The Shrinking World - Period 1 Vocabulary

The Shrinking Rio Grande

# 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.

Modèles CCC, DCC et shrinkage

09_Concrete Properties_Creep and Shrinkage

Natural Fibers Overview of Natural Fibers Natural fibers are derived from plants and animals, making them biodegradable and environmentally friendly. They have been used for thousands of years, with origins tracing back to ancient civilizations. Common types include cotton, jute, linen, wool, cashmere, and silk, each with unique properties and uses. Detailed Descriptions of Key Natural Fibers Cotton: Originating around 3000 BC, cotton is the most universal fiber known for its high absorbency and comfort. However, it wrinkles easily and shrinks when washed. Jute: Known as burlap, jute is one of the cheapest fibers, primarily used for carpet backing. It is brittle and breaks easily, typically woven in a plain weave. Linen: Derived from the flax plant, linen is elegant and durable, becoming softer with each wash. It is the strongest vegetable fiber, often used in high-end apparel. Wool: An animal protein fiber from sheep, wool is warm and resilient but may irritate sensitive skin. It requires dry cleaning to maintain its shape and is susceptible to moth damage. Cashmere: A luxurious fiber from goats, cashmere is soft and warm, with a yield of only half a pound per goat per year, making it rare and expensive. Silk: Produced by silkworms since 2460 B.C., silk is known for its strength and luxurious feel, often used in high-end fabrics like brocade and chiffon. Historical Context and Uses The use of natural fibers dates back to ancient civilizations, with cotton and silk being traded along the Silk Road. Jute and linen have been staples in various cultures for their durability and versatility in textiles. Wool has been a primary material for clothing in colder climates, while silk has been associated with luxury and wealth throughout history. Historical Context and Usage The use of cotton dates back to ancient civilizations, with evidence of its cultivation in the Indus Valley. Jute has been utilized for centuries, primarily in South Asia, for making ropes and burlap. Linen was favored in ancient Egypt for its coolness and comfort in hot climates, often used in burial garments. Wool has been a staple in colder regions, providing warmth and insulation for centuries. Cashmere became popular in Europe during the 18th century, symbolizing luxury and wealth. Silk was a major trade commodity along the Silk Road, influencing cultural exchanges between East and West. Manufactured Fibers Overview of Manufactured Fibers Manufactured fibers are created through chemical processes from substances that are not fibers at any stage of production. They allow for customization and enhancement of properties beyond what natural fibers can offer, such as durability and elasticity. Key Types of Manufactured Fibers Rayon: Made from regenerated cellulose, rayon was first produced in the U.S. in 1911. It is soft but loses strength when wet and should not be ironed with high heat. Nylon: Developed by DuPont in 1939, nylon is the first synthetic fabric, used in apparel and non-apparel items like tires and airbags. It is known for its quick-drying properties. Polyester: Originating in the 1930s, polyester is the most widely used manmade fiber, resistant to wrinkles but can feel clammy against the skin. Spandex: Introduced in 1959, spandex is highly elastic, used in athletic wear and swimwear, but is sensitive to chlorine. Applications and Characteristics Manufactured fibers are used in a wide range of products, from clothing to industrial applications, due to their versatility. They can be engineered for specific functions, such as moisture-wicking in athletic wear or durability in outdoor gear. The development of synthetic fibers has revolutionized the textile industry, allowing for mass production and lower costs. Applications and Innovations Rayon is often used in apparel and medical supplies due to its softness and versatility. Nylon's strength and elasticity make it suitable for a wide range of applications, from clothing to industrial uses. Polyester's resistance to wrinkles and fading has made it a popular choice for everyday clothing and home textiles. Spandex's elasticity allows for comfortable, form-fitting garments, revolutionizing activewear and swimwear design. Fabric Construction Techniques Weaving Techniques Plain Weave: The simplest and most common weave, characterized by a checkerboard pattern. Examples include burlap and linen. Twill Weave: Features diagonal lines, providing durability. Denim is a popular example, known for its ruggedness. Satin Weave: Produces a shiny surface by floating warp yarns over filling yarns, commonly used in luxurious fabrics. Specialized Weaves Basket Weave: A variation of plain weave that uses two or more warp and filling threads, resulting in a looser fabric. Pile Weave: Creates a three-dimensional texture, as seen in velvet and terry cloth, which is highly absorbent. Jacquard Weave: Allows for intricate patterns to be woven into the fabric, used in brocade and decorative textiles. Fabric Properties and Uses Different weaves impart unique properties to fabrics, such as breathability, durability, and aesthetic appeal. Understanding the weave type is crucial for selecting the right fabric for specific applications, such as clothing, upholstery, or industrial use. The choice of fiber and weave affects the final product's performance, care requirements, and longevity. Overview of Weaving Techniques Fabric construction involves various weaving techniques that determine the texture, strength, and appearance of the fabric. Common weaving methods include plain weave, twill weave, satin weave, and pile weave, each with unique characteristics and applications. Detailed Descriptions of Weaving Techniques Plain Weave: The simplest and most common weave, characterized by a checkerboard pattern. Examples include burlap and linen. Twill Weave: Features diagonal lines, providing durability and a unique texture. Denim is a well-known example of twill weave. Satin Weave: Known for its shiny surface, satin weave involves floating yarns to create a smooth finish, often used in luxurious fabrics. Pile Weave: Creates a three-dimensional texture, with examples including velvet and terry cloth, known for their softness and absorbency. Applications of Weaving Techniques Plain weave fabrics are widely used in everyday clothing and home textiles due to their simplicity and versatility. Twill weave fabrics like denim are popular in casual wear and home decor, valued for their durability. Satin weave is often used in evening wear and formal attire, providing a luxurious appearance. Pile weave fabrics are commonly used in towels and upholstery, offering comfort and absorbency. Types of Weaves Plain Weave: Balanced, no right or wrong side, wrinkles easily. Examples include calico, batiste, and muslin. Rib Weave: Includes broadcloth and poplin, characterized by fine crosswise ribs and high thread counts, often used in shirts. Basket Weave: A variation of plain weave that uses multiple warp and filling threads as one, resulting in a looser weave. Specialty Fabrics Velvet: A luxurious fabric made from silk or rayon, featuring a soft texture and rich appearance. Corduroy: A napped fabric with ridges, made from two sets of filling yarns, providing a unique texture. Brocade: A heavy fabric with raised patterns, often produced using jacquard or dobby weaving techniques. Overview of Textile Fibers Rayon Fiber Rayon is a fiber made from regenerated cellulose derived from trees, first produced in the US in 1911. Originally known as artificial silk, rayon is known for its softness and versatility in applications. It can be woven into apparel or used in non-woven forms for medical supplies, feminine products, and filters. Key characteristics include shrinkage and loss of strength when wet; it should not be ironed with hot temperatures. Nylon Developed by DuPont in 1939, nylon is a synthetic fiber made from cotton. Commonly used in apparel such as hosiery and in non-apparel items like tires, airbags, and fishing lines. Known for its easy care, quick drying properties, and low-temperature ironing requirements. Polyester Originating in the 1930s in England, polyester is one of the most widely used manmade fibers. It is utilized in both apparel (knits and woven fabrics) and non-apparel items like seat belts and artificial arteries. Polyester is recognized for its resistance to wrinkles and its somewhat clammy feel. Spandex Created by DuPont in 1959, spandex is known for its exceptional elasticity, stretching up to 500%. Commonly used in swimwear, athletic apparel, and disposable diapers, spandex is sensitive to chlorine damage. Historical Context and Applications Historical Development of Fibers Rayon was the first manmade fiber, marking a significant development in textile technology in the early 20th century. The introduction of nylon in 1939 by DuPont revolutionized the textile industry, leading to the creation of synthetic fabrics. Polyester's rise in the 1930s and spandex's introduction in 1959 further diversified fabric options available for consumers. Applications of Fabrics Apparel: Each fiber has specific applications; for example, rayon is used in clothing, while nylon is favored for hosiery and outdoor gear. Non-Apparel: Many fibers are also used in industrial applications, such as polyester in seat belts and spandex in athletic wear. Medical Uses: Non-woven fabrics like rayon are crucial in medical supplies, showcasing the versatility of textile fibers. ok

