking? How have human ideas changed throughout history? The word humanus means “human” and is associated with being refined, cultured, and worthy of dignity. The humanities are also connected to the philosophical idea expressed by the Greek thinker Protagoras: “Man is the measure of all things.” This emphasizes the role of human beings in understanding and interpreting the world. According to the Webster Dictionary, the humanities include fields such as philosophy, literature, language, and art, excluding theology and the natural and social sciences in the traditional classification. The study of the humanities includes the appreciation of art, which can deepen our understanding of life, reality, and human experiences. B. What Is Art? The word art comes from the Latin word ars, which means skill or ability. Art is a form of human expression through which people communicate their thoughts, emotions, experiences, imagination, beliefs, and perspectives. Art is not limited to beauty. It can also express sadness, anger, humor, social issues, personal experiences, and different views of the world. Art can be understood as a way of grasping the world, particularly human society and spiritual experiences, rather than focusing only on the physical world. Art can take many forms, including the following fine arts: Painting Sculpture Architecture Literature Dance Music Film Works of art can also be classified as verbal or non-verbal. Verbal art uses words to express ideas and emotions. Example: Poems, novels, and plays. Non-verbal art communicates through images, sounds, movements, or forms without relying primarily on words. Example: Paintings, instrumental music, and dance. Art is also influenced by how an artist uses a medium, applies techniques, and expresses the content of an artwork. C. What Is Art? Art is a way for people to share how they experience and understand the world. It can communicate personal feelings, cultural beliefs, social issues, and human experiences. An artwork can be beautiful, emotional, meaningful, thought-provoking, disturbing, humorous, symbolic, or intentionally ordinary. Therefore, art is not limited to objects that people consider beautiful. Its meaning also depends on the artist’s purpose, the methods used, the context, and the viewer’s interpretation. D. Relationship Between Humanities and the Arts The humanities and the arts are closely connected because both explore and communicate human experiences, ideas, emotions, and culture. The humanities help us understand human experiences, while the arts provide ways to express and interpret those experiences. For example, consider a painting depicting poverty. Art communicates the experience of poverty through images, colors, and composition. History explains the social conditions during the period represented. Philosophy encourages us to think about justice and human dignity. Literature presents stories about people experiencing poverty. Sociology helps explain the social relationships and circumstances connected to poverty. This shows that appreciating art involves more than deciding whether an artwork is beautiful. It also requires understanding the artist, society, culture, history, ideas, and emotions behind the work. E. Differences Between Humanities and Art Arts focus more on the creative and expressive aspects of human culture. They involve creating works that communicate ideas, emotions, and experiences. Humanities focus more on studying, analyzing, and interpreting human experiences and cultural works. Arts often emphasize the form, style, techniques, and materials used to create an artwork. Humanities often emphasize the content, meaning, values, and historical or cultural context of a work. Art can be personal and subjective because people may interpret an artwork differently. The humanities use analysis and interpretation to understand human experiences, although interpretations may also vary. F. Importance of Arts and Humanities Arts and humanities help students become well-rounded individuals who can: Become adaptable by understanding different situations and perspectives. Think creatively by developing original ideas and solutions. Develop critical thinking by analyzing and interpreting information. Become responsible citizens by understanding society, culture, and human differences. Improve communication by learning different ways to express ideas and emotions. Understand others by recognizing different experiences, beliefs, and values. II. Why Do We Study Art? Art Appreciation develops our ability to observe, interpret, analyze, and evaluate works of art. 1. Art Develops Creativity Art encourages people to think beyond ordinary ideas and explore different possibilities. Example: Creating a sculpture using clay allows an artist to experiment with different shapes and forms. 2. Art Communicates Emotions Art allows people to express feelings that may be difficult to communicate through ordinary language. Example: Music can communicate sadness, excitement, peace, or nostalgia. 3. Art Reflects Culture Art shows the traditions, beliefs, lifestyles, and values of a particular community. Example: Traditional Filipino weaving, dances, architecture, and music provide insights into Filipino culture. 