Lesson 13 - Statements, Requests, Conjuctions, Double Passages

Italiano GR1 - Frase complessa, Frase principale, Subordinate (argomentali, implicite o esplicite, soggettive o oggettive, ecc)

Suggestions

To express concern/ To ask for another opinion or suggestions

# 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.

ENGLISH SUMTEST 1

French sports, adverbs, frequency, and suggestions+responses

Research which suggests that who you want to be associated with has a role (social groups/communities of practise)

Jeckel Fall 2026 Exam #2 Study Suggestions

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.

Understanding Geography and Its Implications The Nature of Geography Geography transcends mere location; it investigates the reasons behind spatial phenomena and the interplay of social forces that shape places. Maps are not neutral; they embed cultural and ideological biases that influence perceptions of space. For example, the Mercator projection distorts the size of landmasses, affecting our understanding of global geography. Core concepts include human/environment relationships, space, place, region, movement, landscape, and location, each contributing to a comprehensive understanding of geography. Space is both a measurable entity (e.g., coordinates) and a cultural construct influenced by language and technology, exemplified by the concept of space-time compression. The Lefebvre triad illustrates the complexity of spatial understanding: spatial practice (how space is used), representations of space (how space is conceptualized), and representational spaces (the lived experiences of space). The concept of scale is crucial; phenomena like global warming manifest differently across various scales, challenging the notion that 'global' is inherently dominant. Globalization and Its Challenges Globalization fosters closer relationships between distant places, but its effects are uneven, contradicting the 'flat world' argument that location is becoming irrelevant. The course critiques the neoliberal perspective that reduces all values to monetary worth, particularly in education, as discussed in Deresiewicz's 'The Neoliberal Arts'. The 'End of Geography' argument posits that technological advancements diminish the importance of location, yet the course emphasizes that geographical context remains significant in understanding social dynamics. Globalization's impact is not uniform; it creates winners and losers, necessitating a critical examination of its implications on local cultures and economies. The interconnectedness of global economies can lead to cultural homogenization, raising concerns about the preservation of local identities and practices. Historical context: The rise of globalization can be traced back to colonialism and the expansion of trade networks, which laid the groundwork for contemporary global interactions. The Neoliberal Arts and Higher Education The Impact of Neoliberalism on Education Neoliberalism has transformed American higher education, prioritizing marketable skills over intellectual growth, as articulated by Deresiewicz. The shift from mission statements focused on learning to vague buzzwords reflects a broader trend of commodifying education, where the value of knowledge is measured by its economic utility. David Brooks identifies three purposes of college: commercial (career preparation), cognitive (learning to think), and moral (developing personal beliefs), with only the commercial purpose being widely recognized today. The decline of the moral purpose in education is evident in the increasing focus on vocational training at the expense of critical thinking and the humanities. Historical rebuttal: The moral purpose of education has deep roots in American history, dating back to land-grant colleges and the G.I. Bill, which aimed to democratize access to education. The concept of 'learned helplessness' illustrates how students internalize market-driven narratives, feeling powerless against economic forces that dictate their career paths. The Role of Buzzwords in Education Buzzwords like leadership, service, and creativity are critiqued for perpetuating neoliberal assumptions and undermining genuine educational values. Leadership is framed as creating a hierarchy, where a select few lead while the majority follow, detracting from the ideal of collective citizenship. Service is often portrayed as a benevolent act by the privileged, reinforcing social hierarchies rather than fostering genuine community engagement. Creativity is redefined within a business context, limiting it to predetermined outcomes rather than encouraging open-ended exploration and innovation. The push for technocratic solutions within a static market framework fails to address pressing issues like climate change and social inequality, which require transformative approaches. Counterbalancing institutions, such as the arts and democracy, are increasingly subsumed by market logic, leading to a homogenization of cultural and educational values. Discussion and Reflection Critical Questions for Consideration Should moral education, as defined by Deresiewicz, be a fundamental purpose of higher education? How do personal experiences reflect the 'retrofitting' of educational values towards neoliberal ideals? In what ways can students and educators advocate for a return to the intellectual and moral purposes of education? What role do counterbalancing institutions play in resisting the commodification of education? How can we redefine success in education beyond marketable skills to include critical thinking and civic engagement? What strategies can be employed to challenge the prevailing narratives of learned helplessness among students? Neoliberalism and Higher Education Conceptual Framework of Neoliberalism Deresiewicz argues that neoliberalism is a choice rather than an inevitable outcome, suggesting that societal structures can be altered through collective action. Neoliberalism emphasizes market-driven solutions, often at the expense of public goods and services, particularly in education. The commodification of higher education leads to a focus on profit rather than the intellectual and moral development of students. Proposed Solutions to Neoliberalism in Education Deresiewicz advocates for treating higher education as a right, promoting high-quality, low- or no-cost public education. He emphasizes the need to restore the intellectual and moral purposes of education, moving away from purely market-driven motives. Collective student action is highlighted as a means to challenge the neoliberal framework and advocate for public solutions. Discussion Questions and Their Implications Should moral education be a fundamental purpose of higher education? This question invites reflection on the role of ethics in academic institutions. The concept of 'retrofitting' suggests adapting existing structures to better serve public interests; students are encouraged to reflect on their experiences with this. Understanding these themes is crucial as they set the stage for discussions on