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MIDTERM (LESSON 1) SPECIALIZED CRIME INVESTIGATION 2 WITH INTERVIEW AND INTERROGATION INTRODUCTION Special crime investigation deals with the study of major crimes based on the application of special investigative technique. The study concentrates more on physical evidence, its collection, handling, identification and preservation in coordination with the crime laboratory. Special crime investigation involves a close relationship between the prober in the field and the crime laboratory technician. They work together as a team, reacting to and extending one another’s theories and findings both working patiently and thoroughly to solve a crime from their investigative discoveries. The present criminal justice system in our country, the court relies more on physical evidence rather than extra-judicial confession. WHAT IS INTERROGATION? Interrogation is a process of questioning by which police obtain evidence. The purpose of an interrogation is to elicit from the suspect or from his or her relatives or associate's information that they may be suppressing in order to protect the suspect from being subjected to criminal prosecution (Galero-Muftuoglu, 2017, p. 187). Interrogation process is largely outside the governance of law except for rules concerning the admissibility at trial of confessions obtained through interrogation and limitations on the power of police to detain the suspected persons against their will. THREE OBJECTIVES OF INTERROGATION Aside from obtaining information detrimental to a suspect’s case, the following are the three objectives of interrogation: 1. Establish the innocence of a suspect by clearing up facts that seem to point to guilt; 2. Obtain from the suspect or relatives and friends of the suspect: A. The names of accomplices; B. The facts and circumstances surrounding the crime; C. Follow-up leads provided unwittingly, or with ulterior motive, such as faking an alibi; D. The location of stolen goods; E. The location of physical evidence, such as documents, a weapon, or a burglar’s tool. 3. Obtain from the suspect alone: A. Admission – it refers to the express or implied statement tending to support the suspect’s involvement in the crime, but insufficient by itself to prove guilt; B. Confession – it pertains to an oral or written statement acknowledging it. WHAT IS AN INTERVIEW? Interview is defined as a structured conversation where one person or “interviewer” seeks to gather information from one another or the “interviewee” as part of any investigation or intelligence operation. The objective is to obtain accurate and reliable information while respecting human rights; eliciting facts is the aim, not confession. In the process of interviewing the suspects there is the added potential goal of obtaining an admission of guilt or a confession. However, this must not be the primary or sole purpose of interview as even a confession must be substantiated by information and evidence. This will reduce the likelihood of a false accusation and will also enable officers to present stronger case against the suspect, should a confession later be retracted. WHAT IS AN INVESTIGATIVE INTERVIEW? Investigative Interviewing, is a technique developed by practitioners to respond to the large body of scientific evidence that abusive and coercive techniques elicit unreliable information. It uses building rapport with the interviewee, which prevent abusive practices, and also improves the collection and reliability of information. It is a non-coercive approach using open questions to improve the flow of communication and information (Norwegian Center for Human Rights, 2017). GOALS OF INVESTIGATIVE INTERVIEW 1. Eliciting more accurate and reliable information during interviews. 2. Strengthening the capacity, efficiency, and professionalism of interviews. 3. Eliminating reliance on unlawful, ineffective, and counterproductive coercive questioning techniques. 4. Providing successful, affordable, and accessible methods and practices with minimal resources. 5. Delivering more effective information-gathering operations. 6. Fostering greater public trust in and cooperation with criminal justice institutions. 7. Ensuring that no person is subjected to coercion, torture or other forms of ill treatment. 8. Protecting the physical and mental integrity of all persons who interact with public authorities. REID METHOD Reid Method is also known as The Reid Technique of Interviewing and Interrogation, is the interrogation technique widely used by police departments. The Reid Technique involves three components namely: 1. Factual Analysis 2. Behavioral Analysis Interview 3. Interrogation (Nine Steps) FACTUAL ANALYSIS It is an inductive approach where each individual suspect is evaluated with respect to specific observations relating to the crime. It relies not only on crime scene analysis, but also on information learned about each suspect. Its goal is establishing an estimate of a particular suspect’s probable guilt or innocence based on such things as the suspect’s biosocial status like: gender, race, occupation, marital status, etc., opportunity and access to commit the crime, and evaluation of physical and circumstantial evidence. It is also intended to identify characteristics about the suspect and the crime which will be helpful during an interrogation of the suspect believed to be guilty such as motive or the suspect’s personality type. BEHAVIORAL ANALYSIS INTERVIEW It is a non-accusatory question and answer session, involving both standard investigative questions and structured “behavior provoking” questions to elicit behavior symptoms of truth or deception from the person being interviewed. The investigator first asks background questions, to establish personal information about the suspect and allow the investigator to evaluate the suspect’s normal verbal and nonverbal behavior. The investigator then asks behavior-provoking questions intended to elicit different verbal and nonverbal responses from truthful and deceptive suspects (Inbau, F., Reid, J.E., Buckley, J. et.al., 2013, p.63). The investigator will also ask some investigative questions during this stage. It provides objective criteria to render an opinion about the suspect’s truthfulness through evaluating responses to the behavior-provoking and investigative questions. INTERROGATION (NINE STEPS) An interrogation only occurs when the investigator is reasonably certain of the suspect’s involvement in the issue under investigation (Inbau, F., Reid, J.E., Buckley, J. et.al., 2013, p.99). This is composed of Nine steps, they are: 1. Direct, Positive Confrontation 2. Theme Development 3. Handling Denials 4. Overcoming Objections 5. Procurement and Retention of Suspect’s Attention 6. Handling the Suspect’s Passive Mood 7. Presenting an Alternative Question 8. Having the Suspect Relate Details of the Offense 9. Converting an Oral Confession to a Written Confession NINE STEPS 1. Direct, Positive Confrontation. This is where the investigator tells the suspect that the evidence demonstrates the person’s guilt. If the persons guilt seems clear to the investigator, the statement should be unequivocal. 2. Theme Development. This is where the investigator presents a moral justification(theme) for the offense, such as placing the moral blame on someone else or outside circumstances. The investigator presents the theme in a monologue and in a sympathetic manner. 3. Handling Denials. When the suspect asks for permission to speak at this stage, likely to deny accusations, the investigator should discourage allowing the suspect to do so. The innocent suspect are less likely to ask for permission and more likely to promptly and unequivocally deny the accusation. 4. Overcoming Objections. When attempts at denial do not succeed, a guilty suspect often makes objections to support a claim of innocence, phrases such as I would never do that because I love my job are commonly used. The investigator should generally accept these objections as if they where truthful, rather than arguing with the suspect, and use the objections to further develop the theme. 5. Procurement and Retention of Suspect’s Attention. The investigator must procure the suspect’s attention so that the suspect focuses on the investigator’s theme rather than on punishment. One way the investigator can do this is to close the physical distance between himself or herself and the suspect. The investigator should also channel the theme down to the probable alternative components. 6. Handling the Suspect’s Passive Mood. The investigator needs to intensify the theme presentation and concentrate on the central reasons he or she is offering as psychological justification and continue to display an understanding and sympathetic demeanor in urging the suspect to tell the truth. 7. Presenting an Alternative Question. The investigator should present two choices, assuming the suspect’s guilt and develop as a logical extension from the theme, with one alternative offering a better justification for the crime e.g., “Did you plan this thing out or did it just happen on the spur of the moment?” The investigator may follow the question with a supporting statement which encourages the suspect to choose the more understandable side of the alternative. 8. Having the Suspect Relate Details of the Offense. After the suspect accepts one side of the alternative thus admitting guilt, the investigator should immediately respond with a statement of reinforcement acknowledging that admission. The investigator then seeks to obtain a brief oral review of the basic events, before asking more detailed questions. 9. Converting an Oral Confession to a Written Confession. The investigator must convert the oral confession into a written or recorded confession. The website provides some guidelines, such as repeating Miranda Warnings, avoiding leading questions, and using the suspect’s own language. PEACE METHOD PEACE Model (Planning and Preparation, Engage and Explain, Account, Closure, Evaluation), developed in the United Kingdom in response to a number of documented forced confessions and wrongful convictions in the 1980s and 90s (Norwegian Center for Human Rights, 2017). STEP ONE: PLANNING AND PREPARATION It is one of the most important steps in investigative interviewing; without it, interviews may fall before they even begin. Planning – refers to the process of getting ready to interview, both mentally and strategically. Preparation – covers what needs to be ready prior to the interview such as the location of the interview, the environment, as well as technical and administrative matters. Essential Elements of Good Planning • Obtain as much background information as possible on the incident under investigation, including all relevant information on the person to be interviewed. • Assess what additional information is needed and how can it be best obtained. • Follow the legislation and associated guidelines and rules. • Understand the purpose of interview based on an investigation plan recognizing all the relevant and competing hypotheses to be explored, including the possibility that the suspect is innocent. • Prepare the technicalities of the interview (attending to exhibits, logistics, venue, equipment functioning, seating, lawyer, interpreter, and so on) (Norwegian Center for Human Rights, 2017). STEP TWO: ENGAGE AND EXPLAIN Engaging the interviewee and building rapport is the first step to encouraging a conversation. It is the most influential factor in ensuring productive interviews (Norwegian Center of Human Rights, 2017). At the outset the interviewee must be informed why they have been brought in for questioning and the formalities that apply. Officers must be aware that being interviewed can make people nervous and conversation that calms the interviewee may be needed. However, interviewers shall not work towards a pretend “friendship” with interviewees. The aim is to engage the interviewee so that a cooperative and relaxed relationship (one that stimulates memory and communication) is sustained throughout the interview (Boyle, and Vullierme, 2015, p. 23). In engaging with the interviewee, the officer should seek the following (Norwegian Center for Human Rights, 2017): 1. Create an empathetic and respectful relationship from the outset. 