4. Art Records History Artworks can provide evidence of past events, traditions, people, and ways of life. Example: Historical paintings can show how people dressed and how important events were represented in the past. 5. Art Develops Empathy Art allows us to understand experiences and perspectives that may be different from our own. Example: A film about poverty can help viewers understand the struggles of people living in difficult conditions. 6. Art Encourages Critical Thinking Art encourages viewers to examine and question what they see rather than simply accepting an artwork at face value. When appreciating art, ask: Why did the artist create this? What does the artwork mean? What message is being communicated? Why did the artist use these materials? How does the artwork make me feel? Does the artwork reflect the society in which it was created? These questions help us understand an artwork beyond its physical appearance. COMMON ASSUMPTIONS ABOUT ARTS An important part of Art Appreciation is examining our assumptions. People often have preconceived ideas about what art should be. Assumption 1: "Art must be beautiful." Assumption 2: "I can't appreciate art because I am not talented." Assumption 3: "Art is only for talented people." Assumption 4: "Art must look realistic." Assumption 5: "Expensive art is automatically good art." Assumption 6: "Art has no practical purpose." CLASSIFICATIONS OF ARTS Art can be classified in different ways. One common approach is to group it according to the medium or form used. Visual Arts Performing Arts Literary Arts Applied Arts Traditional and Contemporary Art The Nature of Art Functions and Theories of Arts Art has existed in virtually every human society. Across time and cultures, people have created artworks not only for beauty but also for communication, worship, political expression, social identity, education, remembrance, and personal expression. Understanding the functions of art helps explain why art is made, while studying art theories provides different ways of interpreting and evaluating artworks. Lesson 2. I. Functions of Art The function of art refers to the purpose, role, or use that an artwork serves for an individual, a community, or society. A single artwork can perform several functions at the same time. 1. Personal Function Art can serve the personal needs of the artist or viewer. Artists often create art to express emotions, experiences, beliefs, dreams, memories, or personal identity. Personal functions may include: expressing emotions and feelings; exploring personal experiences; relieving stress or emotional tension; developing creativity; expressing identity and individuality; communicating ideas that may be difficult to express through words. For example, a painter may create an artwork after experiencing sadness, happiness, fear, or loss. The resulting work becomes a visual representation of the artist's emotional experience. Art can also affect viewers personally. A song, painting, sculpture, or film may inspire someone, remind them of an experience, or help them understand their own feelings. Example: Vincent van Gogh's The Starry Night is often discussed in relation to emotion and personal experience. Its swirling sky, intense movement, and expressive colors contribute to its emotional impact. 2. Aesthetic Function The aesthetic function of art focuses on beauty, visual pleasure, harmony, creativity, and appreciation of form. Art may be created simply because people enjoy looking at beautiful or interesting things. Artists achieve aesthetic qualities through elements such as: color; line; shape; texture; balance; proportion; rhythm; harmony; contrast; composition. Aesthetic value does not necessarily mean that an artwork must be traditionally beautiful. Some works may be strange, unsettling, or unconventional yet still provide a powerful aesthetic experience. Example: Decorative patterns found in textiles, pottery, architecture, and jewelry often serve both practical and aesthetic purposes. 3. Social Function Art performs a social function when it influences, reflects, or addresses relationships among people and communities. Art can help strengthen: community identity; cultural traditions; shared values; social relationships; collective memory. It can also draw attention to social problems such as: discrimination; poverty; inequality; violence; environmental destruction; human-rights concerns. Murals, films, posters, songs, photography, and public performances are commonly used to communicate social messages. Example: Community murals may depict local history, important personalities, cultural traditions, or social struggles. 4. Political Function Art has long been used to influence political thought and public opinion. Political art may: support governments or leaders; criticize political systems; encourage nationalism; promote revolution or reform; protest injustice; expose corruption; defend human rights. Throughout history, governments have also commissioned art to demonstrate political power. Statues, monuments, portraits, architecture, posters, and propaganda are examples of artworks that may have political functions. Example: Political cartoons often use humor, exaggeration, symbolism, and satire to comment on government policies or public officials. 