political economy later in the course. Nations and States: Definitions and Dynamics Definitions and Distinctions A nation is defined as an 'imagined community' characterized by shared identity elements such as language, history, and values. A state is a politically organized entity with a defined territory, government, and permanent population, distinct from the concept of a nation. The term 'nation-state' refers to the overlap of these two concepts, though real-world examples often reveal discrepancies. Historical Context and Evolution The Peace of Westphalia (1648) marked a significant shift in the understanding of statehood, establishing the principles of territoriality and sovereignty. Prior to this, populations were defined by territory; post-Westphalia, territory began to define populations, influencing global governance. Colonialism played a crucial role in spreading the nation-state model worldwide, often disregarding existing cultural and ethnic identities. Contemporary Challenges to Nation-States The concept of territoriality is challenged by globalization, migration, and technological advancements, leading to phenomena like deterritorialization. Non-state actors, such as the UN and IMF, play significant roles in global governance, often complicating traditional state authority. The rise of independence movements (e.g., Catalonia, Scotland) reflects growing discontent with established nation-states and their governance. The Future of Nation-States Independence Movements and Globalization Recent independence movements are fueled by historical grievances and the perceived artificiality of nation-states, often drawn from colonial legacies. The decline of interstate wars has created a more favorable environment for secessionist movements, as seen in Scotland and Catalonia. Globalization has lowered the costs of independence, allowing smaller regions to seek autonomy without the need for large military forces. The Role of Technology and Identity Technology, particularly social media, has facilitated democratic uprisings and the organization of independence movements. However, rather than unifying populations, the internet has often highlighted differences, leading to increased tribalism and identity politics. The concept of nations being 'made' rather than 'given' suggests that identity can be constructed through education, media, and political narratives. The Concept of 'Lands in Limbo' Regions like Nagorno-Karabakh and Abkhazia exemplify the challenges of non-recognition, facing economic isolation and high unemployment rates. The difficulty of gaining international recognition for breakaway states is often tied to the interests of powerful nations, which fear encouraging separatism within their borders. The tension between self-determination and multiculturalism raises questions about the future of nation-states and the inclusivity of national identities. The Role of Technology and Nation-States Technology and Social Dynamics The internet was anticipated to unify people, yet it has led to increased tribalism as individuals focus on differences rather than commonalities. The phenomenon of 'secession from the public good' highlights how individuals withdrawing from public institutions, like schools, undermines national cohesion and identity. The nation-state's survival is attributed to its monopoly on violence and territorial defense, necessitating active democratic engagement at all levels of governance. Global Challenges and Nation-State Dynamics Global issues such as climate change require international cooperation, which becomes increasingly complex with the involvement of multiple nation-states. Alternatives to traditional nation-states include communitarian models, such as the Kurdish region in Syria, and proposals for a stronger United Nations or European Union-style governance. Nation-building is an ongoing process, as seen in Pakistan's struggle to define its identity post-partition, reflecting the complexities of national narratives and the role of religion in politics. Foundations of Political Economy Historical Context of Political Economy The term 'economy' originates from the Greek 'oikonomos', meaning household manager, indicating the historical link between state management and economic relations. The separation of the economy as a distinct sphere emerged around 300 years ago, leading to a perception of economic relations as superior to other social relations. Early political economists viewed the state as a manager of resources, including food, infrastructure, and education, shaping societal relations. Economic Frameworks and Theories Neoclassical economics emphasizes rational, profit-maximizing individuals and the market's inherent logic, favoring private property rights. Marxian economics critiques this view, focusing on class struggles and the ownership of surplus value by capitalists, highlighting the labor-capital contradiction. Both frameworks represent forms of economic determinism, suggesting that market forces or class relations dictate societal outcomes. Globalization and Economic Structures Evolution of Global Economic Systems Globalization is propelled by advancements in communication, transportation, and logistics, yet it remains uneven due to digital divides and political choices. Historical progression from feudalism to post-Fordism illustrates shifts in economic structures, including the transition from industrial to service economies. Commodification in modern economies emphasizes the creation of desire over mere production, leading to cycles of innovation and consumption. Global Economic Hierarchies The classification of countries into core, semi-periphery, and periphery highlights disparities in capital management and resource supply. The Apple example illustrates how core countries benefit from R&D while peripheral countries provide cheap labor for assembly, maximizing profits at the core. The rise of platform capitalism and the gig economy raises questions about job stability and the distribution of economic benefits. Population Dynamics and Theories Malthusian Theory and Critiques Malthus's principle posits that population grows geometrically while food supply increases arithmetically, leading to checks on population growth. Elwell's reinterpretation of Malthus suggests that checks on population are constant and that productivity gains lead to population increases rather than simple overshoot. Robbins critiques the Malthusian narrative, arguing that affluence and technology play a more significant role in resource consumption than sheer population numbers. Historical Population Controls and Transitions The 'Four Horsemen' of pre-industrial society—disease, famine, war, and conquest—historically regulated population growth. The Demographic Transition Model illustrates the decline of death rates followed by birth rates, influenced by urbanization and women's education. Criticisms of the model highlight its Eurocentric bias and the oversimplification of complex societal interactions, particularly regarding colonialism and exploitation.