2. Explain the reasons, background, rights, formalities and procedure for the interview, including information about audio/video recording. 3. Establish certain ground rules by telling interviewees: • That what they have to say is important so they need to report everything they can and try their hardest no to leave anything out. • Not to edit as they go even if they believe some information has no relevance to the matter being investigated • That they need to concentrate because striving to retrieve memories can be hard work • That they should feel free to speak up if the officer: asks a question they do not understand; asks a question they do not know the answer to; misunderstand what the interviewee has said; asks a leading or inappropriate question. STEP THREE: ACCOUNT Interviewers should allow the interviewee to present their uninterrupted free account of the case or event under investigation; this is after establishing the ground rules for the interview. It is important that the interviewee is provided with the opportunity to present their side of the story, before more detailed questions are asked (Norwegian Center for Human Rights, 2017). Three main steps in getting the free account from the interviewee: 1. Introduce and explain the form and purpose of the free and uninterrupted account 2. Hand over the initiative (“give the floor”) to the victim, witness or suspect (as applicable) 3. Employ active listening while the interviewee presents the free and uninterrupted account Active listening assists the interviewer to establish rapport and help elicit a full and accurate account. Use TED’S PIE: Tell me, Explain, Describe Show Me-Precisely, In detail, Exactly. Using this approach helps build rapport and prevents the interviewer contaminating the account being given. The TED’S PIE approach makes use of encouragements/invitations to obtain an account (Norwegian Center for Human Rights, 2017). TYPES OF QUESTIONING OPEN-ENDED QUESTIONS Refers to the questions that allow the suspect to reply with longer, more detailed responses and lack direction from the interviewer. These can be questions such as; “What happened?” or questions that begin by asking the suspect to “tell”, “explain” or “describe” some event or situation (Boyle, and Vullierme, 2015, p.26) CLOSED QUESTIONS Refers to the questions that require more definite and distinct answers. Examples include, “What time was that?”, “Who else was present?”, “What is his address?” such questions allow more control over what the suspect says and are useful where the suspect has left out information that you need. However, they can limit the account given (Boyle, and Vullierme, 2015, p. 26) FORCED-CHOICE QUESTIONS Refers to the questions that greatly restrict the possible answers to those that you have determined. The question may be “Was it a rifle or a handgun?” when the weapon may have been a shotgun. The suspect may simply pick one of the choices offered in order to please the interviewer or just move the questioning on. You should avoid these as they don’t suggest an open mind, and because answers may lie outside those conceived of by the interviewer. Do not limit the interview in this way (Boyle, and Vullierme, 2015, p. 26) MULTIPLE QUESTIONS Refers to the questioning where the interviewer asks more than one question at the same time. This can easily confuse an interviewee and make the answers given equally confusing to the interviewer. An example would be to ask, “When did he say that and what did he do and who else was present?” (Boyle, and Vullierme, 2015, p. 26). LEADING QUESTIONS Refers to the questions that induce a particular reply and may be judged to have manipulated the interviewee. An example would be to ask, “You wanted to injure him, didn’t you?” They can lead the suspect to the point where they agree with what was being said even where they are uncertain or have no clear memory (Boyle, and Vullierme, 2015, p. 26). STEP FOUR: CLOSURE As the interview comes to an end, the interviewing officer should explain what will happen next by giving the interviewee appropriate information about the next stages of the process: for example, inform suspects of potential pre-trial detention, tell witnesses whether or not they should expect to attend court, etc. (Norwegian Center for Human Rights, 2017). Finally, the interviewee should be asked if they have any questions for the interviewing officer at this stage. This has little or no real effect if the communication has been coercive. However, if the interview has been conducted as outlined above, this question may add to the interviewee’s perception of having been treated fairly (Boyle, and Vullierme, 2015, p. 26). The goal of the closure are the following (Norwegian Center for Human Rights, 2017): 1. Ensure there is a mutual understanding of the interviewee’s accunt by reviewing and summarizing it 2. Verify that all aspects have been sufficiently covered by checking that interviewees have given all the information they are able and willing to provide 3. Secure the integrity and dignity of the interview, the legitimacy of any subsequent criminal proceedings, and keep channels open for future communication. STEP FIVE: EVALUATION This is the phase wherein the interviewee evaluates the entire process of the interview and determines if his objectives were met. He also evaluates the method he used in acquiring useful statements from the witness, victim, or suspect and the effectiveness of said method. (Galero-Muftuoglu, 2017, p. 186) If the interview is evaluated by a supervisor, senior officer or colleague, make sure that the interviewing officers are given the opportunity to comment on their own performance, before the evaluator gives their points, starting with what was positive, moving on to what could be improved next time (Norwegian Center for Human Rights, 2017) LESSON 2 SPECIALIZED CRIME INVESTIGATION 2 WITH INTERVIEW AND INTERROGATION MENDEZ METHOD The Mendez Principles, also known as the new Principles on Effective Interviewing for Investigations and Information Gathering. It was named after Juan Mendez, the Argentine lawyer, torture survivor and former UN Special Rapporteur. It is a concrete alternative to interrogation methods that rely on coercion to extract confessions. They provide guidance on obtaining accurate and reliable information in full respect of the human rights and dignity of all, including through the implementation of legal and procedural safeguards in the first hours of police custody (IRCT, 2021). The Mendez Method has three parts; Before, During, and After the interview. BEFORE THE INTERVIEW – ENSURING A NON-COERCIVE ENVIRONMENT Creating a non-coercive environment involves the respect and fulfillment of human rights from the first moment of contact between the interviewee and authorities. This allows law enforcement, intelligence, security or military officials to create conditions conductive to gathering accurate and reliable information during the interview, to fulfill State obligations under international law and to protect the lights of the interviewee. Unlawful and unprofessional behavior, and a lack of accountability, at the early stages of contact may taint the overall judicial process irreversibly (Mendez, 2016, p. 14-15). KEEPING THE INTERVIEW INFORMED Showing concern for the interviewee from the initial contact is the first opportunity for creating trust and rapport. This is more likely when an interviewee is given early, explicit explanations of why they have brought in for questioning., which formalities apply, and how the interview will proceed. Explaining procedures and likely activities is an early opportunity to display sincerity, provide predictability, to be respectful and attentive, and promote trust. The right to be informed by the detaining authority about the reasons of arrest applies regardless of manner, or the formality or informality with which an arrest is conducted, and regardless of the reasons for the deprivation of liberty (Mendez, 2016, p.15). Information regarding an interviewee’s rights and how to exercise them should be conveyed verbally, in clear, non-technical, and precise language upon arrest; and it should also be provided in writing by the detaining authority upon arrival at the place of detention in a language and format they understand. NOTIFICATION OR FAMILY OR THIRD PARTY A key safeguard for detainees is their right to promptly notify a family member, friend, or other person of their choice about the fact, place and circumstances of their detention. The detaining authority is responsible for enabling the communication with the third party and recording who has been notified and when the notification took place (Mendez, 2016, p. 16). Foreign nationals who are arrested or detained must be informed immediately of their right to communicate with a consular and diplomatic representative of their country or origin. Asylum seekers should be informed of their right to contact relevant international agencies. Contact is to be facilitated by the detaining authority (Mendez, 2016, p.17). ACCESS TO LAWYER All detained persons being interviewed have a right to a lawyer, including through legal aid, before any questioning by authorities – independent of their status or formal designation. Access to a lawyer is inextricably linked to the protection of rights, prevention of torture and other ill-treatment, and helps to protect against compelled self-incrimination. The interviewee is entitled to a lawyer of their own choosing, or to have one provided for them free of charge when the interests of justice so require. The presence of the lawyer is compulsory for detained children interviewed as suspects (Mendez, 