5. Religious and Spiritual Function Religion has been one of the most important influences on art throughout history. Art has been used to: represent gods, saints, ancestors, or spiritual beings; tell religious stories; decorate sacred spaces; support prayer or meditation; communicate religious teachings; strengthen faith; perform rituals. Examples include: church paintings; religious icons; Buddhist sculptures; Islamic calligraphy; Hindu temple sculptures; Indigenous ritual objects. Many great works of architecture were created primarily for religious purposes, including churches, mosques, temples, shrines, and cathedrals. 6. Cultural Function Art preserves and expresses the culture of a society. Through art, communities communicate their: beliefs; customs; traditions; values; historical experiences; symbols; languages; ways of life. Traditional dances, textiles, music, pottery, architecture, festivals, and crafts preserve cultural identity from one generation to another. Philippine example: Indigenous weaving traditions such as T'nalak, Inabel, and other regional textiles demonstrate local craftsmanship, cultural identity, symbolism, and community traditions. 7. Historical Function Art can act as a visual record of history. Paintings, sculptures, architecture, photographs, monuments, and other works may reveal information about: clothing; technology; social classes; occupations; beliefs; political events; wars; ceremonies; daily life. Although an artwork should not always be treated as a completely objective historical record, it can provide valuable evidence about how people understood their world. Example: Historical paintings may portray important national events and help preserve collective memory. 8. Educational Function Art can teach people ideas, values, skills, or information. Before widespread literacy, paintings, sculptures, and stained-glass windows often communicated religious or historical stories to people who could not read. Today, art continues to educate through: posters; illustrations; films; documentaries; infographics; cartoons; theater; murals; educational videos. Art can make complicated ideas easier to understand because it combines information with visual or emotional experience. 9. Economic Function Art also contributes to economic activity. Artists and creative professionals work in industries such as: painting; sculpture; architecture; fashion; advertising; graphic design; photography; filmmaking; animation; music; theater; game design; crafts. Museums, galleries, concerts, cultural festivals, tourism, and art markets also generate employment and income. Art therefore has both cultural and economic value. 10. Practical or Utilitarian Function Some artworks combine beauty with practical use. Examples include: pottery; furniture; clothing; architecture; jewelry; baskets; textiles; household decorations. A chair, for example, has the practical function of providing a place to sit. However, its design may also demonstrate artistic creativity. This connection is especially visible in applied arts, crafts, architecture, and industrial design. 11. Commemorative Function Art can preserve the memory of important people, places, or events. Examples include: monuments; statues; memorials; portraits; historical markers. Commemorative artworks allow societies to remember historical achievements, tragedies, sacrifices, and national heroes. 12. Entertainment Function Art can also provide enjoyment and recreation. Examples include: movies; theater; music; dance; animation; comics; digital games. Although entertainment may seem simple, it can also communicate important cultural, moral, social, or political ideas. II. Functions of Art Across History and Cultures The functions of art change depending on historical and cultural context. Prehistoric Societies Prehistoric art includes cave paintings, carvings, small sculptures, and ritual objects. Possible functions included: communication; ritual practices; storytelling; hunting-related beliefs; spiritual expression; recording community life. For example, cave paintings depicting animals may have been connected to rituals, teaching, or beliefs about hunting. Ancient Civilizations In ancient societies such as Egypt, Greece, Rome, Mesopotamia, India, and China, art often supported religion, government, and social hierarchy. In Ancient Egypt, art was closely connected with religion and beliefs concerning the afterlife. In Ancient Greece, artists emphasized idealized human bodies, proportion, balance, and harmony. Ancient Roman art often celebrated military victories, political leaders, and imperial authority. l Medieval Period European medieval art was strongly influenced by Christianity. Art commonly appeared in: churches; manuscripts; mosaics; sculptures; stained-glass windows. Its primary purpose was often religious education and worship. Renaissance During the Renaissance, artists increasingly studied: anatomy; perspective; nature; mathematics; humanism. Art still performed religious functions, but there was greater emphasis on humanity, individuality, intellectual achievement, and realistic representation. Modern Period Modern artists experimented with new ideas and rejected many traditional artistic rules. Art increasingly became a way to: express individuality; explore emotions; question society; experiment with color and form; challenge artistic conventions. Movements such as Impressionism, Expressionism, Cubism, Surrealism, and Abstract Expressionism introduced radically different approaches to creating art. Contemporary Period Contemporary art may address issues such as: identity; gender; globalization; migration; technology; consumerism; climate change; inequality; politics; human rights. Contemporary artists frequently work with photography, installation, performance, video, digital art, and mixed media in addition to traditional painting and sculpture. III. Major Theories of Art An art theory is a perspective or framework used to understand what makes something art and how an artwork should be interpreted or evaluated. Several theories can be applied to the same artwork. Three major approaches are Formalism, Expressionism, and Social Commentary. 