Absolutely 💗 I made this directly from the Unit 1 Review video. The biggest thing your teacher says at the end is that the test won’t just ask you to memorize definitions — you need to be able to apply the concepts to new situations and explain your reasoning using evidence. 🧬 BIOLOGY UNIT 1 TEST STUDY GUIDE 1. 🔬 Scientific Thinking & Experimental Design Know the difference: Observation * Something you directly see, measure, or notice. * Example: The plant grew 4 cm. Inference * A conclusion/explanation based on observations and evidence. * Example: The plant grew because it received more sunlight. Hypothesis * A testable prediction. * Usually written as: If ___, then ___, because ___. Variables Independent variable * What the scientist changes. Dependent variable * What the scientist measures. ⭐ Easy way to remember: Independent = I change it. Dependent = Data I collect. Control group * Used as a comparison. * It helps scientists see whether the independent variable actually caused a difference. Constants * Things that are kept the same during an experiment. Fair test A good experiment should change one main variable while keeping other important conditions controlled. Experimental evidence You need to be able to decide whether results: * Support the hypothesis * Do not support the hypothesis ⚠️ Don’t automatically say a hypothesis was “proven.” Scientists use evidence to determine whether results support it. Repeated trials Scientists repeat experiments and collect multiple measurements because one trial may not be reliable. Sources of error Be able to identify things that could have affected an investigation, such as: * Something not being kept constant * Measuring incorrectly * Equipment problems * Human error * Not enough trials ⸻ 📊 2. Working With Data Your teacher specifically says you need to be able to: Read: * Tables * Graphs * Diagrams * Written scenarios Identify patterns and trends Look for things like: * Increasing * Decreasing * Staying the same * One group being higher/lower than another Compare groups Use actual evidence from the data. ❌ Weak: Group A did better. ✅ Better: Group A had a higher growth rate than Group B. Make predictions Use the pattern in the data to predict what could happen next. Result vs. Conclusion Result = WHAT happened Conclusion = WHAT the results mean Example: Result: Plants receiving more light grew 5 cm taller. Conclusion: The data suggests that greater light exposure increased plant growth. ⸻ 🌱 3. Characteristics of Living Things You need to understand what separates living things from nonliving things. Living things have characteristics such as: 🧫 Cells Living things are made of cells. ⚡ Energy Living things need and use energy. 🌱 Growth & development Living things grow and change throughout their lives. 🧬 Reproduction Living things can produce new organisms. 👀 Response Living things respond to changes in their environment. ⚖️ Maintaining internal conditions Living things maintain stable internal conditions. This is called homeostasis. Evidence questions You may be given an unfamiliar example and asked: Is it living or did it come from something living? Don’t just guess based on whether it moves. Look at the evidence and the characteristics of life. ⸻ 🔬 4. Microscopes & Cellular Observation Your teacher says you need to understand: Purpose of a microscope A microscope allows scientists to observe biological structures that are too small to see with the naked eye. Magnification Magnification makes something appear larger. You need to understand how changing magnification affects what you see. Generally: ⬆️ Higher magnification * Object appears larger * You see a smaller area * You may see more detail ⬇️ Lower magnification * Object appears smaller * You see a larger area Evidence from microscopes Scientists can use observations made with microscopes as evidence. Microscope parts Your video says you should be able to identify microscope parts and know their functions, so make sure you know the parts your class used, especially: * Eyepiece/ocular lens * Objective lenses * Stage * Light source * Diaphragm * Coarse adjustment * Fine adjustment ⸻ ⚛️ 5. Chemistry of Life The atom Know the basic structure of an atom and the roles of its