206, p.17). PREPARATION FOR THE INTERVIEWER Once an individual has been identified as a person the authorities wish to interview, the appointed interviewer should start thorough preparations. Being fully prepared increases an interviewer’s ability to effectively communicate with the interviewees, and hence, the likelihood of obtaining reliable information. Before commencing an interview, it is crucial to maximize the investigative and evidentiary value of the information already gathered. When preparing for an interview - and throughout the process – interviewers should exercise caution to avoid ‘confirmation bias’. Interviewers should continually monitor their own emotions about the subject matter and their feelings towards the interviewee, to be able to project calm and self-control throughout the interview (Mendez, 2016, p.19). DURING THE INTERVIEW – ESTABLISHING AND MAINTAINING RAPPORT Effective interviewers are adaptable, listen carefully, communicate empathy, and adopt the ethos that non-coercive, humans, ethical, lawful and appropriate questioning serves the interest of all involved: the interviewer, the interviewee and the information-gathering authorities. They recognize that the interviewer’s role is to acquire the best possible information for decisions to be made. Only courts determine guilt or innocence. The development of rapport is essential in supporting effective information-gathering. During the interview, rapport entails establishing and maintaining a relationship characterized by: respect and trust; a non-judgmental mindset; non-aggressive body language; attentiveness; and patience (Mendez, 2016, p.20). INFORMATION GATHERING TECHNIQUES Active listening helps the interviewer process the information provided by the interviewee. By listening actively, the interviewer shows that they are following what the interviewee is saying and making efforts to understand. The interviewer takes care not to lead the interviewee inadvertently by using verbal or visual cues, including sounds, gestures or questions, which may be interpreted as agreeing or disagreeing with what the person is saying. Accurate summaries of what the interviewee has said may facilitate the positive progression of the interview and assist the interviewer and interviewee in recalling important details (Mendez, 2016, p.21). ENCOUNTERING RELUCTANCE Interviewers may encounter interviewees who are reluctant to talk and therefore should anticipate how they will handle such situations. Not wanting or agreeing to answer questions may be a deliberate choice. This decision must always be respected and has no bearing on the interviewer’s right to the presumption of innocence. Reasons why an interviewee might be reluctant to talk can include general anxiety or uncertainty about the process, especially if the person has never been involved in such a situation before. It is also possible that an interviewee maybe willing to provide information but is unable to do so. This can be because they did not have the relevant information to begin with, or they failed to register the details. Interviewers should not draw negative inferences from the interviewee’s failure or refusal to answer questions and should remain non-judgmental when an interviewee may make admission to crimes or convey embarrassing information (Mendez, 2016, p.21). SUSPENDING THE INTERVIEW It is appropriate and permissible for interviewers to suspend the interview in order to follow-up on information received or conduct additional enquiries. Other reasons to suspend an interview are (Mendez, 2016, p.22): 1. If the interviewee requires medical attention, 2. If a person originally interviewed as a witness becomes a suspect in the course of an interview; and 3. If the lawyer or the interviewee may request a break, for instance in order to rest or to consult in private. A refusal to accept such a request by the interviewer may affect the reliability of information gathered from the interview. AFTER THE INTERVIEW – ASSESSMENT AND ANALYSIS An effective interviewer should always end the interview respectfully and on a professional note. This increases the likelihood of keeping channels open for future communication, avoids possible misunderstandings and can improve trust in public institutions. The interviewer should review the information obtained with the interviewee and the lawyer, if involved; and, where a written record (as opposed to an audio/video recording) has been made, invite them to sign as a confirmation of the record’s accuracy. An amendments should be recorded, and if relevant, any refusal of the interviewee to sign the interview record. Once the interview has been completed, the interviewer ensures that the information provided during the process is subject to the appropriate level of privacy and of data protection. The interviewer should assess and analyze the following (Mendez, 2016, p.23): 1. The value and reliability of the information obtained and how it fits with known evidence, information gaps and other intelligence gathered. 2. What further enquiries are necessary in order to advance the investigation or operation; and 3. Whether all relevant safeguards were applied effectively. KINESIC INTERVIEW METHOD Kinesic Interview Method involves analyzing a person’s behavior to assess deception (Orlando, 2014). The study of kinesics focused on observable outward physical behavior of the body in order to ascertain the person’s current emotional state and the role the body plays in communicating the information. It states that, by understanding the vocabulary of the body language, along with the diagnosis of a person’s verbal output, an interviewer could more easily assess a person’s truthfulness or deception regarding current issues under discussion (Walters, 2002, p.2). It has two phases: the Practical Kinesic Analysis Phase; and the Practical Kinesic Interrogation Phase. PRACTICAL KINESIC ANALYSIS PHASE During the analysis phase, the interviewer uses several techniques to observe and analyze the subject’s behavior in order to determine the subject’s truthful and deceptive behaviors or at least to determine those areas most sensitive to the subject and, therefore, in need of further attention through verbal inquiry. It recognizes the cues of truthful and deceptive behavior generated by the subject through: 1. Verbal Cues – this involves the identification of symptoms of speech quality and content which give the interviewer the most productive body of data necessary to determine truth and deception. 2. Practical Kinesic Statement Analysis – assessment of truth and deception through the use of verbal cues coupled with methods of human recall and symptoms made self-evident in the statement taking process. 3. Body Language Cues – it refers to the observable body language cues of deception that are unbalanced or inconsistent in relation to the speech cues or emotional symptoms generated by the suspect at the same time. 4. Kinesic Subject Control – it refers to the various techniques available to the interviewer to take control and command of the interview environment. From proxemics to mirroring or the use of enhanced information gathering skills. 5. Confession Behaviors – it is the verbal and nonverbal acceptance cues generated by a subject who is prepared to give an admission of confession. PRACTICAL KINESIC INTERROGATION PHASE Practical Kinesis Interrogation Phase involves the interviewer determining the subject’s frame of mind in response to the interview stress. It also helps the interviewer in determining if the subject is suffering from personality disorder or psychosis. It also helps the interviewer determine the subject’s personality type which enables him to understand how the subject thinks and to determine the subjects’ strengths to be avoided and the weaknesses that can be exploited. Lastly it will help the investigator in determining the defense mechanism of the subject which keeps the subject from having to face the reality of his actions; and by identifying and disarming these mechanisms, the interrogator can obtain admission or confession (Walters, 2002, p.3). GUIDELINES OF CUSTODIAL INVESTIGATION According to the PNP Operational Procedures Manual (2011), the duties of the Police during custodial investigation are as follows: 1. The arresting officer, or the investigator, as the case may be, shall ensure that a person arrested, detained or under custodial investigation shall, at all times, be assisted by counsel, preferably of his own choice (PNP, 2011, p.33). 2. The arresting officer, or the investigator, as the case may be, must inform the person arrested, detained or under custodial investigation of the following rights under the Miranda Doctrine in a language or dialect known to and understood by him (PNP, 2011, p.33). a. That he has the right to remain silent; b. That if he waives his right to remain silent, anything he says can be used against him in court; c. That he has the right to counsel of his own; d. That, if he cannot afford one, he shall be provided with an independent and competent counsel; and e. That he has the right to be informed of such rights. 3. If the person arrested, detained, or under custodial investigation opted to give a sworn statement, the arresting officer, or the investigator, as the case may be, must reduce it in writing (PNP, 2011, p.34). 4. The arresting officer must ensure that, before the sworn statement is signed, or thumb marked, if there is inability to read and to write, the document shall be read and adequately explained to the person arrested, detained or under custodial investigation by his counsel of choice, or by the assesting counsel provided to him, in the language or dialect known to him (PNP, 2011, p.34). 5. The arresting officer, or the investigator, as the case may be, must ensure that any extrajudicial confession made by a person arrested, detained or under custodial investigation shall be (PNP, 2011, p.34): a. In writing; b. Signed by such person in the presence of his counsel; or c. In the latter’s absence, upon a valid waiver, and in the presence of any of the parents, elder brothers and sisters, his spouse, the municipal mayor, the municipal judge, district school supervisor, priest, imam or religious minister chosen by him. It is important to note that failure of the arresting officer, or the investigator, to observe the above mention procedures shall render the extrajudicial confession inadmissible as evidence in any proceeding (PNP, 2011, p.34) 6. The arresting officer, or the investigator, as the case may be, must, under established regulations, allow the person arrested, detained, or under custodial investigation visits by or conferences with the following: a. any member of his immediate family, b. any medical doctor, c. priest, imam or religious minister chosen by him or by any member of his immediate family or by his counsel, or by any Non-Governmental Organization (NGO) duly accredited by the Commission on Human Rights (CHR) or by any international NGO duly accredited by the Office of the President. 