Hibiscus Noun — A genus of flowering plants with large, colorful blooms. 2. Heroines Noun — Legendary or admired women noted for courage or achievements. 3. Posthumous Adjective — Occurring or published after death. 4. Obligatory Adjective — Required. 5. Delegation Noun — A group chosen to represent others. 6. Anonymity Noun — The state of being unknown or unacknowledged. 7. Veritable Adjective — Actual, true, or real; often used to emphasize. 8. To wince Verb — To flinch or shrink back from pain. 9. To emblazon Verb — To decorate or inscribe with heraldic or symbolic imagery. 10. Tribute Noun — A gift or acknowledgment of respect or admiration. 11. Monolithic Adjective — Massive, uniform, and often rigid or inflexible. 12. Mythologizer Noun — One who creates or promotes myths. 13. Orchid Noun — A flowering plant of the orchid family with intricate blooms. 14. Coquette Noun — A woman who flirts without serious intentions. 15. (To) censor Noun/Verb — One who suppresses or removes objectionable material; to suppress or remove objectionable material. 16. Clairvoyance Noun — The ability to perceive things beyond normal sensory contact. 17. Pious Adjective — Devoutly religious or dutiful; sometimes hypocritically so. 18. Gullible Adjective — Easily deceived or tricked. 1 / 3 Chapters 1,23 of ITB Study online at https://quizlet.com/_k1exr9 19. To agitate Verb — To stir up public interest or anger on a topic. 20. Doe Noun — A female deer or rabbit. 21. Mourning Clothes Noun — Clothing worn to signify mourning, traditionally black. 22. Chamber Pot Noun — A portable container used for toileting in bedrooms. 23. To coax Verb — To persuade gently or with flattery. 24. Matins Noun — Morning prayers in Christian liturgy. 25. Exodus Noun — A mass departure. 26. Dynastic Adjective — Relating to a ruling family line. 27. Centennial Noun — A 100-year anniversary or celebration. 28. Specter Noun — A ghost or something feared as a threat. 29. Epistle Noun — A formal or elegant letter. 30. To scowl Verb — To frown in anger or displeasure. 31. Blithe Adjective — Casual or cheerful indifference that may be improper. 32. Canopy Noun — A decorative or protective covering overhead. 33. Languish Verb — To weaken, suffer neglect, or become feeble. 34. Confession Noun — A formal admission of one's sins with repentance and desire for absolution. 35. To inaugurate Verb — To induct into office with suitable ceremonies; to commence officially. 2 / 3 Chapters 1,23 of ITB Study online at https://quizlet.com/_k1exr9 36. Pilgrimage Noun — A journey to a sacred place for religious reasons. 37. Immortal Adjective — Not subject to death; living forever

# Glandular Tissue & Lymphatic System ## Chapter 7: Glandular Tissue ### Summary This chapter details the endocrine and exocrine glands of the head and neck, their locations, secretions, functions, innervations, lymphatic drainage, and blood supply. Understanding these glands is crucial for dental professionals to identify disease processes. ### Key Information #### Gland Types - **Exocrine Gland:** Has a duct to empty secretions directly to the site of use (e.g., salivary glands). - **Endocrine Gland:** Ductless, secretes directly into the vascular system (e.g., thyroid gland). - Motor nerves regulate secretion flow; sensory nerves are also present. #### Lacrimal Glands - **Type:** Paired almond-shaped exocrine glands. - **Secretions:** Lacrimal fluid (tears) for lubricating the conjunctiva and eyeball. - **Location:** Lacrimal fossa of the frontal bone, just inside the lateral part of the supraorbital rim. - **Ducts:** Lacrimal ducts collect tears, which then pass to the lacrimal punctum, lacrimal sac, nasolacrimal duct, and finally drain into the inferior nasal meatus. - **Innervation:** Parasympathetic fibers from the greater petrosal nerve (branch of facial nerve), synapsing at the pterygopalatine ganglion. Postganglionic fibers reach the gland via maxillary branches of the trigeminal nerve and lacrimal nerve. - **Lymphatic Drainage:** Superficial parotid lymph nodes. - **Blood Supply:** Lacrimal artery (branch of ophthalmic artery); venous return via superior ophthalmic vein. - **Pathology:** Dry eye syndrome (DES) or keratoconjunctivitis sicca (KCS) due to reduced lacrimal fluid production. #### Salivary Glands - **Function:** Produce saliva to lubricate and cleanse the oral cavity, aid digestion, and contribute to immune defense. - **Control:** Autonomic nervous system. - **Types:** Major (large, encapsulated, named ducts) and Minor (smaller, more numerous, unencapsulated, shorter unnamed ducts). Both are exocrine. ##### Major Salivary Glands 1. **Parotid Salivary Gland** - **Type:** Largest encapsulated major salivary gland. - **Secretions:** Serous type only (25% of total salivary volume). - **Location:** Parotid space, posterior to mandibular ramus, anterior and inferior to each ear, overlying the masseter muscle. - **Duct:** Parotid duct (Stensen duct) opens into the oral cavity opposite the maxillary second molar. - **Innervation:** Efferent (parasympathetic) fibers from the otic ganglion of the glossopharyngeal nerve (ninth cranial nerve) via the lesser petrosal nerve. Postganglionic fibers carried by the auriculotemporal nerve (mandibular division of trigeminal nerve). Facial nerve passes through but does not innervate. - **Lymphatic Drainage:** Deep parotid lymph nodes. - **Blood Supply:** Transverse facial artery (branch of external carotid artery); venous return via retromandibular vein. - **Pathology:** Enlargement and tenderness with mumps (parotitis), most salivary gland cancers involve the parotid. 2. **Submandibular Salivary Gland** - **Type:** Second largest encapsulated major salivary gland. - **Secretions:** Mixed serous and mucous (60-65% of total salivary volume). - **Location:** Submandibular fossa in the submandibular space, inferior and posterior to the body of the mandible. - **Duct:** Submandibular duct (Wharton duct) opens at the sublingual caruncle in the floor of the mouth. - **Innervation:** Efferent (parasympathetic) fibers of the chorda tympani nerve (facial nerve) synapsing in the submandibular ganglion. Postganglionic fibers delivered by the lingual nerve (mandibular division of trigeminal nerve). - **Lymphatic Drainage:** Submandibular lymph nodes. - **Blood Supply:** Glandular branches of the facial artery; venous return mainly by the facial vein. - **Pathology:** Most common site for salivary stones (sialoliths). 3. **Sublingual Salivary Gland** - **Type:** Smallest, most diffuse, and only unencapsulated major salivary gland. - **Secretions:** Mixed, predominately mucous (10% of total salivary volume). - **Location:** Sublingual fossa in the sublingual space at the floor of the mouth, deep to the sublingual fold, anterior to the submandibular gland. - **Ducts:** Ducts of Rivinus (8-20 small ducts) open along the sublingual fold; sometimes form a larger Bartholin duct opening at the sublingual caruncle. - **Innervation:** Same as submandibular gland: efferent (parasympathetic) fibers of the chorda tympani nerve (facial nerve) and submandibular ganglion. Postganglionic fibers delivered by the lingual nerve (mandibular division of trigeminal nerve). - **Lymphatic Drainage:** Submandibular lymph nodes. - **Blood Supply:** Sublingual artery (off lingual artery); parallel venous return. ##### Minor Salivary Glands - **Type:** More numerous than major glands, unencapsulated. - **Secretions:** Mainly mucous, except von Ebner glands (serous only). - **Location:** Scattered throughout oral mucosa (buccal, labial, lingual, soft palate, posterior hard palate, floor of mouth). Von Ebner glands associated with circumvallate lingual papillae. - **Ducts:** Single, short ducts directly into the oral cavity. - **Innervation:** Preganglionic from facial nerve, postganglionic from various branches of the trigeminal nerve. - **Lymphatic Drainage & Blood Supply:** Various nodes and arteries depending on location. - **Pathology:** Mucocele (blockage of duct from trauma). #### Thyroid Gland - **Type:** Largest endocrine gland (ductless). - **Secretions:** Thyroxine (hormone) directly into the vascular system to stimulate metabolic rate. - **Location:** Anterolateral regions of the neck, inferior to the thyroid cartilage, at the junction of the larynx and trachea. - **Innervation:** Sympathetic nerves through cervical ganglia (do not control secretion; pituitary gland regulates hormone release). - **Lymphatic Drainage:** Superior deep cervical lymph nodes. - **Blood Supply:** Superior and inferior thyroid arteries (possibly thyroid ima artery); venous return via superior, middle, and inferior thyroid veins. - **Pathology:** Goiter (enlarged thyroid gland), loss of mobility indicating neoplastic growth. #### Parathyroid Glands - **Type:** Usually four small endocrine glands (ductless). - **Secretions:** Parathyroid hormone directly into the vascular system to regulate calcium and phosphorus levels. - **Location:** Adjacent to or within the thyroid gland on its posterior surface (not visible or palpable). - **Innervation:** Same as thyroid gland: sympathetic nerves through cervical ganglia. - **Lymphatic Drainage:** Superior deep cervical lymph nodes. - **Blood Supply:** Primarily inferior thyroid arteries (possibly anastomotic branch between inferior and superior thyroid arteries); venous return via superior, middle, and inferior thyroid veins. #### Thymus Gland - **Type:** Endocrine gland (ductless) and part of the immune system. - **Function:** T-cell lymphocytes mature here. Grows until puberty, then shrinks (involution). - **Location:** Thorax and anterior region of the base of the neck, inferior to the thyroid gland, superficial and lateral to the trachea, deep to the sternum. - **Innervation:** Branches of the vagus nerve (tenth cranial nerve) and cervical spinal nerves. - **Lymphatic Drainage:** Lymphatic system begins within the gland and terminates in the internal jugular vein (no afferent vessels). - **Blood Supply:** Inferior thyroid and internal thoracic arteries; venous return via veins in the posterior surface directly into brachiocephalic veins. - **Pathology:** Thymic rests (ectopic accessory thymic tissue). ## Chapter 10: Lymphatic System ### Summary This chapter covers the lymphatic system, its components (vessels, nodes, ducts, tonsils), and its role in fighting disease. It