1. Formalism Formalism focuses primarily on the visual or structural qualities of an artwork. Instead of concentrating on the artist's biography or political message, formalists analyze how the artwork is organized. Formal analysis examines the elements of art, including: line; shape; form; color; value; texture; space. It also examines the principles of design, including: balance; contrast; emphasis; movement; pattern; rhythm; proportion; unity; variety. Main Question of Formalism How is the artwork visually constructed? A formalist might ask: What colors dominate the artwork? How are shapes arranged? Is the composition balanced? Where does the viewer's eye move? How do lines create movement? How does texture affect the work? How are contrast and emphasis created? Example When analyzing The Starry Night formally, a student may discuss: swirling curved lines; strong contrast between the bright stars and dark landscape; movement created by the sky; exaggerated color; visual balance between the village and the sky. The analysis concentrates on what is visually present rather than the artist's biography. 2. Expressionism or Expressive Theory Expressive theory views art as a means of communicating the emotions, experiences, imagination, or inner life of the artist. The value of the artwork is often connected to its ability to communicate feelings effectively. Main Question What emotion or personal experience does the artwork communicate? Students might ask: What emotion seems to dominate the artwork? How do colors communicate emotion? How does the artist's brushwork affect the mood? What personal experience may have influenced the artwork? How does the artwork make the viewer feel? Example Edvard Munch's The Scream may be interpreted through expressive theory. The distorted figure, dramatic sky, curving lines, and intense colors may communicate feelings such as: anxiety; fear; isolation; emotional distress. From an expressive perspective, the emotional effect of the artwork is particularly important. 3. Social Commentary Theory Social commentary views art as a way of examining, criticizing, or communicating ideas about society. Artists may address issues such as: injustice; poverty; war; oppression; inequality; discrimination; corruption; environmental problems; political power. Main Question What does the artwork say about society? Other questions include: What social problem does the artist address? Who is represented in the artwork? What social groups or institutions are being criticized? What message does the artwork communicate? Does the artist encourage social change? Example Pablo Picasso's Guernica can be interpreted as a powerful response to the suffering caused by war. The distorted figures, chaotic arrangement, and dramatic imagery communicate destruction and human suffering. Through social commentary, the artwork can be understood as an anti-war statement. IV. Additional Art Theories Although formalism, expressionism, and social commentary are important, students can also understand several additional theories. 4. Representational or Imitational Theory This theory emphasizes an artwork's ability to represent or imitate reality. The idea is historically associated with the concept of mimesis, meaning imitation. Questions include: How accurately does the artwork represent reality? Are the human figures realistic? Are perspective, proportion, and anatomy convincing? Does the artwork resemble its subject? Realistic portraits and landscapes are often analyzed through this approach. However, artistic value does not depend entirely on realism because many important artworks are abstract or highly stylized. 5. Institutional Theory Institutional theory argues that something may become recognized as art partly because it is accepted within the art world. The art world may include: artists; critics; museums; galleries; curators; collectors; art historians. This theory becomes useful when discussing modern and contemporary works that may not resemble traditional art. For example, an ordinary object placed in a museum may lead viewers to question: What makes something an artwork? 6. Functional Theory Functional theories emphasize what art does. An artwork may be valuable because it: teaches; communicates; decorates; inspires; entertains; supports rituals; encourages reflection. Under this perspective, the purpose and effect of the artwork are important. 