7. After interrogation, a person under custodial investigation shall have the right to be informed of his right to demand physical examination by an independent and competent doctor of his own choice. If he cannot afford the services of a doctor of his own choice, he shall be provided by the State with a competent and independent doctor to conduct physical examination. If the person arrested is female, she shall be attended to preferably by a female doctor (PNP, 2011, p.34-35). The physical examination of the person under custodial investigation shall be contained in a medical report, which shall be attached to the custodial investigation report. LESSON 3 LEGAL REQUIREMENTS FOR ADMISSION AND CONFESSION Admissions and confessions are only legally valid if made voluntarily, knowingly, and intelligently, with judicial or extrajudicial distinctions affecting their admissibility. DEFINITIONS AND DISTINCTIONS ●ADMISSION – A voluntary acknowledgment of a fact relevant to a case, which does not necessarily imply guilt. It can be judicial (made in court or pleadings) or extrajudicial (made outside court) and may be used as evidence against the declarant, though extrajudicial admissions are not conclusive and require proof of credibility and relevance. ●CONFESSION – A direct acknowledgment of guilt for the offense charged or any offense necessarily included therein. Confessions are always statements of criminal liability and can be judicial or extrajudicial. CORE LEGAL REQUIREMENTS 1. Voluntariness – the statement must be given freely, without coercion, force, intimidation, or inducement. Any confession obtained through threats, violence, or improper influence is inadmissible. 2. Knowledge and Intelligence – the accused must understand the nature and consequences of the statement. This ensures that the confession or admission is made knowingly and intelligently. 3. Assistance of Counsel – during custodial investigation or after arrest, the accused is entitled to competent and independent legal counsel. Extrajudicial confessions made without counsel may be inadmissible as they violate constitutional rights. 4. Judicial vs. Extrajudicial Confessions: Judicial Confession – Made in open court or in pleadings; sufficient for conviction without additional evidence. Extrajudicial Confession – Made outside court; requires corroboration by independent evidence to be admissible. 5. Relevance and Evidentiary Value – the admission or confession must relate to facts in issue and not be excluded by privilege or other legal rules. Judicial admissions are conclusive, while extrajudicial admissions are evaluated for credibility and weight by the court. 6. Corpus Delicti Rule – a confession alone is insufficient for conviction; the prosecution must establish that a crime has actually been committed. LEGAL REQUIREMENTS FOR ADMISSION Admissions can be classified as judicial (made in the course of judicial proceedings) or extrajudicial (made outside of court). For Judicial Admissions: ●Can be made in pleadings, during trial via stipulations/manifestations, or at other stages such as pre-trial. ●Requirements: They do not require formal proof and are conclusive upon the party making them. They can only be contradicted by showing that they were made through a palpable mistake or that no such admission was made. For Extrajudicial Admissions: ●Must be relevant to the issue at hand. ●May be given in evidence against the maker (as an admission against interest), but are generally subject to regular rules of relevance and hearsay exceptions. LEGAL REQUIREMENTS FOR CONFESSION Because confessions directly admit criminal liability and carry heavy penal consequences, they face strict constitutional and statutory safeguards—particularly when made outside of court (extrajudicial confessions). To be admissible as evidence in court, an extrajudicial confession must meet the following mandatory requirements: Voluntariness: ●The confession must be given freely and knowingly. It must not be the product of torture, force, violence, threat, intimidation, or any other influence that vitiates the individual's free will. Observance of Miranda Rights (Custodial Safeguards): ●If a person is under custodial investigation, they must be proactively informed in a clear, understandable manner of their rights: to remain silent, that any statement can be used against them, to have competent and independent counsel preferably of their choice, and to be provided free legal counsel if they cannot afford one. Assistance of Competent and Independent Counsel: ●The confession must be made with the active presence and genuine representation of independent counsel. ●Any waiver of the right to counsel must be made in writing and executed in the presence of the counsel. Form and Language: ● Extrajudicial confessions must ideally be in writing and signed (or thumb marked) by the confessant. ● They must be expressed clearly and interpreted/read to the accused in a language or dialect that they fully understand. The Exclusionary Rule: ● Under constitutional law, any confession obtained in violation of the right to counsel, Miranda rights, or through coercion is inadmissible as evidence in any proceeding (the "fruit of the poisonous tree" doctrine). Corroboration (Corpus Delicti Rule): ● An extrajudicial confession alone is insufficient to sustain a criminal conviction. It must be corroborated by independent evidence of the corpus delicti (proof that the crime actually happened and someone is criminally responsible). CORE REQUIREMENTS FOR ADMISSIBILITY Consciousness of Impending Death: At the time the statement was made, the declarant must have been under the fixed belief that death was near and inevitable. Complete despair of recovery must be apparent, though the exact moment of death does not need to be immediate. Subject Matter: The statement must concern the cause and surrounding circumstances of the declarant's impending death. Statements about unrelated past grudges or matters are inadmissible. Case Type Limitation: Traditionally and under most statutory rules (such as the Philippine Rules of Evidence), dying declarations are admissible primarily in criminal prosecution for homicide, murder, or parricide where the death of the declarant is the subject of the charge. Competency of the Declarant: The declarant must have been a competent witness at the time the statement was made (i.e., possessing the capacity to perceive and communicate the event). Declarant Must Be Deceased: The declarant must have actually died, and their death must be the subject of the inquiry. CONSTITUTIONAL SAFEGUARDS ●The accused has the right to remain silent and cannot be compelled to confess. ●Any admission or confession must respect due process and fundamental rights under the Philippine Constitution DYING DECLARATION VS. INDEPENDENT RELEVANT STATEMENT Dying declaration and independent relevant statement are both types of statements made by individuals that are considered to be reliable evidence in court. However, the key difference between the two lies in the circumstances under which they are made. A dying declaration is made by a person who believes they are about to die, and their statement is considered to be particularly trustworthy due to the belief that they have no reason to lie. On the other hand, an independent relevant statement is made by a person who is not in imminent danger of death, but their statement is still considered to be reliable because it is made independently of any external influence or coercion. Both types of statements play a crucial role in the legal system in determining the truth of a matter. PRINCIPLES OF A DYING DECLARATION ●A dying declaration is an out-of-court statement made by a victim regarding the cause and surrounding circumstances of their impending death. Under the rules of evidence, it serves as an exception to the hearsay rule and is admissible because of the principle of necessity (since the declarant is dead and cannot testify) and the trustworthiness presumption (that a person at the point of death has no motive to fabricate the truth). INDEPENDENT RELEVANT STATEMENTS ●An independent relevant statement (sometimes referred to as verbal acts or statements relevant independent of the truth of the facts stated) is an out-of-court statement offered in court not to prove the truth of the matter asserted, but simply to prove that the statement was made, heard, or that it had a legal effect. ●These statements are admissible in court if they meet the requirements of relevance and reliability. The declarant must have personal knowledge of the facts stated in the statement, and the statement must be relevant to the issues in the case. ●Because the truth of the utterance does not matter, these statements are not hearsay at all and are freely admissible. CATEGORIES AND EXAMPLES Statements as Verbal Acts / Constitutive Facts: Words that legally constitute a crime, contract, or civil wrong. ●Example: Words of defamation in a libel case, or words offering a bribe in a corruption case. The statement is proven just to show it was uttered. Statements Showing State of Mind / Knowledge / Notice: Words used to establish what someone knew, their belief, or their mental state. ●Example: Telling a defendant that a specific machine is dangerous. This is admissible not to prove the machine is dangerous, but to prove the defendant had notice or knowledge of the danger. Statements Showing Effect on the Hearer: Words that explain why a listener acted the way they did. ●Example: Threats made to a victim to explain why the victim acted in self-defense or fled in fear. Identifications: Out-of-court statements identifying a person (e.g., a witness pointing out a suspect in a lineup), which are relevant to establish identification independent of the factual narrative. COMPARISON Dying Declarations are considered highly reliable due to the belief that a person facing imminent death would not lie. On the other hand, Independent Relevant Statements do not carry the same level of reliability, as they are not made under the same circumstances. Dying Declarations are admissible as exceptions to the hearsay rule, while Independent Relevant Statements must meet the requirements of relevance and reliability to be admissible. Dying Declarations are made by individuals who believe they are about to die, and the statements pertain to the cause or circumstances of their impending death. In contrast, Independent Relevant Statements are made by individuals who have personal knowledge of the facts stated in the statement, and the statements are relevant to the issues in the case. Dying Declarations are often used in cases where the declarant's impending death is a central issue, such as murder trials. Independent Relevant Statements, on the other hand, are used to provide additional context or evidence to support a party's case. In some cases, both types of statements may be used in conjunction to strengthen a party's argument.