details the location, drainage patterns, and clinical significance of lymph nodes and tonsils in the head and neck. ### Key Information #### Lymphatic System Overview - **Components:** Vessels, nodes, ducts, tonsils. - **Function:** Part of the immune system, fights infection and cancer, drains tissue fluid (lymph). - **Lymphatic Vessels:** Parallel venous blood vessels, have one-way valves, drain lymph. - **Lymph Nodes:** Bean-shaped bodies in clusters, filter toxic products from lymph, contain lymphocytes (white blood cells), involved in lymphocyte production. - **Afferent vessels:** Lymph flows into the node. - **Efferent vessel:** Lymph flows out of the node at the hilus. - **Primary node (regional/master node):** First node lymph drains into from a particular region. - **Secondary node (central node):** Node that primary nodes drain into. - **Lymphatic Ducts:** Larger vessels formed by converging lymphatic vessels. - **Right lymphatic duct:** Drains right side of head and neck, right arm, and thorax into the junction of the right subclavian and right internal jugular veins. - **Thoracic duct:** Drains left side of head and neck, left arm, thorax, and entire lower half of the body into the junction of the left subclavian and left internal jugular veins. - **Tonsils:** Masses of lymphoid tissue near airway and food passages, contain lymphocytes, drain into superior deep cervical lymph nodes. #### Lymph Nodes of the Head ##### Superficial Lymph Nodes of the Head - **Occipital Lymph Nodes:** - **Location:** Posterior base of the head (occipital region). - **Drainage:** Scalp in the occipital region. - **Empties into:** Deep cervical nodes. - **Posterior Auricular, Anterior Auricular, and Superficial Parotid Lymph Nodes:** - **Posterior Auricular:** Posterior to each auricle and external acoustic meatus. - **Anterior Auricular:** Immediately anterior to each tragus. - **Superficial Parotid:** Superficial to each parotid salivary gland. - **Drainage:** External ear, lacrimal gland, adjacent scalp and face. - **Empties into:** Deep cervical nodes. - **Facial Lymph Nodes:** - **Location:** Along the facial vein. - **Subgroups:** Malar (infraorbital), Nasolabial (along nasolabial sulcus), Buccal (around labial commissure), Mandibular (superior to mandible, anterior to masseter). - **Drainage:** Skin and mucous membranes where located, drain superior to inferior. - **Empties into:** Deep cervical nodes via submandibular nodes. ##### Deep Lymph Nodes of the Head - Cannot be palpated extraorally. - **Deep Parotid Lymph Nodes:** - **Location:** Deep within the parotid salivary gland. - **Drainage:** Middle ear, auditory tube, parotid salivary gland. - **Empties into:** Deep cervical nodes. - **Retropharyngeal Lymph Nodes:** - **Location:** Near deep parotid nodes, at the level of the atlas. - **Drainage:** Posterior palate, pharynx, paranasal sinuses, nasal cavity. - **Empties into:** Deep cervical nodes. #### Cervical Lymph Nodes - Paired, unilaterally drain tissues (except submental nodes, which drain bilaterally). - Categorized into superficial and deep. - Medical community uses a 7-level classification (Node Levels I-VII). ##### Superficial Cervical Lymph Nodes - **Submental Lymph Nodes (Node Level I, Sublevel a):** - **Location:** Inferior to the chin, within the submental fascial space and submental triangle. - **Drainage:** Lower lip, chin, floor of mouth, apex of tongue, mandibular incisors with periodontium and gingiva. - **Empties into:** Submandibular nodes or directly into deep cervical nodes. - **Clinical Significance:** Risk for spread of cancers from floor of mouth, apex of tongue, mandibular anterior alveolar process, lower lip. - **Submandibular Lymph Nodes (Node Level I, Sublevel b):** - **Location:** Inferior border of the mandibular ramus, superficial to the submandibular salivary gland. - **Drainage:** Cheeks, upper lip, body of tongue, anterior hard palate, most teeth (except mandibular incisors and maxillary third molars), sublingual and submandibular salivary glands. Secondary nodes for submental and facial regions. - **Empties into:** Deep cervical nodes. - **Clinical Significance:** Risk for spread of cancers from oral cavity, anterior nasal cavity, midface structures, submandibular salivary gland. - **External Jugular Lymph Nodes (Superficial Cervical Nodes):** - **Location:** Along the external jugular vein, superficial to the SCM muscle. - **Drainage:** Secondary nodes for occipital, posterior auricular, anterior auricular, and superficial parotid nodes. - **Empties into:** Deep cervical nodes. - **Anterior Jugular Lymph Nodes (Anterior Cervical Nodes):** - **Location:** Along the anterior jugular vein, anterior to larynx, trachea, superficial to SCM muscle. - **Drainage:** Infrahyoid region of the neck. - **Empties into:** Deep cervical nodes. ##### Deep Cervical Lymph Nodes - **Location:** Along the internal jugular vein, deep to the SCM muscle, from skull base to root of neck. - Divided into superior and inferior based on omohyoid muscle crossing internal jugular vein. - **Node Level II (Superior one-third):** - **Location:** From digastric muscle superiorly to hyoid bone/carotid bifurcation inferiorly. - **Drainage:** Oral cavity, nasal cavity, nasopharynx, oropharynx, laryngopharynx, larynx, parotid salivary gland. - **Jugulodigastric lymph node (tonsillar node):** Prominent node in this group, drains palatine tonsils. - **Node Level III (Middle one-third):** - **Location:** From hyoid bone/carotid bifurcation superiorly to cricothyroid notch/cricoid cartilage/omohyoid muscle inferiorly. - **Drainage:** Oral cavity, nasopharynx, oropharynx, laryngopharynx, larynx. - **Node Level IV (Inferior one-third):** - **Location:** From omohyoid muscle superiorly to clavicle inferiorly. - **Drainage:** Laryngopharynx, esophagus, larynx. - **Node Level V (Posterior cervical triangle):** - **Location:** From skull base at posterior SCM border to clavicle. - **Drainage:** Nasopharynx, oropharynx (Sublevel a), thyroid gland (Sublevel b). - **Node Level VI (Anterior compartment):** - **Location:** Inferior to hyoid bone, between medial margins of common carotid arteries. - **Drainage:** Thyroid gland, specific parts of larynx, esophagus. - **Superior Deep Cervical Lymph Nodes:** - **Location:** Deep to SCM muscle, superior to omohyoid muscle crossing internal jugular vein. - **Drainage:** Posterior nasal cavity, posterior hard palate, soft palate, base of tongue (bilateral drainage), maxillary third molars, TMJ, esophagus, trachea, thyroid gland. Secondary nodes for most other head and neck nodes. - **Empties into:** Inferior deep cervical nodes or directly into jugular trunk. - **Inferior Deep Cervical Lymph Nodes:** - **Location:** Deep to SCM muscle, inferior to omohyoid muscle crossing internal jugular vein, extending into supraclavicular fossa. - **Drainage:** Posterior scalp and neck, superficial pectoral region, part of arm. Secondary nodes for superficial head nodes and superior deep cervical nodes. - **Jugulo-omohyoid lymph node:** Drains tongue and submental triangle; enlarged node can indicate tongue carcinoma. - **Empties into:** Jugular trunk (right) or thoracic duct (left). - **Clinical Significance:** Communicates with axillary lymph nodes, high risk for spread of breast cancer. - **Accessory Lymph Nodes:** - **Location:** Along the eleventh cranial (accessory) nerve. - **Drainage:** Scalp and neck regions. - **Empties into:** Supraclavicular nodes. - **Supraclavicular Lymph Nodes:** - **Location:** Superiorly along the clavicle. - **Drainage:** Lateral cervical triangles. - **Empties into:** Jugular trunks or directly into right lymphatic duct/thoracic duct. - **Clinical Significance:** Final endpoint of lymphatic drainage from entire body, high risk for spread of cancers from lungs, esophagus, stomach. #### Tonsils - **Palatine Tonsils:** - **Location:** Oral cavity, between anterior and posterior faucial pillars. - **Lingual Tonsil:** - **Location:** Dorsal surface of the base of the tongue. - **Pharyngeal Tonsil (Adenoids):** - **Location:** Midline of the posterior wall/roof of the nasopharynx. - **Tubal Tonsil:** - **Location:** Nasopharynx, posterior to openings of the auditory tube. - **Drainage:** All tonsils drain into the superior deep cervical lymph nodes, particularly affecting the jugulodigastric lymph node if infected. #### Clinical Considerations with Lymphatic System Pathology - **Lymphadenopathy:** Dramatic increase in size and change in consistency of lymphoid tissue due to infection or cancer. - **Infection:** Nodes are slightly firmer, extremely mobile, and tender. - **Cancer:** Nodes can become bony hard, fixed to surrounding tissue, usually not tender initially (pain is a late finding). - **Lymphadenitis:** Inflammation of a lymph node, common with microbial infections. - **Metastasis:** Spread of cancer from a primary site to a secondary site via lymph. - Involvement of primary nodes offers a better prognosis than secondary nodes or lymphatic ducts. - Head and neck cancers frequently spread to cervical lymph nodes (80% of cases). - Node metastasis is a significant prognostic factor for squamous cell carcinoma survival. ### Learning Objectives Tasks: - Define and pronounce key and anatomic terms. - Locate and identify glands and associated structures on diagrams, skulls, and patients. - Discuss glandular pathology. - Integrate understanding into clinical dental practice. - List and discuss lymphatic system components. - Locate and identify lymph nodes and tonsils on diagrams and patients. - Identify lymphatic drainage patterns for the head and neck. - Describe and discuss pathology of lymphoid tissue. - Compare the relationship of the lymphatic system to the overall function of the immune system.

WPS 264 Shrinkage & swelling