7. Contextual Theory Contextual approaches emphasize the historical, cultural, religious, political, or economic circumstances surrounding an artwork. Questions include: When was the artwork created? Where was it created? What was happening in society at the time? Who commissioned the artwork? What beliefs influenced the artist? Who was the intended audience? Context can dramatically affect interpretation. V. Comparison of Major Art Theories Theory Primary Focus Central Question Formalism Elements and principles of art How is the artwork visually organized? Expressionism Emotion and personal experience What feelings does the artwork communicate? Social Commentary Social and political meaning What does the artwork say about society? Representational Theory Realistic representation How successfully does the work represent reality? Functional Theory Purpose of the artwork What function does the artwork perform? Contextual Theory Historical and cultural background How does context influence the artwork's meaning? Institutional Theory Recognition by the art world Why is this considered art? The important point is that no single theory must completely explain an artwork. Theories provide different perspectives. For example, one painting can be analyzed formally because of its colors and composition, expressively because of its emotional intensity, and socially because it addresses injustice. VI. Applying Art Theories to Specific Artworks Students can use a simple four-step process: Step 1: Describe Identify exactly what can be observed. Questions: What do you see? What colors are present? What people, objects, or symbols appear? What materials were used? Avoid interpretation at this stage. Step 2: Analyze Examine how the elements of art are organized. Consider: line; color; texture; shape; balance; contrast; emphasis; movement. Step 3: Interpret Determine possible meanings. Ask: What message does the artwork communicate? What emotions does it express? What symbols are present? What cultural or social ideas are represented? Step 4: Evaluate Make a reasoned judgment. Ask: Is the artwork effective? What makes it important? Does it successfully communicate its message? Which art theory best helps explain it? VII. Sample Applications Artwork 1: Vincent van Gogh's The Starry Night Formalist Perspective A formalist may focus on the painting's: curved lines; swirling movement; contrasting colors; strong visual rhythm; exaggerated shapes. The night sky dominates the composition and creates energetic movement. Expressionist Perspective An expressive interpretation may emphasize the intense emotional quality of the painting. The exaggerated sky and dramatic colors may suggest powerful emotions, imagination, or inner experience. Social Commentary Perspective Social commentary is less central to this particular artwork because it does not primarily address a specific political or social problem. This demonstrates an important principle: Not every theory is equally useful for every artwork. Artwork 2: Pablo Picasso's Guernica Formalist Analysis Students may observe: fragmented shapes; distorted figures; dramatic contrasts; crowded composition; strong movement; limited color palette. These formal qualities create tension and disorder. Expressionist Analysis The distorted human and animal figures communicate: fear; suffering; panic; grief. The emotional intensity contributes strongly to the artwork's impact. Social Commentary Analysis This is especially important. The artwork is associated with the destruction and suffering caused by war. It may therefore be interpreted as a powerful criticism of violence and conflict. Thus, Guernica demonstrates how one artwork can be studied using several theories. Artwork 3: Juan Luna's Spoliarium The Spoliarium is particularly important when discussing Philippine art. Formalist Perspective Students can examine: dramatic lighting; contrast; composition; scale; human figures; movement; use of color. The arrangement directs attention toward the fallen figures. Expressionist Perspective The artwork may communicate: tragedy; suffering; exhaustion; loss; human vulnerability. Social and Historical Perspective Because of its historical context and later associations with Philippine nationalism, the work may also invite broader interpretations relating to power, oppression, dignity, and historical experience. VIII. Functions and Theories Are Different Students sometimes confuse functions of art with theories of art. A simple distinction is: Function asks: Why was the artwork created or what does it do? Theory asks: How can we understand, interpret, or evaluate the artwork? For example, a political mural may have the social function of raising awareness. However, we can analyze the same mural using: formalism to examine its colors and composition; expressionism to examine emotion; social commentary to interpret its political message. IX. Relationship Between Artist, Artwork, Audience, and Society Art can be understood through four interconnected components: Artist → Artwork → Audience → Society The artist produces the work. The artwork contains visual forms, symbols, ideas, and materials. The audience interprets the artwork based on personal knowledge and experiences. Society and culture influence both the artist and the audience. Because people come from different backgrounds, the same artwork can produce different interpretations. WEEK 3 1. Broad Chronological Development of Art History Art history charts how humanity