GCSE CHEMISTRY REVISION PODCAST The ultimate Grade 6 chemistry recap Welcome to your GCSE Chemistry revision podcast! Today we’re covering five important areas: halogens, halogen reactivity, covalent bonding, simple molecular substances and carbon allotropes. Let’s get started! PART 1: HALOGENS Halogens are found in Group 7 of the periodic table. They are non-metals and exist as diatomic molecules, which means they have two atoms joined together. The four main halogens you need to know are fluorine, chlorine, bromine and iodine. Remember their colours: Fluorine is pale yellow. Chlorine is green. Bromine is red-brown. Iodine is grey-black. Their physical states also change down the group. Fluorine and chlorine are gases, bromine is a liquid, and iodine is a solid. As you go down Group 7, melting and boiling points increase, and reactivity decreases. PART 2: REACTIVITY Why does reactivity decrease? Halogens react by gaining one electron. As you go down Group 7, atoms have more electron shells. This means there is more shielding and the outer region is further from the nucleus. The nucleus attracts an incoming electron less strongly, so gaining an electron becomes harder. Remember: MORE SHELLS, MORE SHIELDING, LESS REACTIVE. Now, let’s talk about displacement reactions. A more reactive halogen can displace a less reactive halogen from a compound. For example, chlorine can displace bromine from potassium bromide because chlorine is more reactive. The equation is: Cl₂ + 2KBr → 2KCl + Br₂. Remember, a less reactive halogen cannot displace a more reactive one. PART 3: COVALENT BONDING A covalent bond is a shared pair of electrons between two non-metal atoms. Atoms share electrons to achieve a full outer shell. For example, hydrogen shares one pair of electrons to form H₂. Oxygen shares two pairs of electrons with another oxygen atom to form O₂. Carbon can form four covalent bonds, which is why it can form molecules such as methane, CH₄. PART 4: SIMPLE MOLECULAR SUBSTANCES Simple molecular substances have strong covalent bonds inside their molecules but weak intermolecular forces between different molecules. This is probably one of the most important things to remember for your exam! They have low melting and boiling points because only a small amount of energy is needed to overcome the weak intermolecular forces. The covalent bonds inside the molecules are NOT broken when they melt or boil. They also usually cannot conduct electricity because they have no free-moving charged particles. PART 5: CARBON ALLOTROPES Allotropes are different structural forms of the same element. Let’s start with diamond. In diamond, each carbon atom forms four covalent bonds. This makes it extremely hard and gives it a very high melting point. It cannot conduct electricity because it has no delocalised electrons. Next is graphite. In graphite, each carbon forms three covalent bonds. It has layers that can slide over each other, making it soft and slippery. It also has delocalised electrons, meaning it CAN conduct electricity. Graphene is a single layer of graphite. It is extremely strong, lightweight and conducts electricity. Finally, fullerenes are hollow structures made from carbon atoms. They can form spheres or tubes. FINAL MEMORY CHECK Let’s recap the five biggest facts: Halogens become LESS reactive down Group 7. A more reactive halogen displaces a less reactive halogen. Covalent bonding involves SHARING electrons. Simple molecules have WEAK intermolecular forces, giving them LOW melting and boiling points. Diamond has FOUR bonds per carbon, while graphite has THREE. That’s your chemistry recap! Remember to practise exam questions, use scientific keywords and explain WHY things happen. Good luck with your chemistry exam!