[Music] [Music] this is the story of the greatest scientific discovery ever the discovery that everything is made of atoms the vast variety and richness of everything we see around us in the world and beyond how it's built up how it all fits together is all down to atoms and the mysterious laws they obey as scientists delve deep into the atom it's the very part of matter they unraveled nature's most shocking secrets they had to abandon everything they believed in and create a whole new science a science that today underpins the whole of physics chemistry biology and maybe even life itself but for me the story of how humanity solved the mystery of the atom is both inspiring and remarkable it's a story of great geniuses of men and women driven by their thirst for knowledge and glory it's a story of false starts and conflicts of ambition and revelation a story that leads us through some of the most exciting and exhilarating ideas ever conceived of by the human race and for a working physicist like me it's the most important story there is [Music] [Music] on the 5th of October 1906 in a hotel room near Trieste a German science is called Ludwig Boltzmann hanged himself Boltzmann had a long history of psychological problems and one of the key factors in his depression was that he'd been vilified even ostracized for believing something that today we take for granted he believed that matter cannot be infinitely divisible into ever smaller pieces instead he argued that ultimately everything is made of basic building blocks atoms it seems incredible now that Boltzmann's revelation was so controversial but a hundred years ago arguing atoms were real was considered by most to be a waste of time although philosophers since the Greeks had speculated that the world might be made out of some kind of basic unit of matter they realized that they were far too small to see even under the most powerful microscopes speculating about them was therefore a complete waste of time but then in the middle of the 19th century whether or not the atom was real was suddenly a question of burning importance the reason was this steam by the 1850s it was changing the world it powered the mighty engines the trains the ships the factories of the Industrial Revolution so figuring out how to use it more effectively became a matter of crucial commercial political and military significance not surprisingly then it became the key question of 1965 [Music] the demand to build more powerful and efficient steam engines in turn created an urgent need to understand and predict the behavior of water and steam at high temperatures and pressures not the alts Minh and his scientific allies showed that if you imagine steam is made of millions of tiny rigid spheres atoms then you can create some powerful mathematical equations and those equations are capable of predicting the behavior esteemed with incredible accuracy but these same equations plunge Boltzmann and his fellow atomists into controversy their enemies argued that since the atoms referred to in their calculations were invisible they were merely a mathematical convenience rather than real physical objects to claim that imaginary entities were real seem presumptuous even blasphemous you see boss most critics argued that it was sacrilegious to reduce God's miraculous creation down to a series of collisions between tiny inanimate spheres Boltzmann was condemned as an irreligious materialist the tragic irony of Boltzmann's story is that when he took his own life in 1906 he was unaware that he'd been vindicated you see a year before he died a young scientist had published a paper which undeniably irrefutable proclaimed the reality of the atom you might have heard of this young scientist his name was Albert Einstein in 1905 the year before Boltzmann suicide Albert Einstein was 26 years old his brash arrogance had upset most of his professors and teachers and he was barely employable then he got his girlfriend pregnant that was followed by a hasty marriage he needed a job any job having not quite distinguished himself a university he took up a job as a patent clerk here in bern in switzerland he'd moved into the small one-bedroom Apartments on cram gasser with his young wife from a laborer despite dire personal straits the young Einstein had a burning ambition he was desperate to make his mark as a physicist and in 1905 during one miraculous year the mark he made was truly incredible having an undemanding job meant that young einstein had plenty of time on his hands both at work and here in his tiny apartment to think deep thoughts in the space of just a few months he was to publish several papers that would change science forever now everyone's heard of his theory of relativity even if they don't understand it and his paper on the nature of light was to win him the Nobel Prize a few years later but ironically it wasn't either of these two papers that had the most impact on the discovery of atoms the one that made all the difference was a short paper on how tiny grains of pollen danced in water almost 80 years earlier in 1827 a Scottish botanist called Robert Brown sprinkled pollen grains in some water and examined it through a microscope what he found was really strange because instead of the pollen grains floating gently in the water they danced around furiously almost as though they were alive now while this so called Brownian motion was strange scientists soon forgot about it they found it mundane even boring I mean who cared if the pollen giggled about in the water and what had the jiggling to do with atoms anyway for nearly 80 years brown's discovery remained a little-known scientific anomaly then Einstein changed everything in one staggering insight I Stein saw that Brownian motion was all about atoms in fact he realized that the jiggling of pollen grains in water could settle the raging debate about the reality of atoms forever his argument was simple the pollen will only jiggle if they were being jostled by something else so I said that the water must be made of tiny atoms like particles which themselves are jiggling and are continually buffeting the pollen if there were no atoms then the pollen would stay still so Boltzmann and his contemporaries had been rowing furiously about this question for nothing the answer was there all along Einstein proved that for Brownian motion to happen atoms must exist Einstein später went way beyond just verbal arguments with flawless mathematics he proved that the dance of the pollen revealed the size of the atom and it's mind-numbing ly tiny 1/10 of a millionth of a millimeter across a single human hair itself one of the narrowest things visible to the naked eye is over a million atoms wide let me put it another way there are more atoms in a single glass of water than there are glasses of water in all the oceans of the world sort of hurts your head just to think about it Einstein's paper ended the debate about whether the atom was real or not and Boltzmann had been totally vindicated the atom had to be real [Music] [Music] by the early years of the 20th century the atom had arrived scientists we'd argued that the atom was real were no longer heretics in a dramatic sudden reversal they became the new orthodoxy but they were to pay a huge price for their success before that even had a chance to congratulate each other on discovering the atom it ripped the rug out from under their feet and sent them spiraling into a bizarre and at times terrifying new world and it all kicked off here in what by 1910 was the world center for atomic physics Manchester two of the most extraordinary men in the history of science worked here in the physics departments of Manchester University between 1911 and 1916 they were Ernest Rutherford and Niels Bohr on the face of it two very different personalities and the unlikeliest of collaborators Rutherford was from a remote part of New Zealand and grew up on a farm Bohr was born in Copenhagen wealthy and erudite virtually an aristocrat Rutherford was the ultimate experimentalist he loved technology and ingenious arrangements of batteries coils magnets and radioactive rocks but he was also blessed with a profound intuition in contrast war was the ultimate theoretician to him science was about deep thought and abstract mathematics pen and paper chalk and blackboard were his tools logic was his path to truth although their approaches to their work couldn't have been any more different they had one thing in common they were prepared to ditch three centuries of scientific convention if it didn't fit what they believed to be true they were genuine revolutionaries Rutherford and Bohr were two of the most extraordinary minds ever produced by the human race but it would take every bit of their dogged tenacity and inspirational brilliance to take on the atom in 1907 ernest rutherford took over the physics departments in manchester this was a period of momentous scientific change just over ten years earlier in germany came the first demonstration of weird rays that see through flesh to reveal our bones these rays were so inexplicable scientists didn't know what to call them so they were named x-rays and a couple of years after that in Cambridge it was shown that powerful electric currents could produce strange streams of tiny glowing charged particles that were called electrons and in 1896 in Paris came the most significant discovery of all one that more than any other would unlock the secrets of the atom the metal uranium was shown to emit a strange and powerful energy that was named radioactivity it seemed straight out of science fiction radioactive metals were warm to touch they could even burn the skin and the rays could pass through solid matter as if it wasn't there it truly was a marvel of the modern age Rutherford was obsessed with radioactivity all sorts of questions plagued him how has it made why did it come in different forms how far could it travel through a vacuum or through air did it alter the materials that are encountered in Manchester together with his assistants hands Geiger of Geiger counter fame and Ernest Marsden he devised a series of experiments that would probe the Enigma of radioactivity 1909 Manchester