expresses beliefs, values, and environments over time through visual mediums: Prehistoric & Ancient Art (c. 40,000 BCE – 400 CE): Begins with cave paintings (e.g., Lascaux) and fertility artifacts, evolving into formal artistic conventions in Ancient Egypt, Greece, and Rome that focused on mythology, idealism, human proportion, and architectural grandeur. Medieval Art (c. 500 – 1400): Dominated by religion in Western art (Byzantine, Romanesque, Gothic), prioritizing spiritual symbolism and devotional function over naturalism. Renaissance & Baroque (c. 1400 – 1750): Marked by a "rebirth" of classical values, perspective, anatomical realism, and humanism (Da Vinci, Michelangelo), transitioning into the dramatic lighting, emotional intensity, and dynamic motion of the Baroque period. Modern Art (c. 1860s – 1970s): Key movements—including Impressionism, Cubism, Surrealism, and Abstract Expressionism—broke away from traditional representation, questioning the very definition and purpose of visual art. Contemporary Art (c. 1970s – Present): Focuses on concepts, diversity, digital mediums, and global issues rather than unified styles, inviting viewer participation and critique. 2. Primary and Secondary Sources in Art History Art historical research relies on evaluating both direct artifacts and academic interpretations: Primary Sources: Direct, firsthand evidence from the time period or artist being studied. The Artwork Itself: The physical object (paintings, sculptures, architecture, textiles) revealing material, medium, brushwork, and condition. Historical Artifacts: Letters, artist diaries, sketchbooks, manifests, contract documents, or contemporary reviews written at the time of creation. Secondary Sources: Analyses, interpretations, or reviews created after the event by non-eyewitnesses. Academic Works: Art history textbooks, peer-reviewed journal articles, biography monographs, and museum exhibition catalogs that analyze primary materials. 3. Art in Its Social, Political, and Economic Contexts Art does not exist in a vacuum; it functions as a mirror and driver of its environment: Social Context: Reflects cultural values, religious doctrines, gender roles, and community identity. For example, medieval stained-glass windows served a educational social function for an illiterate public. Political Context: Serves as propaganda, power projection, or resistance. Rulers throughout history commissioned monumental architecture and portraits to assert legitimacy, while modern artists often use art to protest state policies or social injustices. Economic Context: Driven by patronage, trade, and market systems. The rise of a wealthy merchant class in 17th-century Holland shifted art production away from church altarpieces toward portraits, landscapes, and still lifes bought on an open market. History of Art and Sources of Art In Art Appreciation, the study of the History of Art and Sources of Art helps us understand not only how artworks changed through time, but also why they were created and what they tell us about society. 1. Broad Chronological Development of Art History Art developed alongside human civilization. A simplified chronological view is: Prehistoric Art – cave paintings, carvings, and sculptures created to express beliefs, experiences, and daily life. Ancient Art – Egyptian, Greek, Roman, and other civilizations produced art connected with religion, rulers, mythology, and society. Medieval Art – art was strongly influenced by Christianity and religious institutions. Renaissance Art – renewed interest in classical ideas, humanism, science, and realistic representation. Baroque and Rococo Art – emphasized drama, emotion, movement, decoration, and religious or royal power. Modern Art – artists experimented with new styles, ideas, materials, and ways of representing reality. Contemporary Art – reflects current social issues, technology, culture, identity, politics, and everyday experiences. 2. Primary and Secondary Sources in Art History Primary sources are original materials or direct evidence from the period being studied. Examples include: Original paintings, sculptures, buildings, and photographs Artists' letters, journals, and sketches Historical documents and inscriptions Objects and artifacts Secondary sources are materials created later that analyze, interpret, or discuss primary sources. Examples include: Art history books Scholarly articles Museum catalogs Biographies and documentaries Critical studies of artists and artworks Simple distinction: Primary = direct/original evidence Secondary = interpretation or analysis of evidence 3. Art and Its Social, Political, and Economic Contexts Art does not exist separately from society. The social, political, and economic conditions of a particular period can influence what artists create, what subjects they choose, and how their works are received. Social context – Art can reflect traditions, beliefs, customs, identity, and everyday life. Political context – Art may represent rulers, national identity, political events, or social concerns. Economic context – Wealth, trade, patronage, and access to materials can influence the production and development of art. Key Idea: Art is both a product of its time and a record of human experience. By studying an artwork's history, sources, and context, we can better