PSYCHOLOGY TEST #1 — COMPLETE STUDY NOTES Test Format (40 Marks) Part A: Fill in the Blank — 10 marks (Knowledge) Part B: Identification — 10 marks (Inquiry) Part C: Short Answer — 10 marks (Communication) Part D: Theory Application — 10 marks (Application) 1. THE PHYSICAL HUMAN BRAIN Frontal Lobe Functions: Controls higher thinking skills, decision-making, problem-solving, planning, attention, intelligence, personality, emotions and voluntary movements. Associated disorders: ADHD, schizophrenia and bipolar disorder. Damage can cause: Paralysis, mood changes, personality changes, difficulty speaking, loss of spontaneity and unusual social behaviour. Remember: Frontal = Thinking and personality. Parietal Lobe Functions: Processes sensory information, especially touch. Helps with spatial awareness, balance, recognizing objects and understanding surroundings. Associated disorders: Alzheimer's disease, ADHD and schizophrenia. Damage can cause: Sensory difficulties, disorientation, poor coordination and difficulty recognizing or locating objects and body parts. Remember: Parietal = Touch and surroundings. Occipital Lobe Functions: Processes visual information, including colours, shapes, movement and objects. Responsible for vision. Associated disorders: Schizophrenia, bipolar disorder, autism and depression. Damage can cause: Blindness, visual hallucinations and difficulty seeing colours or movement. Remember: Occipital = Vision and seeing. Temporal Lobe Functions: Responsible for hearing, recognizing faces and objects, understanding language, learning, memory and emotions. Associated disorders: Schizophrenia, Alzheimer's disease and autism. Damage can cause: Memory loss, speech difficulties, difficulty understanding language, difficulty recognizing faces and objects, and changes in behaviour. Remember: Temporal = Hearing and memory. Cerebellum Functions: Controls balance, posture, coordination, voluntary movements, reflexes, motor skills and timing. Associated disorders: Autism, schizophrenia and dyslexia. Damage can cause: Poor coordination, tremors, dizziness, difficulty walking and slurred speech. Remember: Cerebellum = Balance and coordination. Brain Stem Functions: Controls automatic body functions such as breathing, heart rate, blood pressure and digestion. Also helps regulate sleep, alertness and balance. Associated disorders: Autism and sleep disorders such as insomnia. Damage can cause: Organ problems, sleep difficulties, balance problems and serious problems with automatic body functions. Remember: Brain Stem = Keeps you alive. Quick Memorization: Frontal = Thinking. Parietal = Touch. Occipital = Vision. Temporal = Hearing and memory. Cerebellum = Balance. Brain Stem = Automatic functions. 2. SIGMUND FREUD Who was Sigmund Freud? Austrian neurologist and psychologist. Founder of psychoanalysis. Believed the unconscious mind strongly influences human behaviour. Believed childhood experiences help shape personality. Freud's 7 Main Theories 1. Psychoanalysis A method of studying and understanding the unconscious mind. Freud believed hidden thoughts, feelings and childhood experiences influence behaviour. Used therapy to help people understand their unconscious thoughts. Example: Someone may have a fear without understanding where it originally came from. 2. Three-Part Psyche Freud believed personality was made up of three parts: the Id, Ego and Superego. Id Represents biological wants and desires. Follows the pleasure principle. Wants immediate satisfaction without thinking about consequences. Example: Eating all the cookies because you want them. Remember: Id = Wants. Ego Balances the Id and Superego. Follows the reality principle. Makes realistic decisions and considers consequences. Example: Deciding to eat one cookie instead of all of them. Remember: Ego = Reality. Superego Represents your conscience. Tells you what is right and wrong. Develops through experiences, rules and values. Example: Knowing you shouldn't take someone else's cookies. Remember: Superego = Morals. 3. Oedipus Complex Freud believed young children experience unconscious feelings of attachment toward the parent of the opposite sex and rivalry toward the same-sex parent. Named after the Greek character Oedipus, who unknowingly killed his father and married his mother. Remember: Opposite-sex parent = Attachment; same-sex parent = Rivalry. 4. Sexual Desires (Libido) Freud believed sexual energy, called libido, influences human personality and behaviour. He believed frustration of desires could affect mental health. The term Freudian slip comes from his ideas about unconscious thoughts accidentally appearing in speech. Example: Accidentally saying what you were actually thinking instead of what you meant to say. 5. Examination of Dreams Freud believed dreams were a window into the unconscious mind. He thought dreams revealed hidden thoughts, feelings and desires. Example: A dream might represent a hidden fear or worry. 6. Stages of Development Freud believed personality develops through five stages. Each stage focuses on a different area of pleasure. Oral Stage (0–18 months): Pleasure comes from the mouth, such as sucking and feeding. Anal Stage (18 months–3 years): Focuses on toilet training and control. Phallic Stage (3–6 years): Focuses on the body and awareness of gender differences. Latency Stage (6–puberty): Sexual urges are less noticeable. Children focus more on friendships, school and learning. Genital Stage (puberty–adulthood): Focuses on mature relationships and sexual interests. Remember the order: Oral → Anal → Phallic → Latency → Genital. 7. Defence Mechanisms Freud believed the mind uses defence mechanisms to protect itself from uncomfortable thoughts and feelings. They happen unconsciously. Important examples: Denial: Refusing to accept reality. Example: Saying you didn't fail a test when you did. Repression: Pushing upsetting memories out of awareness. Projection: Blaming others for your own feelings. Example: Calling someone jealous when you are jealous. Displacement: Taking your feelings out on someone else. Example: Being upset at school and snapping at a family member. Rationalization: Making excuses for behaviour. Example: Saying a test was unfair because you didn't study. How Freud Applies to Psychology Helps explain how the unconscious mind influences behaviour. Helps explain how childhood experiences affect personality. Studies how dreams and hidden feelings may affect people. Explains how defence mechanisms protect people from uncomfortable emotions. Influenced the development of psychotherapy and talk therapy. 3. CONDITIONING Conditioning is a type of learning where behaviour changes through experiences and associations. There are two main types: Classical and Operant Conditioning. A. Classical Conditioning Learning through association. Happens when someone connects two stimuli. A person learns to associate something with a natural response. The response eventually becomes automatic. Example: Pavlov's Dogs Pavlov rang a bell before giving dogs food. Food naturally caused the dogs to salivate. Eventually, the dogs started salivating just from hearing the bell. Four Important Terms: US (Unconditioned Stimulus): Something that naturally causes a reaction. UR (Unconditioned Response): The natural reaction to the stimulus. CS (Conditioned Stimulus): Something originally neutral that becomes associated with the unconditioned stimulus. CR (Conditioned Response): The learned reaction to the conditioned stimulus. Example from your notes: Toilet and Shower Every time someone flushes a toilet, the shower becomes very hot. Eventually, the person jumps back just from hearing the toilet flush. US: Hot water. UR: Jumping back. CS: Toilet flushing. CR: Jumping back when hearing the toilet flush. Remember: Classical = Association. B. Operant Conditioning Learning through rewards and punishments. Behaviour changes depending on its consequences. People learn which behaviours lead to positive or negative outcomes. Usually involves voluntary behaviours. Four Types of Operant Conditioning: 1. Positive Reinforcement Adding something pleasant to increase a behaviour. Example: Getting a reward for good grades. 2. Negative Reinforcement Removing something unpleasant to increase a behaviour. Example: Homework stops once you finish your chores. 3. Positive Punishment Adding something unpleasant to decrease a behaviour. Example: Getting extra chores for breaking a rule. 4. Negative Punishment Removing something pleasant to decrease a behaviour. Example: Losing phone privileges for breaking a rule. Important to Remember: Positive = Adding something. Negative = Removing something. Reinforcement = Increases behaviour. Punishment = Decreases behaviour. Positive does NOT mean good, and negative does NOT mean bad. Classical vs. Operant Conditioning Classical = Learning through association. Operant = Learning through consequences. Classical = Usually automatic responses. Operant = Usually voluntary behaviours. Classical example = Pavlov's dogs. Operant example = Getting rewarded for good grades. 4. COGNITIVE BIAS What is Cognitive Bias? The way we personally see and interpret the world. Everyone processes information differently. Our perceptions can influence our behaviour and decisions. Many biases happen unconsciously, without us realizing. Example: Two people experience the same situation but remember and interpret it differently. Confirmation Bias The tendency to look for and remember information that supports what you already believe. People often ignore information that goes against their beliefs. Example: You believe someone is rude, so you only notice when they act rude and ignore when they are nice. Tests That Measure Cognitive Bias 1. Rorschach Inkblot Test People look at inkblots and explain what they see. Their interpretations are recorded and analyzed. Remember: Inkblots = What do you see? 2. Thematic Apperception Test (TAT) People look at a series of pictures and create stories about them. The stories are analyzed to understand their thoughts and feelings. Remember: Pictures = Tell a story. 3. Word Association Test People are given words and respond with the first word that comes to mind. Responses can be analyzed to explore subconscious thoughts. Remember: Words = First thing that comes to mind. 4. Graphology The study of handwriting and how it may relate to personality traits. Remember: Graphology = Handwriting. 5. ETHICS IN PSYCHOLOGICAL STUDIES Ethics are rules that protect people who participate in psychological research. Five Ethical Principles 1. Minimizing Harm - Participants should not experience unnecessary physical or emotional harm. 2. Informed Consent - Participants must understand the study and agree to participate. 3. Confidentiality and Anonymity - Personal information and identities must be protected. 4. Avoiding Deception - Researchers should not mislead participants unnecessarily. 5. Right to Withdraw - Participants can leave the study at any time without being forced to stay. Remember: Harm, Consent, Privacy, Honesty, Withdraw. Controversial Experiments 1. Milgram Obedience Study (1963) Researcher: Stanley Milgram. Purpose: To investigate how far people would obey authority, even when it went against their conscience. What happened? Participants were told they were taking part in a learning experiment. They were assigned the role of the teacher. They were instructed to give increasing electric shocks to a learner for incorrect answers. The learner was actually an actor, and the shocks were fake. Many participants continued because an authority figure told them to. Main takeaway: - People may obey authority even when they believe their actions are wrong. Ethical issues: - Deception and psychological stress. 2. Stanford Prison Experiment (1971) Researcher: Philip Zimbardo. Purpose: To investigate how people behave when placed in positions of power or powerless situations. What happened? Participants were randomly assigned to be prisoners or guards. The experiment was designed to imitate a prison. Some guards began treating prisoners unfairly. The experiment became harmful and was stopped early. Main takeaway: - Situations and social roles can influence human behaviour. Ethical issues: - Psychological harm, lack of protection and insufficient oversight. Difference Between the Two Experiments Milgram = Obedience to authority. Stanford = Power and social roles. Milgram = Stanley Milgram, 1963. Stanford = Philip Zimbardo, 1971. 6. ALFRED ADLER AND CARL JUNG Both were psychologists who studied personality. They were originally influenced by Freud but disagreed with some of his ideas. A. Alfred Adler Who Was Alfred Adler? Austrian psychologist born in 1870. Founder of Individual Psychology. Believed people are motivated by the desire to improve themselves and overcome feelings of inferiority. 1. Inferiority Complex Adler believed people naturally experience feelings of inferiority or not being good enough. People try to overcome these feelings through self-improvement and achievement. Example: Someone who struggles in school works harder to improve their grades. 2. Compensation Trying to overcome a weakness by improving another area of life. Example: Someone who struggles with sports focuses on becoming better at music. 3. Napoleon Complex Describes someone who overcompensates because they feel inferior due to a perceived disadvantage. Often associated with people who are shorter in height. Example: Someone acts overly aggressive to prove themselves. 4. Fictional Finalism (Fictional Story) Adler believed people create an idea or goal about who they want to become at a young age. This imagined goal influences their decisions and behaviour throughout life. Example: A child believes they will become a doctor and makes decisions based on that goal. 5. Birth Order Adler believed birth order could influence personality and behaviour. Being the oldest, middle or youngest child may affect how someone develops. 6. Three Major Life Tasks Occupational Tasks: Career, education and work. Societal Tasks: Friendships and social connections. Love Tasks: Relationships, marriage and family. Remember: Work, Friends, Love. B. Carl Jung Who Was Carl Jung? Swiss psychologist born in 1875. Originally influenced by Freud. Agreed that the unconscious mind influences behaviour. Disagreed with Freud's strong focus on sexuality. Often included spirituality and the soul in his psychological theories. 1. Collective Unconscious Jung believed all humans share a deeper unconscious mind. It contains universal symbols and patterns passed down through generations. These universal patterns are called archetypes. Example: Different cultures have similar ideas about heroes, mothers and villains. 2. Introvert vs. Extrovert - Jung developed a personality theory based on where people direct their mental energy. Introverts: Focus their energy inward toward themselves. Prefer reflecting on their own thoughts and feelings. Draw energy from their inner world. Extroverts: Focus their energy outward toward people and their surroundings. Direct their attention toward the outside world. Important: Introvert does not automatically mean shy, and extrovert does not simply mean outgoing. 3. Psychological Balance Jung believed people need balance between opposite personality traits. Understanding different sides of your personality helps with personal development and mental health. Difference Between Freud, Adler and Jung Freud = Unconscious mind, childhood experiences and sexual energy. Adler = Inferiority, compensation and self-improvement. Jung = Collective unconscious, archetypes and introversion/extroversion. MOST IMPORTANT THINGS TO MEMORIZE If you are short on time, make sure you know these: Brain Parts Frontal = Thinking. Parietal = Touch. Occipital = Vision. Temporal = Hearing and memory. Cerebellum = Balance. Brain Stem = Automatic functions. Freud Id = Wants. Ego = Reality. Superego = Morals. Oral → Anal → Phallic → Latency → Genital. Defence mechanisms = Protect the mind from uncomfortable thoughts and feelings. Conditioning Classical = Association. Operant = Consequences. Positive = Add. Negative = Remove. Reinforcement = Increase behaviour. Punishment = Decrease behaviour. Cognitive Bias Confirmation bias = Looking for information that supports your beliefs. Rorschach = Inkblots. TAT = Pictures and stories. Word Association = Words. Graphology = Handwriting. Ethics Minimizing harm. Informed consent. Confidentiality and anonymity. Avoiding deception. Right to withdraw. Experiments Milgram = Obedience to authority. Stanford = Power and social roles. Adler Inferiority complex = Feeling inferior. Compensation = Overcoming weaknesses. Fictional finalism = Goals that guide behaviour. Three tasks = Occupational, societal and love. Jung Collective unconscious = Shared unconscious patterns. Archetypes = Universal symbols and characters. Introvert = Focuses inward. Extrovert = Focuses outward.