particles: Particle Charge Proton + Neutron 0 Electron − Chemical bonds Atoms can interact with each other and form chemical bonds. You need to understand how atoms interact to form bonds, not just memorize the word “bond.” ⸻ 🖤 6. Why Carbon Is Important Your review specifically says you need to understand: Why carbon is especially important in living organisms. Carbon is important because it can form many different bonds and build the large, complex molecules needed by living things. Structure → Function This is a BIG idea. The structure of a molecule affects its function. In other words: What something looks like/is built like → affects what it can do. You should be able to apply this idea to unfamiliar examples. ⸻ 🧬 7. Biological Molecules Know the four major types of biological molecules and their general roles: 🍞 Carbohydrates Generally used for: * Quick/short-term energy * Some structural purposes 🥑 Lipids Generally used for: * Long-term energy storage * Cell membranes * Insulation/protection 💪 Proteins Used for many jobs, including: * Structure * Transport * Movement * Enzymes 🧬 Nucleic acids Used to: * Store and transmit genetic information ⭐ Remember: Carbs → energy Lipids → long-term energy/storage & membranes Proteins → many jobs, including enzymes Nucleic acids → genetic information ⸻ 🧪 8. ENZYMES ⭐ VERY IMPORTANT Your video has a whole section on enzymes, so definitely study this. What do enzymes do? Enzymes help biological chemical reactions happen more efficiently. They are biological catalysts. Enzyme + substrate An enzyme interacts with the substance it acts on, called the substrate. The substrate interacts with the enzyme’s active site. Think: Enzyme → active site → substrate Structure & function The shape/structure of an enzyme is important because it affects how it interacts with its substrate. That’s another example of: Structure → function Conditions affect enzymes Changes in environmental conditions can affect enzyme activity. For example: * Temperature * pH You need to be able to look at an enzyme investigation and interpret what happened. ⸻ 🌡️ 9. pH & Biological Systems pH scale The pH scale tells you how acidic or basic something is. Remember: 🔴 Low pH → acidic ⚪ pH 7 → neutral 🔵 High pH → basic Why does pH matter? Changes in pH can affect biological processes. This is especially important with enzymes, because changing the conditions can change enzyme activity. Test-style question You might see an experiment where an enzyme is tested at different pH levels. You should be able to: 1. Identify what was changed. 2. Look at the data. 3. Identify the pattern. 4. Explain what happened. 5. Use evidence from the data to support your conclusion. ⸻ 🚨 WHAT YOUR TEACHER REALLY WANTS YOU TO KNOW The last part of your video is SUPER important. It basically says: Don’t just memorize definitions. You need to be able to take what you know and use it in a new situation. For example, they might NOT ask: What is an independent variable? Instead, they could give you an experiment and ask: Which variable is the independent variable? You have to figure it out from the situation. ⸻ ⭐ THE BIG 10 TO KNOW BEFORE THE TEST If you’re short on time, make sure you can answer these: 1. What’s the difference between an observation and an inference? 2. What makes a hypothesis testable? 3. What’s the independent variable vs. dependent variable? 4. Why do scientists use controls, constants, and repeated trials? 5. How do you use data to support a conclusion? 6. What characteristics make something living? 7. How does changing microscope magnification affect what you see? 8. What are the four major biological molecules and their general jobs? 9. How do enzymes interact with substrates, and how can conditions affect enzyme activity? 10. What does pH tell you, and how can changing pH affect biological processes? 🧠 One sentence to remember the whole unit: Scientists use experiments → collect data → find patterns → make conclusions about how living systems work. And honestly, based on the video, #1, #2, #3, #4, #5, enzymes, and pH are the areas I’d focus on the most because the review repeatedly emphasizes applying those ideas to investigations rather than simply memorizing vocabulary.