University these are the props goldleaf Beaton said it's just a few atoms thick a movable phosphorescent screen that flashed when struck by radioactive rays and inside this box is the star attraction a tiny piece of the metal radium radium is an extraordinarily powerful source of a kind of radioactivity the Rutherford had named alpha rays they weren't really rays they were more like a steady stream of particles and radium spat up these particles like a machine gun that never ran out of bullets Rutherford set his students a simple enough task use the radium gun shoot the alpha radioactivity at the gold leaf and with the phosphorescent plate count the number of particles that come out the other side in practice that meant sitting alone in the dark and counting tiny almost invisible flashes on the phosphorescent screen it was deeply tedious but Rutherford insisted that they keep at it weeks passed and the team of researchers found nothing unusual the alpha particles seemed to punch through the gold almost as though it wasn't there very occasionally they would swerve slightly as they went through hardly front-page news now comes what must be the most consequential off-the-cuff remark in the history of science one that changed the world the story goes that Rutherford bumps into his assistant Geiger in the corridor outside the lab Geiger reported that so far they've seen nothing unusual now in response Rutherford could have easily just nodded and walked on but he didn't he later claimed that he said what he said at the time for the sheer hell of it but I don't believe him Rutherford had great scientific intuition and I think he had a hunch that something was about to happen here's what he said to Geiger tell young Marsden to go back and see if he can detect any alpha particles on the same side of the gold leaf as the radium source in other words see if any alpha particles are bouncing back now it's an extraordinary suggestion from Rutherford and one day he had no logical reason to make after all Geiger Marsden had spent weeks seeing alpha particles do nothing but streams straight through the gold leaf almost as though it wasn't there why would any bounce back the Geiger Marsden were young and in all the big New Zealand er they did their master's bidding and went back into their dark lab and watched patiently for days they saw absolutely nothing they strained their eyes to the points of myopia but didn't see a single alpha particle bouncing back off the gold it seemed that rather for suggestion really was a stupid one but then the impossible happened one afternoon in 1909 Geiger burst into Rutherford's office with some astonishing news very very occasionally an alpha particle would indeed ricochet back off the gold leaf Geiger calculated that only 1 in 8,000 alpha particles would do this it's a tiny percentage but Rutherford's mind reeled with the news he would later say it was like firing a shell at a piece of tissue paper and have it bounce back at you there and then Rutherford knew he'd struck physics cold although it would take him over a year to fully understand why the alpha particles would do this when he did he would show humanity for the first time the inside of an atom now people had barely got used to the idea that atoms existed but now Rutherford knew that this my new world 1/10 of a millionth of a millimetre across had his own internal structure within the atomic there's a sub atomic world and Ernest Rutherford believed he knew what it looked like Rutherford realized that the bouncing alpha particle revealed an atom that was totally unexpected it had no familiar analogy on earth so Rutherford looked for one in the heavens he pictured the atom as a tiny solar system electrons tiny particles of negative electricity orbit around a minut positively charged object called the nucleus [Music] Rutherford calculated that the nucleus was 10,000 times smaller than the atom itself that's why only 1 in 8,000 alpha particles bounce back they're the ones that hit the Tony nucleus by chance the rest whizzed by without hitting anything the first astonishing consequence of this idea is that Rutherford's atom is almost entirely empty space that's why nearly all the alpha particles race through the gold atoms as if there's nothing there there really is nothing there consider the bizarre implications of Rutherford's atom by imagining it on a bigger scale if the nucleus were the size of a football then the nearest electron will be an orbit half a mile away the rest of the atom will be completely empty space let me explain another way if you were to suck out all the empty space from every atom in my body then I would shrink down to a size smaller than a grain of salt of course I'd still weigh the same and if you did the same thing to the entire human race then all 6 billion of us would fit inside a single Apple the atom was unlike anything we had ever encountered before and it would only get stranger and stranger almost immediately a problem surfaced and it was a big one according to the tried and trusted science of the time the electrons should lose their energy run out of speed and spiral into the nucleus in less than a blink of an eye Rutherford's atom contradicted the known laws of science the atom didn't care that it defied scientific convention it's almost entirely empty space and it's gonna stay that way I show no signs of shrinking down to the size of a grain of salt and the earth is well the size of the earth it's not getting smaller not surprisingly all the established scientists of the day including Einstein were battled scientific ideas they put their faith in all their lives had failed completely to explain the atom the atom now required a new generation of scientists to follow in Rutherford's footsteps bold brilliant and above all young it was crucial they had no loyalty or attachment to ideas held by previous generations one of the first of this new breed was niels bohr he sailed from Denmark in 1911 and made his way it's English soil having finished his studies in Copenhagen war decided to move abroad and be at the center of the new physics the trail led you to britain manchester university ernest rutherford or made it his mission to solve the puzzles of why the atom didn't collapse and why there was so much empty space as one of the new breed of theoretical physicists he was fearless in his thinking and was prepared to abandon common sense and human intuition to find an explanation so in a leap of genius he started to look for clues about the atoms structure not by looking at matter but by examining the mysterious and wonderful nature of light our atoms and lights are clearly connected most substances glow when they're heated and for centuries people had realized that different substances glow with their own distinctive colors a bit like a signature so the green of copper the yellow of sodium and the red of lithium these colors associated with different substances are called spectra and Bohr's great insights was to realize that spectra are telling us something about the inner structure of the atom that they could explain all that empty space Bohr's idea was to take Rutherford's solar system model of the atom and replace it with something that's almost impossible to imagine or visualize so sensible ideas like empty space and particles moving around in orbits fade away and they're replaced with something that is one of the most misunderstood and misused concepts in the whole of science the quantum jump now it takes most working physicists many years to come to terms with quantum jumps and in fact or himself said that if you think you've understood it then you haven't really thought about it enough so I'm going to take a deep breath and under 30 seconds try and explain to you one of the most complicated concepts in the whole of science but one that underpins the entire universe Bohr described the atom not as a solar system but as a multi-story building the ground floors where the nucleus lives were the electrons occupying the floors above mysterious laws mean the electrons can only live on the floors never in between and other mysterious laws mean that sometimes that can instantaneously jump from one film to another these are what we call quantum jumps now Bohr had absolutely no idea what these laws were but thinking like this allowed him to make a startling prediction when an electron jumps from a higher floor to a lower one it gives off light more significantly the color of the light depends on how big or small the quantum jump the electron makes so an electron jumping from the third floor to the second floor might give off red light when an electron jumping from the tenth floor to the second floor blue light to test his new theory Bohr used it to make a prediction could it explain the mysterious signature in the spectrum of hydrogen after months of calculating furiously who finally came up with the results and his prediction was surprisingly accurate for the first time ever it looked like the spectrum can be explained back in 1913 that was big news but Bohr's new idea rested on a single seriously controversial supposition why should the electrons in the atom behave as though they were in a multi-story building and why should they magically perform quantum jumps from one story to another there was no precedent for it anywhere else in science when one physicists claimed the jumps were nonsense Moore replied yes you're completely right but that doesn't prove the jumps don't happen only that you cannot visualize them but not being able to visualize things seem to go against the whole purpose of science all the scientists in particular felt that science was supposed to be about understanding the world not about making up arbitrary rules that seemed to fit the data conflict between the two generations of scientists was inevitable cause weird new Adam and his crazy quantum jumps were a shot across the bow silence and the old school reacted and leading the traditionalists was giant of the