CES Form 2: Overcoming Growth Challenges and Undesirable Behaviours

Overcoming institutional voids - Gao et al. (2017)

# 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.

Philosophy: Human Existence, Desire, and Overcoming

Many ways for enzymes to help overcome activation barriers

Chapter 6: Solving Problems and Overcoming Objections

M1 S4: Overcoming Host Immune Response

Religion Book Studies Ch. 8 - Are you Overcome with Fear?

Ch 8: Transport Across Membranes: Overcoming the Permeability Barrier

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

📚 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.

Overcoming Communication Barriers

QUIZ #1 — POWER NOTES 1. Normative vs. Positive Political Science Normative = what SHOULD be. * Based on values, beliefs, and opinions. * Asks: “What should the government do?” Positive = what IS. * Based on evidence and observable facts. * Asks: “What actually happens?” Easy memory trick: 👉 Normative = “should” 👉 Positive = “is” Example: * “The government should provide free college.” → Normative * “States that spend more on education have higher graduation rates.” → Positive ⸻ 2. Approaches in Political Science An approach is basically a particular way of looking at politics. Know these: Rational Choice * Assumes people make decisions based on their interests and preferences. * People weigh costs and benefits. Behavioralism * Focuses on observable political behavior. * Looks at things like voting, public opinion, participation, etc. * Uses evidence/data to study behavior. Institutionalism * Focuses on institutions and rules. * Institutions can shape how people behave and what political outcomes happen. Constructivism * Focuses on how ideas, beliefs, identities, and social norms shape politics. Feminist approach * Examines how gender and power relationships affect politics. Normative approach * Focuses on questions about values, justice, rights, and what government ought to do. ⸻ 3. Methodologies Methodology = how political scientists study something. Two big categories: Quantitative * Uses numbers and statistics. * Example: Surveying 5,000 voters and analyzing their responses. Qualitative * Uses words, observations, interviews, documents, or detailed cases. * Example: Interviewing voters to understand why they support a candidate. If the professor says: “Describe one methodology.” You can say: Quantitative research uses numerical data and statistical analysis to identify patterns or relationships. That’s a solid answer. 👏 ⸻ 4. Theory A theory is an explanation of how or why something happens. It helps political scientists: * organize information * explain political behavior * make predictions that can be tested Example: A theory might explain why some people are more likely to vote than others. ⚠️ A theory in science does NOT mean “just a guess.” ⸻ 5. Transaction Costs Transaction costs = the time, effort, and resources required to reach an agreement or make a decision. Think: “How hard/expensive is it to get everyone to agree?” Example: If 500 people have to agree on one decision, getting everyone together, discussing the issue, and reaching an agreement creates transaction costs. Conformity Costs Conformity costs = the costs people face when they have to accept a decision they don’t personally prefer. Example: A group votes 8–2 to raise a fee. The two people who voted against it still have to pay it. 👉 That’s a conformity cost. ⸻ 6. Formal vs. Informal Institutions Formal institutions = Official rules and organizations. Examples: * Constitution * Congress * Courts * Laws * Government agencies Informal institutions = Unwritten rules, norms, traditions, and expectations. Examples: * Political traditions * Social expectations * Unwritten customs * Norms about how politicians are expected to behave Easy memory trick: 👉 Formal = written/official 👉 Informal = unwritten/social ⸻ 7. Overcoming Collective Action Problems Collective action problem = when individuals would benefit from working together, but each person has a reason NOT to participate. Example: Everyone wants a cleaner campus. But each student thinks: “Why should I pick up trash? Other people can do it.” That’s the problem. Ways institutions can help: * Incentives → reward people for participating * Penalties → punish people who don’t participate * Rules → require participation * Leadership/organization → coordinate people * Selective incentives → give specific benefits to people who participate ⭐ Important: Free rider problem = someone benefits from a group effort without helping pay or participate. ⸻ 8. Institutional Design Institutional design = creating rules and procedures that determine how political decisions are made. Basically: Who gets to do what, and what rules do they have to follow? Two important examples: Veto Power Veto power = the ability to stop or block a decision. Example: The president can veto legislation passed by Congress. Agenda Control Agenda control = the ability to decide which issues or proposals get considered. Basically: “What are we even going to talk about?” Someone who controls the agenda can influence which proposals get attention. ⸻ 9. Checks and Balances Checks and balances = each branch of government has powers that can limit the other branches. The three branches: 🏛️ Legislative — Congress * Makes laws ⚖️ Judicial — Courts * Interprets laws 🏠 Executive — President * Enforces laws Examples: Congress → President * Congress passes bills * Congress can override a presidential veto with enough votes President → Congress * President can veto bills Courts → Congress/President * Courts can declare government actions unconstitutional President → Courts * President nominates federal judges, subject to Senate confirmation Congress → Courts * Senate confirms federal judges * Congress controls federal funding and can change the structure/jurisdiction of lower federal courts within constitutional limits Main idea: No single branch is supposed to have unlimited power. ⸻ 🇺🇸 10. Articles of Confederation THIS ONE IS IMPORTANT. The Articles of Confederation were the first governing framework of the United States, used before the Constitution. The biggest problem: The national government was TOO WEAK. Under the Articles: * Congress had limited power * There was no separate executive branch * There was no national judicial branch * Congress couldn’t directly tax citizens * The national government had difficulty enforcing decisions * States retained a lot of power Why was this a problem? The national government had trouble: * raising money * paying debts * regulating commerce * responding effectively to national problems This helped lead to the Constitutional Convention of 1787 and eventually the Constitution. ⭐ Remember this: Articles of Confederation = weak national government Constitution = stronger national government with checks and balances ⸻ 🧠 THE STUFF I WOULD MEMORIZE FIRST If you’re short on time, memorize these: Normative = what SHOULD be. Positive = what IS. Rational choice = people make choices based on interests/costs and benefits. Behavioralism = studies observable political behavior. Quantitative = numbers/statistics. Qualitative = words, interviews, observations, cases. Theory = explanation of how/why something happens. Transaction costs = costs of reaching an agreement. Conformity costs = costs of accepting an outcome you don’t prefer. Formal institutions = official/written rules. Informal institutions = unwritten rules/norms. Collective action problem = difficulty getting people to work together. Free rider = gets the benefit without contributing. Veto power = ability to block a decision. Agenda control = ability to decide what gets considered. Checks and balances = branches limit each other’s power. Articles of Confederation = weak national government. 🔥 One-sentence version of the whole quiz: Political scientists study politics using different approaches and methods, while political institutions create rules that help people overcome collective-action problems, control costs, distribute power, and prevent any one part of government from becoming too powerful.