understand the artwork, the artist, and the society that produced it. WEEK 4 1. The Creative Process in Art The creative process maps the journey from an abstract concept to a finished artwork or craft: Idea / Conceptualization: Sparked by observation, emotion, social issues, or personal experience. The artist or artisan brainstorms, sketches, and researches to refine the core vision. Preparation & Materials Selection: The creator plans the composition and gathers the physical media, tools, and technical equipment required for the project. Execution & Production: The physical transformation phase where skill meets medium. This involves drafting, sculpting, weaving, or painting, often marked by trial, error, and dynamic problem-solving. Refinement & Completion: Final adjustments, detailing, surface finishing, or polishing to ensure the work matches the intended aesthetic and functional standards. Exhibition & Reflection: Presenting the finished product to an audience, allowing viewer feedback, critique, and personal reflection to complete the artistic cycle. 2. Art Mediums, Techniques, and Materials Medium: The primary substance or material used to create an artwork (e.g., oil paint, clay, bronze, digital pixels, watercolor, wood). Technique: The specific manner, method, or technical skill an artist applies to manipulate the medium (e.g., chiaroscuro in painting, coiling in pottery, carving vs. casting in sculpture, cross-hatching in drawing). Materials & Tools: The physical instruments used alongside the medium, such as brushes, chisels, kilns, canvases, palettes, or digital tablets. Artist vs. Artisan: An artist primarily focuses on creating works for aesthetic, emotional, or conceptual expression (fine arts), whereas an artisan is a skilled craftsperson who creates functional or decorative objects (e.g., pottery, woodworking, textiles) using master-level traditional craftsmanship. 3. The Role of the Curator The curator acts as the storyteller, bridge, and custodian between the artwork, the artist, and the public: Selection & Acquisition: Researching, selecting, and collecting artworks or artifacts that align with an exhibition theme or institutional mission. Spatial Design & Presentation: Strategically arranging works in a gallery—considering lighting, sightlines, color schemes, and sequencing—to guide the visitor's physical and emotional experience. Interpretation & Contextualization: Writing wall texts, catalogs, and educational guides that provide historical, cultural, or philosophical context, shaping how the public understands and values the art. Preservation & Stewardship: Ensuring optimal environmental conditions (humidity, lighting, handling) to preserve artworks for future generations. Art and Artisan: Process, Medium, Technique, and Curation In Art Appreciation, understanding how art is made and presented helps us appreciate not only the finished artwork but also the artist's creativity, skills, choices, and purpose. 1. Creative Process in Making Art The creative process refers to the steps an artist goes through in developing an artwork. It may include: Idea or Inspiration – identifying a subject, message, or concept. Planning – deciding the composition, materials, colors, and techniques. Creation – transforming the idea into an actual artwork. Revision – making adjustments or improvements. Finalization – completing and preparing the artwork for presentation. The process may differ from one artist to another. Creativity can involve experimentation, imagination, problem-solving, and personal expression. 2. Art Mediums, Techniques, and Materials Medium refers to the material or form used to create an artwork. Examples include: Medium Examples Painting Oil, acrylic, watercolor Drawing Pencil, charcoal, ink Sculpture Clay, wood, stone, metal Printmaking Woodcut, engraving, lithography Photography Digital or film photography Digital Art Computer-generated images and digital illustrations Technique refers to the method or way an artist uses a medium. For example, a painter may use blending, layering, or brushwork, while a sculptor may use carving, modeling, or casting. The choice of medium, material, and technique affects the appearance, texture, meaning, and overall effect of an artwork. 3. Role of the Curator A curator is a professional who selects, organizes, researches, and presents artworks in a museum, gallery, or exhibition. The curator helps shape how audiences experience and understand art by: Selecting artworks for an exhibition Organizing artworks according to a theme or concept Providing labels, descriptions, and historical information Designing the arrangement and flow of the exhibition Connecting artworks to their cultural and historical contexts Therefore, curation influences how viewers see, interpret, and appreciate artworks. Key Idea Art is more than the finished product. It involves the artist's creative process, the choice of medium and technique, and the curation and presentation of the artwork. Understanding these elements allows us to appreciate both the skill of the artisan and the meaning of the art.

spark reading 8.10.2026

Vocab Speaking: Spare Time

writing spark

Unit 1 Spark

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

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

a spark, a flint: how fire leapt to life