physics world Albert Einstein he hated all his ideas and he was going to fight them anything from a sexual assault on Nats [Music] borther is undeterred and as the 1920s gone the battery needs for one of the greatest conflicts in all science Woodlawn so far the debates about the new atomic physics had been polite from gentlemen now the two sides wheeled out their biggest guns two of the greatest names in physics they were two very true trusting characters on those dicho for the new revolutionary science was a buttoned-up uber competitive German called Verner Heisenberg for the Conservatives as a debonair byron esque Austrian called Owen Schrodinger [Music] [Applause] Oh in Schrodinger passionate and poetic a philosopher and a romantic he wrote books on the ancient Greeks on philosophy on religion he was influenced by Hinduism there's also a very flamboyant character cool suave sophisticated a dapper dresser and a big hit with the ladies [Music] [Applause] schrödinger's promiscuity was legendary he had a string of girlfriends throughout his married life some of them much younger than him in 1925 38 year-old Schrodinger stayed at the Alpine resort of yoson Switzerland for a secret liaison with an old girlfriend whose identity remains a mystery to this day but their passion proved to be the catalyst but Schrodinger's creative genius another physicist said of Schrodinger's week of sexually inspired physics he had two tasks that week satisfy a woman and solved the riddle of the atom fortunately he was up to both he took de Bru's idea of mysterious pilot waves guiding electrons around an atom one crucial step further he argued that the electron actually was a wave of energy vibrating so fast it looked like a cloud around the atom a cloud like wave of pure energy and what's more he came up with a powerful new equation which completely described this way and so described the whole atom in terms of traditional physics the equation he came up with we now call schrödinger's wave equation it's incredibly powerful what's unique about it is that it features a new quantity called the wave function which Schrodinger claimed completely describe the behavior on the subatomic world [Music] Schrodinger's equation and the picture of the Atome painted created during a sexually charged holiday in the Swiss Alps once again allowed scientists to visualize the atom in simple terms it's hard to overestimate the relief Schrodinger's idea brought to the traditional physics community strange though his picture of the Aten was at least it was a picture and scientists love pictures they allowed them to use their intuition but there was still a deep nagging problem one that the radicals felt Schrodinger just couldn't reconcile his new theory still couldn't account for balls strange instantaneous quantum jumps the time had come for the radicals to hit back [Applause] in the summer of the same year one of Niels Bohr's protegees Verner Heisenberg was travelling to an obscure island of the north coast of Germany he was fiercely competitive and took Schrodinger's ideas as a personal affront he felt strongly that the strangeness of the instant quantum jumps was actually the key to understanding the atom he thought the atom was so unique and unusual it shouldn't be compromised through a simple analogy like a wave or an orbit or even a multi-story building he believed it was time to give up any picture of the atom at all Verner Heisenberg while the true geniuses of the 20th century young athletic a great mountain climber an excellent pianist he was also an exceptional student at the age of just 20 who was well on his way to finishing his ph.d and being courted by the great universities across Europe now in the summer of 1925 he was suffering from a particularly bad bout of hay fever his face was swollen up almost beyond recognition he decided to escape alone here to this beautiful but isolated island of helgeland he walked along the beaches he swam he climbed the rock and he pondered ever since he'd encountered atomic physics Heisenberg felt in his bones that all human attempts to visualize the atom to model it with familiar images would always fail the atom he believed was too capricious too strange to ever be explained that simply so he decided to abandon all pictures of it and describe it using pure mathematics alone but as he pondered he realized that the atom didn't just defy visualization it even defied traditional mathematics it was while he was here on helgeland the Heisenberg had an incredible revelation he realized that in order to describe certain properties of atoms he had to use a strange new type of mathematics it seems that certain properties like where an electron is at a given time and how fast it's moving where multiplied together the order in which you multiply there matters let me try and explain if we multiply two numbers together it doesn't matter which or do we do it in so 3 times 4 is clearly the same as 4 times 3 but when it came to atoms Heisenberg realized that the order in which he multiplied quantities together gave a different answer this quickly led him to other discoveries and he was convinced that he'd cracked a code in the atom that he'd somehow found the hidden mathematics within he was so excited he was also very scared that night he climbed to the top of a rock and sat there waiting till dawn he called it his night of helgeland when he returned to his University in getting and he told his colleague Max Born about it and they then worked together intensely for several months developing a whole new theory of the atom a theory that today we call matrix mechanics [Music] matrix mechanics uses complex arrays of numbers rather like a spreadsheet by manipulating these arrays Heisenberg and his mentor the brilliant physicist max all could accurately predict atomic behavior but from Einstein and the traditionalists this was pure scientific heresy an atom can't actually be a matrix of numbers surely we made of atoms not numbers back in Copenhagen Bohr and Paulie were thrilled with matrix mechanics so what if we couldn't imagine the atom as a physical object they exalted in the purity of the mathematics and launched into vicious attacks against Schrodinger's vulgar sensual waves Heisenberg wrote the more I reflect on the physical portion of Schrodinger's equation the more disgusting I find it in fact it's just [ __ ] but Schrodinger was equally scathing of Heisenberg saying he was repelled by his methods and found his mathematics monstrous in Munich in 1926 their enmity began to reach boiling points Schrodinger was to give a lecture on his wave equation Heisenberg scraped together the money to travel down to Munich for the lecture to finally come face to face with his rival what was at stake was more than just Heisenberg's reputation he believed Schrodinger's simplistic approach wasn't just misguided but totally wrong and his intention was nothing less than to destroy Schrodinger's theory Schrodinger delivers his lecture on the new wave mechanics to a packed audience the standing-room-only he writes down his new wave equation to Schrodinger this describes a real physical picture of the atom with electrons as waves surrounding the atomic nucleus 24-year old Verna Heisenberg is in the audience it can hardly contain himself at the end of the lecture he stands up and delivers a monologue attacking Schrodinger's approach for Heisenberg it's impossible to ever have a picture of what the atom is really like the audience is on Schrodinger side they'd much prefer his simple physical interpretation to Heisenberg's abstract complicated mathematics Heisenberg is booed he's told to sit down and be quiet he leaves the lecture sad and depressed Heisenberg returned to Copenhagen with his confidence severely dented there at the Institute he and Bohr reached their darkest moment almost all of the scientific community was against them they felt isolated desperate their backs were against the wall despite this they stubbornly refused to give up their controversial theory this attic room was Heisenberg study back in 1926 Bohr would come up here night after night we're here in Heisenberg would argue about the meaning of the new quantum mechanics they would argue so passionately but on one occasion apparently Heisenberg was reduced to tears and then as Heisenberg stared out of his attic window in despair the part below an extraordinary thought occurred to him it struck him why an atom can't be visualized why can't be understood intuitively it's not just because it's tiny tricky and difficult is because it's inherently unknowable he realized that there was a fundamental limit to how much we can know about the subatomic world for instance if we know where an electron is at a particular moment in time then we cannot know how fast it's moving but if we knew its speed we wouldn't know his position this ambiguity isn't a shortcoming in the theory itself nor was it due to the clumsiness of the way we carry out our measurements but a fundamental truth about the way nature behaves at the subatomic scale it became known as Heisenberg's uncertainty principle and is probably the most profound incredible yet unsettling concepts in the whole of science [Music] what Heisenberg had uncovered through his abstract matrix mechanics was a deep and shocking truth about the atomic world atoms are willfully obscure we can never fully know an atoms position and speed simultaneously the atomic world just refuses to allow that to happen it was completely mind-boggling but once they accepted it Heisenberg and Bohr who found the boost of confidence to be even more bold they realized uncertainty forced them to put a paradox right at the very heart of the atom atoms are not just unimaginable they're self-contradictory they behave both like particles and waves and it gets weirder when you're not looking at an atom it behaved like a spread-out wave but when you look to see where it is it behaves like a particle this is insane first atoms couldn't be