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

9.7 ad 9.10 food signs, suggesting somewhere to eat

Copy Editing Suggestions

Section 8 Unit 50: Dinner: Suggest Alternatives To Others

Subtest II: Math & Science

Section 8 Unit 78: Tensions: Suggest Going Out Together

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

🦠 MICROBIOLOGY — WEEK 1 STUDY NOTES Microbiology Foundations Assigned reading: 1.1 What Our Ancestors Knew 1.2 A Systematic Approach 1.3 Types of Microorganisms 3.1 Spontaneous Generation 3.2 Foundations of Modern Cell Theor/y 1.1 What Our Ancestors Knew First: What is microbiology? Microbiology = the study of very small organisms and infectious agents. Microorganism / microbe = an organism that is generally too small to see without a microscope. Examples include: * Bacteria * Archaea * Fungi such as yeast and molds * Protozoa * Microscopic algae * Some parasites Viruses are also studied in microbiology, although viruses are acellular, meaning they are not made of cells. Important idea Microbes are NOT automatically bad. Many microbes are harmless or helpful. They: * help produce food * live naturally in and on our bodies * help ecosystems function * can be used to make medicines and other products Only some microbes cause disease. 🍞 Humans Used Microbes Before They Knew Microbes Existed Humans were using microorganisms for thousands of years before microscopes existed. One of the biggest examples is: Fermentation Fermentation = microorganisms change sugars/carbohydrates into substances such as: * alcohol * gases * organic acids Microbes involved can include: bacteria + yeast + molds Humans used fermentation to make: * bread * cheese * yogurt * beer * wine * pickled vegetables Easy example Yeast eats/metabolizes carbohydrates in bread dough. ↓ Yeast produces carbon dioxide (CO₂). ↓ Gas becomes trapped in the dough. ↓ Bread rises. Remember Fermentation = microbes changing sugars. ⸻ 🧊 Ötzi the Iceman Ötzi was a preserved human mummy approximately 5,300 years old. Scientists found evidence that he had: * Trichuris trichiura → a parasitic worm * Borrelia burgdorferi → bacterium that causes Lyme disease He also carried a fungus called Fomitopsis betulinus, which has laxative and antibiotic properties. Why does this matter? It shows that ancient people were trying to treat disease long before they understood microorganisms. ⸻ 🦠 Early Ideas About Disease Before microscopes, people didn’t know exactly what caused disease. Some cultures believed disease came from: * supernatural forces * angry gods * fate * bad air But some people began to realize that disease might spread between people. ⸻ Quarantine Ancient societies sometimes separated sick people from healthy people. This is called: Quarantine = separating potentially infected people to prevent disease spread. Even though they didn’t know what bacteria or viruses were, they understood that some diseases could spread. ⸻ 🚿 Sanitation Ancient civilizations also developed ways to improve sanitation. Examples included: * clean-water systems * drainage systems * sewers * aqueducts This was important because removing human waste and providing cleaner water can reduce disease transmission. ⸻ Important People From Early Medicine Hippocrates Who? Greek physician. Important idea: Disease had natural causes, rather than always being caused by supernatural forces. He is commonly called: “Father of Western Medicine.” Remember Hippocrates → disease has natural causes. ⸻ Thucydides Thucydides survived the Athenian plague. He noticed that people who survived the disease usually did not become sick from the same disease again while caring for infected people. This was an early observation of: Immunity Immunity = the body’s ability to resist a particular infection/disease. Remember Thucydides → early idea of immunity. ⸻ Marcus Terentius Varro Varro proposed that extremely tiny creatures that could not be seen might cause disease. He described tiny creatures entering the body through the: * mouth * nose This was an important idea because microscopes did not yet exist. Remember Varro → invisible tiny creatures may cause disease. ⸻ Ibn Sina / Avicenna Ibn Sina wrote the important medical work: Canon of Medicine He described ideas involving: * contagion * spread of disease * transmission through breath * isolation of sick people His work contributed to ideas that later became important for quarantine and infectious-disease control. ⸻ 🔬 Birth of Microbiology The development of the microscope completely changed science. For the first time, scientists could actually see microorganisms. ⸻ Antonie van Leeuwenhoek Extremely important name. In 1675, Antonie van Leeuwenhoek used powerful simple microscopes to observe tiny organisms. He called them: “animalcules” Today we know that some of the organisms he observed were: * bacteria * protists Remember Leeuwenhoek → first to describe bacteria/microorganisms seen through a microscope. Think: Leeuwenhoek = LOOKED at microbes. ⸻ ⭐ Golden Age of Microbiology Approximately: 1857–1914 During this period, scientists made major discoveries connecting microorganisms with: * fermentation * disease * medicine * infection Two huge names: Louis Pasteur and Robert Koch You are going to see both names repeatedly in microbiology. ⸻ Louis Pasteur Pasteur showed that microorganisms are responsible for fermentation. He also developed: Pasteurization Pasteurization = using controlled heat to kill/reduce microorganisms that cause spoilage or disease. He also worked on vaccines, including a vaccine against: rabies Pasteur will become especially important again in Section 3.1. Remember Pasteur → fermentation → pasteurization → vaccines → helped prove germ theory → disproved spontaneous generation ⸻ Robert Koch Koch showed that particular microbes could cause particular diseases. He identified microorganisms associated with diseases including: * anthrax * tuberculosis * cholera Remember Koch → specific microbe → specific disease. ⸻ 🧪 Basic Microbiology Laboratory Tools You don’t need to master these yet, but recognize the terms. Microscope → magnifies microbes. Stains/dyes → add color/contrast so microorganisms are easier to see. Growth media → nutrients/material used to grow microorganisms in the laboratory. Petri dish → shallow dish commonly used to hold growth media. Test tube → can contain liquid or solid/semi-solid growth media. Bunsen burner → flame that can be used during laboratory sterilization procedures. These will make much more sense once you start doing microbiology lab work. ⸻ 1.2 A Systematic Approach Now we move from discovering microbes to: “How do scientists organize and name all these different organisms?” ⸻ Taxonomy Definition Taxonomy = classification, description, identification, and naming of living organisms. Think: Taxonomy = biological organization system. ⸻ Carolus Linnaeus Linnaeus developed an important system for classifying organisms. The main levels used in classification include: Kingdom → Phylum → Class → Order → Family → Genus → Species A common memory trick: K P C O F G S King Philip Came Over For Good Soup You should know the order. ⸻ Species Species is the most specific/basic taxonomic level in this hierarchy. Example: Homo sapiens Homo = genus sapiens = species ⸻ Binomial Nomenclature Very important term. Binomial = two names. Every organism receives a scientific name consisting of: Genus + species Example: Homo sapiens Rules: Genus * first letter CAPITALIZED species * lowercase Both should normally be italicized when typed. Correct: Homo sapiens Not: Homo Sapiens ❌ homo sapiens ❌ Homo Sapiens ❌ ⸻ 🌳 Phylogeny Phylogeny = evolutionary relationship/history between organisms. Scientists can represent these relationships with a: Phylogenetic tree A phylogenetic tree shows how organisms are believed to be evolutionarily related. Organisms with a more recent common ancestor are considered more closely related. ⸻ Classification Changed Over Time Scientific classification did not stay the same. Linnaeus Originally divided nature into kingdoms including: * animals * plants * minerals The mineral kingdom was later abandoned. ⸻ Ernst Haeckel Added: Protista for many unicellular organisms. He later proposed Monera for organisms lacking nuclei. Remember: Haeckel → Protista ⸻ Robert Whittaker Developed a five-kingdom system: Animalia Plantae Fungi Protista Monera ⸻ 🧬 Carl Woese — VERY IMPORTANT Carl Woese used differences in: ribosomal RNA (rRNA) to study evolutionary relationships. His work helped establish the modern: THREE-DOMAIN SYSTEM 🟠 Bacteria 🟣 Archaea 🔵 Eukarya This is very important for your Week 1 material. Memorize: BAE Bacteria Archaea Eukarya ⸻ Bergey’s Manuals These are important references used in bacteriology. They help scientists: * classify bacteria * identify bacteria You probably don’t need every detail yet, but recognize the name: Bergey’s Manual ⸻ How Can Bacteria Be Identified? Scientists can identify microorganisms using things such as: Biochemical tests Look at chemical/metabolic characteristics. DNA/RNA analysis Examines genetic material. Serological tests Use reactions involving antibodies/antigens. ⸻ 1.3 Types of Microorganisms This section is VERY IMPORTANT. You need to understand the major groups. ⸻ 🌎 Three Domains of Life Again: 1. Bacteria 2. Archaea 3. Eukarya ⸻ Before We Continue: Two Big Cell Types You will hear these words constantly: PROKARYOTE vs EUKARYOTE Prokaryotic cells DO NOT have a membrane-bound nucleus. Bacteria = prokaryotic Archaea = prokaryotic Eukaryotic cells DO have a membrane-bound nucleus. Examples include: * animals * plants * fungi * protozoa * algae Super important: Prokaryote = NO nucleus Eukaryote = HAS nucleus ⸻ 🦠 BACTERIA Bacteria are: * unicellular * prokaryotic * found almost everywhere Some bacteria are helpful. Some bacteria can cause disease. Many bacteria have cell walls. You’ll learn much more about bacterial structures later. ⸻ 🌋 ARCHAEA Archaea are also: * unicellular * prokaryotic Like bacteria, they do not have a nucleus. BUT: Archaea ≠ Bacteria They differ in: * genetics * evolutionary history * metabolic pathways * cell membrane composition * cell wall composition Archaea occur in many environments. Important textbook point No archaea have been identified as human pathogens. Remember Bacteria + Archaea = Prokaryotes ⸻ 🔵 EUKARYA Eukaryotic microorganisms include: Algae Protozoa Fungi Helminths These have eukaryotic cells. ⸻ 🌿 ALGAE Algae can be: * unicellular * multicellular They are similar to plants in an important way: They perform photosynthesis. Photosynthesis = using light energy to make chemical energy/food. Remember: Algae → photosynthesis. ⸻ 🧫 PROTOZOA Protozoa are: * unicellular * eukaryotic * structurally more complex than bacteria Many are capable of movement. Remember Protozoa → single-celled eukaryotes, often motile. Motile = able to move. ⸻ 🍄 FUNGI Fungi studied in microbiology include: Yeasts Usually unicellular. Molds Usually grow as multicellular filament-like structures. Examples of fungi can be microscopic even though other fungi, such as mushrooms, are large. Remember Fungi → yeast + molds ⸻ 🪱 HELMINTHS Helminths = parasitic worms. You may think: “A worm isn’t microscopic. Why is it in microbiology?” Good question. Adult worms may be large enough to see. BUT their: * eggs * larvae can be microscopic. Therefore they are studied in microbiology. ⸻ 🦠 VIRUSES Viruses are different from cellular organisms. Viruses are ACELLULAR. Acellular = not made of cells. Viruses cannot reproduce independently. They require a: Host cell to reproduce. Remember Virus = acellular + requires host to reproduce ⸻ ⭐ Major Microorganism Comparison Group Cell type Nucleus? Important idea Bacteria Prokaryotic ❌ Some cause disease Archaea Prokaryotic ❌ Different from bacteria; no known human pathogens Fungi Eukaryotic ✅ Yeasts + molds Protozoa Eukaryotic ✅ Unicellular, often motile Algae Eukaryotic ✅ Photosynthesis Helminths Eukaryotic ✅ Parasitic worms Viruses Acellular No cell Need host to reproduce 🔥 This table is worth knowing very well. ⸻ 3.1 Spontaneous Generation This is mainly about one historical question: Where does life come from? People once believed: Spontaneous Generation Spontaneous generation = the belief that living organisms can arise from nonliving material. Examples people once believed: rotting meat → maggots mud → frogs old food → microorganisms Today we know this idea is incorrect. ⸻ Francesco Redi Redi tested whether maggots appeared spontaneously from meat. He compared meat that flies could reach with meat protected from flies. Result Maggots appeared when flies could access the meat. This suggested: Maggots came from flies — not directly from the meat. Remember Redi → meat + flies + maggots ⸻ John Needham Needham performed experiments with broth. He boiled broth and then observed microbial growth afterward. He interpreted this as evidence supporting: Spontaneous generation. Remember Needham → supported spontaneous generation. ⸻ Lazzaro Spallanzani Spallanzani disagreed. He boiled broth for longer and sealed the containers more carefully. The sealed broth did not show microbial growth. He argued that microbes came from contamination from the environment rather than being generated spontaneously. Remember Spallanzani → argued against spontaneous generation. ⸻ 🦢 Louis Pasteur’s Swan-Neck Flask Experiment This is VERY IMPORTANT. Pasteur used flasks with long curved necks. Why the curved neck? Air could enter the flask. BUT: Dust and microorganisms became trapped in the curved neck. So the broth remained uncontaminated. When microorganisms could reach the broth, microbial growth occurred. Conclusion Microorganisms did NOT spontaneously appear. They came from microorganisms already present in the environment. Pasteur helped establish the principle: “Life comes from life.” Exam memory Pasteur → swan-neck flask → disproved spontaneous generation. ⸻ 3.2 Foundations of Modern Cell Theory Now we move from: “Where do microbes come from?” to: “What is life made of?” Answer: CELLS ⸻ 🧬 Cell Theory The textbook describes the development of the idea that cells are the fundamental units of life. The central ideas are: 1. All living organisms are made of one or more cells. 2. The cell is the fundamental/basic unit of life. 3. Cells arise from pre-existing cells. Think: Life → cells → cells come from cells. ⸻ Robert Hooke In the 1660s, Robert Hooke examined cork with a microscope. He saw tiny compartments and called them: “cells” Remember Hooke → named/described cells. Don’t mix him up with Leeuwenhoek: Hooke → cells Leeuwenhoek → microorganisms ⸻ Matthias Schleiden Schleiden studied plants. He concluded that: Plants are made of cells. Remember: Schleiden → plants ⸻ Theodor Schwann Schwann studied animals. He concluded: Animals are made of cells. Remember: Schwann → animals ⸻ Robert Remak Remak provided evidence that cells form through the division of existing cells. ⸻ Rudolf Virchow Virchow strongly promoted the idea: Cells come from other cells. So: New cells do not spontaneously appear. ⸻ Easy Scientist Memory Hooke → saw/named cells Schleiden → plants Schwann → animals Remak/Virchow → cells come from existing cells ⸻ 🧬 Endosymbiotic Theory This sounds difficult, but the basic idea is simple. Endosymbiotic theory says: Mitochondria and chloroplasts were originally bacteria-like prokaryotic cells. A larger ancestral cell engulfed them. Instead of being destroyed, the cells developed a mutually beneficial relationship. Eventually, the engulfed bacteria evolved into: Mitochondria