Overcoming Exam Stress

Here is your complete, updated master reviewer for Gizmo. Every table has been converted into clean, plain-text blocks, clear definitions are included for every main section, and concrete examples are integrated under every single term so you can copy and paste it directly into flashcards. 1. Literary Devices & Elements What are Literary Devices and Elements? Literary devices and elements are specific techniques, structures, and tools that authors use to shape their writing, convey deeper meanings, create vivid imagery, and build engaging stories. Figurative Language What is Figurative Language? Words or expressions used with a non-literal meaning to make ideas more vivid, creative, and impactful. * Metaphor: Direct comparison between two unlike things without using "like" or "as". * Example: "Time is a thief." / "His voice was music to her ears." * Simile: Comparison of two things using "like" or "as". * Example: "He ran as fast as the wind." / "Her eyes shined like diamonds." * Personification: Gives human traits, emotions, or actions to non-human objects or abstract concepts. * Example: "The wind whispered secrets through the trees." * Hyperbole: Extreme exaggeration used for emphasis or dramatic effect. * Example: "I'm so hungry I could eat a horse." / "I've told you a million times." * Irony: Expressing meaning using language that normally signifies the opposite (verbal, situational, or dramatic). * Example: A fire station burning down. (Situational Irony) * Oxymoron: Two contradictory or opposite words placed side-by-side. * Example: "Deafening silence," "Bittersweet," "Living dead." Sound Devices What are Sound Devices? Resources used by writers to emphasize the auditory aspects of a text, creating musicality, rhythm, or mood. * Assonance: Repetition of internal vowel sounds within nearby words. * Example: "The rain in Spain stays mainly in the plain." * Alliteration: Repetition of initial consonant sounds in neighboring words. * Example: "Peter Piper picked a pack of pickled peppers." * Consonance: Repetition of consonant sounds, especially at the middle or end of words. * Example: "The million alligators slithered through the mud." * Onomatopoeia: Words that imitate or sound like the real-world noise they describe. * Example: Buzz, crash, hiss, sizzle, boom. * Rhyme, Rhythm, & Repetition: Repeating sounds, beat patterns, or words to create emphasis and musicality. * Example: "Rage, rage against the dying of the light." (Repetition) Maxim, Universal Truth, & Philosophy What are Maxims, Universal Truths, & Philosophies? Statements that reflect general human principles, moral guidance, or shared human experiences. * Maxim: A short, simple saying that gives humans practical advice or a rule of conduct. * Example: "Actions speak louder than words." * Universal Truth: A statement or insight about human life that is true for all people across different times and cultures. * Example: "All humans desire love and belonging." * Philosophy: A foundational belief, worldview, or underlying way of thinking that guides how a person lives or interprets life. * Example: Stoicism teaches that we should focus only on what we can control. Poetic Structure & Style What is Poetic Structure & Style? The architectural layout of a poem, including how lines, sounds, meters, and word choices are organized. * Rhyme Types: * End Rhyme: Words at the end of poetic lines rhyme. * Example: "The cat sat on the mat / It chased a little rat." * Internal Rhyme: Rhyming occurs within a single line of poetry. * Example: "I drove the car to the bar." * Eye Rhyme: Words that look like they should rhyme based on spelling, but sound different when spoken. * Example: Love and Move / Laughter and Slaughter. * Perfect Rhyme: Stressed vowel sounds and all following consonants are identical. * Example: Cat and Hat / Light and Night. * Slant Rhyme: Imperfect or near-rhymes with similar but non-identical sounds. * Example: Shape and Keep / Worm and Swarm. * Meter: The systematic pattern of stressed and unstressed syllables across a line of poetry (composed of poetic feet). * Example: Iambic pentameter ("Da-DUM da-DUM da-DUM da-DUM da-DUM"). * Stanza: A grouped set of lines within a poem (categorized as formal structure or free verse). * Example: A 4-line stanza is called a quatrain. * Diction: The author's deliberate choice of words and phrases: * Formal: Professional, elevated, or academic vocabulary. * Example: "I request your prompt assistance regarding this matter." * Informal: Everyday conversational language. * Example: "Can you give me a hand real quick?" * Slang: Highly casual words specific to a particular group, region, or subculture. * Example: "That idea is total cap." * Concrete: Specific words appealing directly to the five physical senses. * Example: "The freezing, crisp air smelled of pine needles." * Abstract: Broad ideas, feelings, or concepts requiring deeper interpretation. * Example: Concepts like freedom, justice, or truth. Tone, Style & Voice What are Tone, Style & Voice? The elements that define the emotional attitude, writing personality, and perspective of the author or narrator. * Tone: The author's or speaker's attitude toward the subject matter or audience. * Example: Sarcastic, formal, cheerful, or pessimistic. * Mood: The overall emotional atmosphere created by the author's choices, felt by the reader. * Example: Spooky, peaceful, romantic, or tense. * Style: The unique "fingerprint" or manner in which an author writes (Formal, Informal, or Poetic/Evocative). * Meaning Details: Includes Denotation (literal dictionary definition of a word) and Connotation (emotional or secondary meaning attached to a word). * Speaker, Point of View (POV), & Narrative Techniques: * Speaker / POV: Who is speaking or telling the story. * 1st Person: Narrator is a character in the story ("I", "we"). * 3rd Person Limited: Narrator focuses on the internal thoughts of only one character ("he", "she", "they"). * 3rd Person Omniscient: All-knowing narrator who knows the thoughts and feelings of every character. * Persona: The specific character or identity assumed by the writer or speaker. * Narrative Techniques: Methods used to present ideas: * Description: Setting scenes using visual and sensory details. * Flashback: Interrupting the timeline to show an earlier past event. * Reflection: The speaker looking back on an event to ponder its meaning. * Internal Monologue: Showing a character's unbroken flow of inner thoughts. * Dialogue: Spoken conversation between characters. * Example: "'I told you not to enter that room,' whispered Sarah." * Repetition: Intentionally repeating words or phrases for emphasis. 2. Narrative & Literary Analysis What is Narrative & Literary Analysis? The practice of examining the components of a story to understand how it is constructed and to uncover hidden meanings, symbols, and context. Elements of a Story / Narrative What are Narrative Elements? The structural building blocks that make up a story's plot, setting, characterization, and core message. * Plot Structure: The sequence of events in a story: * Exposition: Introduction of characters, setting, and basic situation. * Rising Action: Events and complications leading up to the main conflict. * Climax: The turning point or peak emotional intensity of the story. * Falling Action: Events after the climax that wrap up plot points. * Resolution / Dénouement: The final outcome or resolving of the core conflict. * Setting: Time, geographic location, historical period, and environmental conditions of the story. * Characterization: The methods used to reveal a character's personality: * Direct Characterization: Character traits explicitly stated by the narrator. * Example: "John was a lazy and dishonest boy." * Indirect Characterization (STEAL Method): Trait revealed through clues rather than being told directly: * S – Speech: What they say and how they say it. * Example: "Give me your lunch money right now!" (Shows bully behavior) * T – Thoughts: What is revealed through private inner feelings. * Example: I wish I could help, but I'm too terrified. (Shows internal fear) * E – Effect on others: How other characters react around this person. * Example: Everyone stopped laughing the moment she walked in. (Shows intimidating presence) * A – Actions: How the character behaves in specific situations. * Example: Mark carried the heavy grocery bags for the elderly woman. (Shows kindness) * L – Looks: Physical appearance, clothing, and body language. * Example: Sharply tailored suit, zero wrinkles, every hair in place. (Shows meticulous organization) Signs, Symbols, & Meaning (Semiotics) What is Semiotics? The study of signs, symbols, and how human beings create, interpret, and communicate meaning. * Sign: Anything that points to an idea, piece of information, or object. * Example: A red stop sign on the road. * Symbol: A specific kind of sign holding a deeper, secondary meaning beyond its literal appearance. * Example: A dove representing peace, or a red rose representing love. * Motif: A recurring element, image, object, or pattern that carries symbolic meaning throughout a work. * Example: The constant reappearance of a ticking clock representing running out of time. * Binary Oppositions: Contrasting concepts or pairs put together to highlight thematic conflict. * Example: Light vs. Darkness, Good vs. Evil, Youth vs. Old Age. * The Semiotic Triangle: A model explaining how language links to thought and reality: * Signifier: The physical image, written word, or sound used. * Example: The written word "D-O-G". * Reference: The mental concept, thought, or connotation behind the signifier. * Example: Thinking of a four-legged furry pet that barks. * Referent: The actual physical object or reality being represented. * Example: The real, living dog sitting in front of you. Organic Unity What is Organic Unity? The concept that every single element in a text (symbols, plot, tone, character actions) plays a unique role, yet none can function alone—every element is essential to the overall meaning and structure of the work. Contextual Analysis What is Contextual Analysis? Background information surrounding a literary work that helps readers understand it more deeply and recognize the values behind it. * Historical Context: Historical events, movements, and societal conditions influencing the story's era. * Example: Reading a story set during World War II to understand why food rationing occurs in the plot. * Cultural Context: Shared beliefs, customs, values, and traditions shaping character choices and themes. * Example: Analyzing family traditions and societal expectations in a story set in ancient Asia. * Biographical Context: How the author's real-life experiences and personal background impact their writing. * Example: Knowing Edgar Allan Poe experienced loss helps explain the grief themes in his poetry. * Psychological Context: Mental states, inner motivations, trauma, and psychological behaviors of characters or the author. * Example: Examining how traumatic events affect a main character's choices and fears. 3. Author's Purpose & Rhetorical Modes What is Author's Purpose? The primary reason why an author creates a text (a literary piece can have multiple purposes). To Persuade * Core Intent: Convince the reader to act or adopt a specific belief. * Key Techniques & Features: * Ethos (Credibility / Ethics): Establishing trust, authority, or moral character. * Example: "As a doctor with 20 years of experience, I recommend this treatment." * Pathos (Emotion): Appealing to the reader's feelings (sympathy, fear, joy). * Example: "Don't let innocent shelter animals spend another night in the cold." * Logos (Logic): Using facts, statistics, and logical reasoning. * Example: "Data shows that wearing seatbelts reduces injury risks by 45%." * Call-to-Action (CTA): Directly telling the reader what action to take. * Example: "Sign this petition today to protect our rivers!" To Inform * Core Intent: Educate or share facts objectively without personal bias or subjective views. * Key Features: Textbooks, news reports, informational articles, research papers. To Entertain * Core Intent: Provide enjoyment, amusement, or engagement for the reader. * Key Techniques & Features: * Suspense: Creating anxiety or intense anticipation about what will happen next. * Example: "The footsteps grew louder on the wooden floorboards right outside her bedroom..." * Vivid Storytelling: Using rich sensory details so the reader can visualize the scene. * Example: "The crisp, icy wind whipped through the towering pine trees as the sun dipped below the crimson horizon." To Express Emotions * Core Intent: Share deeply personal, subjective experiences and inner feelings. * Key Features: Uses 1st Person POV ("I", "my"), personal journals, lyric poetry, and emotional reflections. To Explain / Analyze * Core Intent: Blend information with deeper critical insight to help readers thoroughly understand a complex topic. To Teach / Impart Values * Core Intent: Convey a moral lesson, ethical value, or clear guidance to the reader. * Key Features: Fables, parables, allegories, and didactic stories. To Criticize Society * Core Intent: Question and challenge societal norms, political issues, or systemic flaws. * Key Features: Uses satire, irony, allegory, social commentary, and exaggeration. To Reflect Human Experience * Core Intent: Represent human culture, shared traditions, and everyday lived realities. To Inspire * Core Intent: Encourage readers to believe, hold onto hope, and overcome challenges.