visualized at all now it seems they change completely in character depending on whether or not you're looking at them the uncertainty principle had changed everything it revealed a shocking contradiction at the heart of nature everything we see is made of atoms and yet atoms themselves are unknowable they can only be understood through mathematics for the first time for Bohr and Heisenberg everything about the atom fell into place by the autumn of 1927 full of confidence and smarting for a fight they knew they were finally ready to take on the Conservatives [Music] for this physics showdown they chose the Solvay conference in Brussels all the world's leading atomic physicists would attend if war and Heisenberg was successful then they would lead a total scientific revolution this is amazing I'm looking at original footage of the Solvay delegates coming out of these doors there's Bohr talking to Schrodinger and and this Heisenberg behind them and there's Paolo Li strange looking guy on there's Einstein coming down with a big smile on his face for the week of the conference all that the delegates could think and talk about was Bohr's quantum mechanics with uncertainty now a central plank it was a truly formidable theory and over the week the final showdown played out between Bohr and his archrival Albert Einstein Einstein hated quantum mechanics and every morning he'd come to war with an argument that he felt picked a hole in the new theory war would go away very disturbed and think very hard about it and by the end of the day he'd come back with a counter argument that dismissed Einstein's criticism and this happened day after day until by the end of the conference Bohr had brushed aside all of Einstein's criticisms and Bohr was regarded as having been victorious and with that his vision play-actor which became known as the Copenhagen interpretation was suddenly at the very heart of atomic physics at the end of the conference they all gather for the team photo never before or since have so many great names of physics being together in one place at the front the elder statesmen of physics Hendrik Lorentz flanked on either side by Madame Curie and Albert Einstein Einsteins looking rather glum because he's lost the argument Louis debris has also failed to convince the delegates of his views victory goes to Niels Bohr he's feeling very pleased with himself next to him one of the unsung heroes of quantum mechanics the German Max Born who developed so much of the mathematics and behind them the two young disciples of Bohr Heisenberg and Pauli Poly's looking rather smugly across at Schrodinger bit like the cat who's got the milk this was the moment in physics when it all changed the old guard was replaced by the new chance of probability became interwoven into the fabric of nature itself and we could no longer describe atoms in terms of simple pictures but only using pure abstract mathematics the Copenhagen view had been victorious although Einstein went to his grave never believed in quantum mechanics solve a 1927 was the turning point at which the rest of the science establishments came to embrace the Copenhagen interpretation and that interpretation is still accepted today all the physics that I use in my research certainly the quantum mechanics that I teach my students and that fills the textbooks on my shelves is based on ideas that were hammered out and crystallized here at the Solvay conference in October 1927 in a sense everything I know about the way the world around me is made up started here the quantum mechanical description of the atom is one of the crowning glories of human creativity over the last of 18 years it has been proven right time after time and it's Authority has never been in doubt it's a monumental scientific achievement between 1905 and 1927 science changed our view of the world it also changed our view of science itself as scientists probed the tiniest building blocks of matter they created the most successful and powerful theory ever quantum mechanics it allows us to describe what everything in the universe is made of how it interacts and how it all fits together but it comes at a huge price at its most fundamental level we have to accept that nature is ruled by chance and probability Heisenberg's uncertainty principle dictates that there are certain limits on the sorts of questions we can ask the atomic world and most crucially while we now know so much more about what an atom is and how it behaves we have to give up any possibility of imagining what it looks like our human nature has forced us to ask questions of everything we see around us in the world what we've discovered has been beyond our wildest imagination [Music]

Suspension, Pistoning & Shrinker

Globalisation: Is the world shrinking?

ENV 226: Essential Ecology Final Exam Study Guide — om single-species thinking to the dynamics of many interacting ecies. A community is more even when all species have similar abundances. Diversity: A combined measure of richness and evenness. More diverse = more likely to pull multiple different species out of a 'hat'. Shannon Diversity Index (H′): The most common diversity index. Higher H′ = more diverse (high richness AND high evenness). Formula: H′ = –Σ(pᵢ · ln pᵢ), where pᵢ is the proportion of individuals in species i. Worked example If a community has 4 species, each at 25% (p = 0.25), then H′ = –[4 × (0.25 × ln 0.25)] = 1.39. If one species dominates (e.g., 70/10/10/10), evenness drops and H′ falls even though richness is the same. Why diversity matters — ecosystem function & services Ecosystem function: Biological, geochemical, and physical processes that take place within an ecosystem (e.g., productivity, nutrient cycling, decomposition, pollination). Ecosystem services: The benefits humans derive from ecosystems. Four major categories: Provisioning: food, water, timber, fiber Regulating: climate regulation, flood control, water purification Cultural: recreation, spiritual, aesthetic, educational values Supporting: soil formation, nutrient cycling, primary production How diversity affects function — mechanism Complementary resource use (niche complementarity): Different species use slightly different resources (e.g., water at different soil depths, nutrients at different times). A diverse community captures more of the available resources than any single species could, raising total productivity. Diversity–stability theory Compensation: Species respond differently to environmental fluctuations. When one species declines, another can increase and 'compensate,' keeping overall ecosystem function steady. Insurance hypothesis: A diverse community is more likely to contain at least one species with traits that help the ecosystem cope with change. Diversity acts as ecological 'insurance' against disturbance. Rules of community assembly — what determines diversity at a site Three filters act in sequence on the regional species pool to determine which species actually end up in a local community: Term Definition Dispersal Who can physically get there. Controlled by distance from source populations and by dispersal ability. Connects to the 'mass effect' / rescue effect — regional diversity (gamma) can rescue local diversity (alpha). Environmental filtering What species can tolerate the abiotic conditions (climate, soil, water, salinity). Example: Ponderosa pine will not survive in the Sonoran Desert — environmental filtering excludes it. Biotic filtering What species can coexist given interactions with other species (competition, predation, facilitation). Strongest where abiotic conditions are benign, because more species can be there to interact. Intertidal zonation paradigm — how the filters stack In rocky intertidal communities, abiotic stress (desiccation, wave action) sets the UPPER limit of a species' distribution — an environmental filter. Competition and predation set the LOWER limit — biotic filters. Take-home: environmental filtering dominates in stressful zones; biotic filtering dominates in benign zones. What maintains diversity Intermediate Disturbance Hypothesis (IDH): Diversity is highest at intermediate frequencies or intensities of disturbance. Low disturbance lets competitive dominants exclude others; high disturbance eliminates all but the most disturbance-tolerant species. The middle keeps both groups in the community. Positive species interactions (facilitation): When one species makes conditions better for another (e.g., a nurse shrub providing shade and moisture for seedlings underneath). Facilitation tends to INCREASE biodiversity, especially in stressful environments. 