and Chloroplasts inside eukaryotic cells. ⸻ Evidence for Endosymbiotic Theory Mitochondria and chloroplasts have similarities to bacteria. They have: Their own DNA Their DNA resembles bacterial DNA. Their own ribosomes Their ribosomes resemble bacterial ribosomes. They reproduce through a process similar to binary fission Binary fission is a major way bacteria reproduce. Easy version Mitochondria and chloroplasts act strangely like bacteria because their ancestors were bacteria. ⸻ Lynn Margulis Lynn Margulis helped develop and promote the modern endosymbiotic theory. Remember Margulis → endosymbiotic theory ⸻ 🦠 Miasma Theory vs Germ Theory This distinction is very important. Miasma Theory Old idea: Disease comes from “bad air” associated with rotting material. Think: Bad smell → disease. This theory was eventually replaced. ⸻ Germ Theory Germ theory = many diseases are caused by microorganisms. Think: Microbe enters/infects body → disease Scientists whose work helped establish germ theory included: * Ignaz Semmelweis * John Snow * Louis Pasteur * Joseph Lister * Robert Koch ⸻ 🧼 Ignaz Semmelweis Semmelweis worked around childbirth. He noticed that patients treated by doctors and medical students had much higher rates of puerperal fever than patients cared for by midwives. Medical students often went from: autopsies → examining living patients without washing their hands. Semmelweis introduced handwashing with chlorinated lime solution. Result Maternal deaths fell dramatically. Remember Semmelweis → HANDWASHING ⸻ 💧 John Snow John Snow investigated cholera outbreaks in London. He connected cholera cases with: contaminated water. His work helped show that disease wasn’t simply coming from “bad air.” He is important in the history of: Epidemiology Epidemiology = study of disease patterns and spread in populations. Remember Snow → cholera + contaminated water + epidemiology ⸻ Joseph Lister Lister applied ideas about microorganisms to surgery. He promoted: * handwashing * cleanliness * sterilization * antiseptic techniques He used carbolic acid (phenol) to reduce infections during surgery. Result Surgical infections decreased. Remember Lister → antiseptic surgery ⸻ Robert Koch — Again Koch developed: Koch’s postulates These helped scientists determine whether a particular microorganism causes a particular disease. Basic idea: specific microorganism → specific disease You will learn Koch’s postulates in more detail later. ⸻ 🔥 WEEK 1 — PEOPLE YOU NEED TO KNOW Scientist/person Remember THIS Hippocrates Disease has natural causes Thucydides Early observation of immunity Varro Invisible creatures may cause disease Leeuwenhoek Observed microbes/bacteria Linnaeus Taxonomy + naming organisms Haeckel Added Protista Whittaker Five kingdoms Woese Three domains; used rRNA Redi Meat + flies + maggots Needham Supported spontaneous generation Spallanzani Evidence against spontaneous generation Pasteur Swan-neck flask; fermentation; germ theory Hooke Described/named cells Schleiden Plants are made of cells Schwann Animals are made of cells Remak/Virchow Cells come from cells Margulis Endosymbiotic theory Semmelweis Handwashing John Snow Cholera + contaminated water Lister Antiseptic surgery Koch Specific microbes cause specific diseases ⸻ 🚨 THE 15 THINGS I WOULD MEMORIZE FIRST Don’t try to memorize every paragraph tonight. Start here: 1. Microbiology = study of microorganisms. 2. Fermentation uses microbes to convert sugars into products such as alcohol, gases, or acids. 3. Leeuwenhoek observed microorganisms. 4. Pasteur and Koch were major scientists during the Golden Age of Microbiology. 5. Taxonomy = classification and naming of organisms. 6. Binomial nomenclature = Genus + species. 7. Three domains = Bacteria, Archaea, Eukarya. 8. Bacteria + Archaea = prokaryotes. 9. Prokaryote = no membrane-bound nucleus. 10. Eukaryote = has membrane-bound nucleus. 11. Virus = acellular and needs a host to reproduce. 12. Spontaneous generation = life arises from nonliving matter. 13. Pasteur’s swan-neck flask helped disprove spontaneous generation. 14. Cell theory = organisms are made of cells, cells are the basic unit of life, and cells come from existing cells. 15. Germ theory = microorganisms can cause disease. ⸻ 🧠 Super-Simple Week 1 Mental Map Think about the entire week’s reading as one story: PART 1 — Humans discover microbes People used microbes before knowing they existed. ↓ Leeuwenhoek sees them. ↓ Scientists begin studying them. ⸻ PART 2 — Scientists organize microbes Linnaeus → Taxonomy ↓ Woese → 3 domains ↓ Bacteria | Archaea | Eukarya ⸻ PART 3 — Scientists ask where life comes from People believed in spontaneous generation. ↓ Redi + Spallanzani question it. ↓ Pasteur disproves it. ↓ Life comes from existing life. ⸻ PART 4 — Scientists understand cells Hooke → cells ↓ Schleiden → plants Schwann → animals ↓ Remak/Virchow → cells come from cells ↓ Cell Theory ⸻ PART 5 — Scientists understand disease Old: Miasma = bad air causes disease ❌ ↓ New: Germ theory = microorganisms can cause disease ✅ ↓ Semmelweis → handwashing Snow → contaminated water Lister → antiseptic surgery Pasteur → microbes Koch → specific microbe causes specific disease