1.2 Succession Primary succession: Colonization of a substrate that has NEVER supported life (e.g., bare bedrock, new volcanic rock, glacial retreat). Soil must be built from scratch, typically by pioneers like lichens and mosses. Secondary succession: Recovery after a disturbance that left soil and some biological legacy behind (e.g., a cleared field, most wildfires). Much faster than primary succession because soil and seed bank persist. Pioneer species: The first species to colonize a disturbed or bare area. Typically fast-growing, high-dispersal, stress-tolerant organisms that modify the site so later-successional species can establish. Quiz-style example The Woodbury Fire burned so intensely on the Tonto NF that only bedrock remained. Recolonization of this area is PRIMARY succession — there is no soil or seed bank left to start from. 1.3 Ecological Energetics Energy: The currency of ecosystems. Most ecological energy originates from the sun as electromagnetic radiation and is stored in tissues (biomass). Trophic level: Organisms that share the same function in the food chain and the same nutritional relationship to primary sources of energy. Level 1 = producers; 2 = primary consumers (herbivores); 3 = secondary consumers (carnivores); 4+ = tertiary / apex predators. Autotroph (primary producer): An organism that produces its own food from inorganic sources — typically plants, algae, and some bacteria via photosynthesis. Consumer (heterotroph): An organism that obtains energy by consuming other organisms. Primary consumers eat producers; secondary consumers eat primary consumers; etc. Production: The rate at which new biomass is created by organisms in an ecosystem (units of mass or energy per area per time). Net primary production (NPP): Gross primary production (total photosynthesis) MINUS the energy plants use for their own respiration. NPP is what is actually available to herbivores. Assimilation and production efficiency Energy is lost at every step of the grazing food chain. Two key efficiencies describe where energy goes: Term Definition Assimilation efficiency (Energy assimilated / energy consumed) × 100%. Assimilated = consumed – egested (waste). Herbivores ≈ 20–50% (tough plant material); carnivores ≈ 80% (similar tissue chemistry). Production efficiency (Energy in new biomass / energy assimilated) × 100%. Endotherms (birds, mammals) are LOW (~1–3%) because most energy is burned as heat; ectotherms (insects, reptiles, fish) are HIGH (~10–50%). Worked example (assimilation efficiency) Eats 400 J, excretes 200 J as waste, puts 50 J into growth. Assimilated = 400 – 200 = 200 J. Assimilation efficiency = 200 / 400 = 50%. The 10% rule Roughly 10% of the energy at one trophic level is transferred to the next. The rest is lost to respiration, heat, and waste. This is WHY food chains are short (usually 4–5 links): there simply isn't enough energy left to support another level. 1.4 Food Webs A food web is many, connected food chains — a map of who eats whom across an entire community. In simple diagrams, arrows point from prey to consumer. Complex diagrams use plus/minus signs to show the direction of effect, and dashed lines to show indirect effects. Top-down control: Higher trophic levels (predators) limit the abundance of lower levels. Removing a top predator releases herbivores, which suppress plants. Bottom-up control: Lower trophic levels (nutrients, producers) limit higher levels. Adding nutrients increases plants, which increases herbivores, which increases predators. Trophic cascade: Indirect effects of a predator propagate down the food web. Classic example: wolves reintroduced to Yellowstone → elk browsing decreases → riparian willow and aspen recover → beavers return → stream ecosystems recover. 2. Ecosystems Ecosystem: A community of organisms PLUS their shared environment. Includes biotic components (plants, herbivores, carnivores, detritivores) and abiotic components (climate, soils, nutrients). 2.1 Ecological building blocks Ecological building block: An atom that (1) makes up organisms and (2) is relatively abundant. Key building blocks: C, H, O, N, P (and sometimes S) — collectively CHONP. Not building blocks: Silicon, aluminum, arsenic, tungsten — they may be abundant in the crust or used by some organisms, but are not core structural elements of life. Potassium is important biologically but is NOT a core 'ecological building block' in this course's sense. 2.2 Liebig's Law of the Minimum Growth is dictated not by the total resources available, but by the SCARCEST resource. The 'limiting nutrient' sets the ceiling on production; adding more of a non-limiting nutrient has no effect until the limit is raised. Application — nutrient pollution A coastal system receives 10 g N, 200 g P, 50 g C, and 20 g O per year as pollutants, and you know the system is N-limited. By Liebig's Law, adding MORE nitrogen is what will most change structure and function — even though phosphorus is arriving in larger quantities, it is not the limiting nutrient. 2.3 Eutrophication Eutrophication is the enrichment of an aquatic system with nutrients (especially N and P) from fertilizer runoff, wastewater, or atmospheric deposition. Process: Excess N fuels algal blooms → algae die and sink → microbial decomposition consumes oxygen → a hypoxic 'dead zone' forms → fish and invertebrates die. Once N is drawn down, the system can become P-limited; phosphorus mined for fertilizer keeps the cycle going. The Gulf of Mexico hypoxic zone is the classic example. 2.4 Nutrient cycles (N, C, P) Term Definition Nitrogen cycle N₂ in atmosphere is biologically inert. Nitrogen-fixing bacteria (free-living and in legume root nodules) convert N₂ → ammonium (NH₄⁺). Nitrification converts NH₄⁺ → nitrite → nitrate (NO₃⁻), the form most plants take up. Denitrification returns N₂ to the atmosphere. Humans roughly DOUBLED global N fixation via the Haber-Bosch process → fertilizer → eutrophication. Phosphorus cycle Largely a SEDIMENTARY cycle — no gaseous phase. P weathers from rock → soil → plants → consumers → back to soil → eventually to ocean sediments. Slow turnover at global scales; a critical component of DNA/RNA, phospholipids, bones, and ATP. Carbon cycle See dedicated section below. C moves among atmospheric, terrestrial, oceanic, and fossil pools. Photosynthesis pulls CO₂ out; respiration and combustion return it. 2.5 Ecotones and cross-ecosystem flows Ecotone: A transition zone between two ecosystems, exhibiting gradients in environmental conditions and a related shift in the composition of plant and/or animal communities (e.g., forest–grassland edge, estuary). Two factors determine how a flow of material/energy from one ecosystem affects another: Relative size of the systems — when the amount of something varies across ecosystems, the LARGER system has a bigger impact on the small system (e.g., a stream flowing into a small pond vs. into the ocean). Quality of the resource — rich subsidies (like salmon carcasses bringing ocean nutrients to streams) matter more than dilute ones. 2.6 Ecological state change & resilience Key components of ecosystems: STRUCTURE (what organisms are there and how they interact), FUNCTION (processes of energy and nutrient movement), and REGIME (which of several possible stable states the system is in). Alternative stable states: An ecosystem can exist in two or more contrasting conditions under the same environmental conditions (e.g., clear lake vs. turbid lake; forest vs. shrubland). Ecological state change (regime shift): A large, persistent, often abrupt shift in the structure and function of an ecosystem, triggered by crossing a critical threshold. Threshold / tipping point: The level of a driver (stressor) at which a system flips to a new state. Hysteresis: Once a system flips, simply reversing the driver does NOT restore the original state — the return path is different from the 'forward' path. Slow vs. fast drivers: Slow drivers (e.g., gradual warming, soil nutrient accumulation) build up until a fast driver (e.g., fire, storm) tips the system across the threshold. Perturbation: Any event (abiotic or biotic) that disturbs the ecosystem. Perturbations that cause regime change can be abiotic (fire, flood, drought) or biotic (pest outbreak, invasion). Resilience: The capacity of a system to absorb disturbance, adapt to change, and recover from adversity while maintaining its essential functions, structure, and identity. The ball-and-cup diagram Picture a ball sitting in a valley (cup) on a hilly landscape. The ball is the current state of the ecosystem; the cup is the 'basin of attraction' for that state. A disturbance pushes the ball; stabilizing (negative) feedback loops pull it back. Strong disturbance or a shrinking cup (loss of resilience) can push the ball over a hill into a NEW cup — that's state change. Negative (stabilizing) feedback loop: A change triggers a response that DAMPENS the change, keeping the system near its current state. Deepens the cup. Positive (amplifying) feedback loop: A change triggers a response that AMPLIFIES the change, pushing the system further from its current state. Flattens the cup and makes state change more likely. Applying resilience to conservation & restoration Manage for resistance — remove stressors that push the ball (exclude high-intensity grazing, reduce pollution). Manage for resilience — rebuild the 'cup' by re-establishing key species, nutrient cycling, and stabilizing feedbacks (planting perennial grasses, restoring hydrology). Passive restoration works when the seed bank, soil, and key species are still intact; active restoration is needed when the system has already crossed the threshold. 3. Landscape Ecology and Biogeography 3.1 Landscape ecology Landscape ecology: The study of spatial patterns of ecosystems and their ecological consequences — explicitly considers the arrangement of habitats across space and how organisms and materials move through them. Spatial elements Term Definition Patch A relatively homogeneous area that differs from its surroundings (e.g., a forest stand in a grassland). Generally the highest-quality habitat. Matrix The background land-cover type that surrounds patches (e.g., desert in Saguaro NP, or agricultural land around forest fragments). Corridor A linear feature connecting patches — allows movement of organisms, genes, and energy. Examples: riparian strips, hedgerows, engineered wildlife crossings (Oracle Road, Tucson). Ecotone See above — the transition zone between landscape elements. Spatial heterogeneity Variability in environmental conditions and habitat types across a landscape. Drives diversity at landscape scales. Scale dependence Ecological patterns and processes depend on the spatial/temporal scale at which they are observed (e.g., a species may look stable regionally but be declining locally). Fragmentation Fragmentation breaks a large continuous habitat into smaller, more isolated patches. Effects include: Loss of total habitat area More edge relative to interior — edge effects (different microclimate, invasives, more predators) penetrate into remaining patches Reduced connectivity — animals cannot move between patches Smaller populations in each patch → inbreeding depression, loss of genetic variability, higher extinction risk Saguaro NP example Mid-sized carnivores in Saguaro NP West crashed after a disease outbreak and never recovered. Why? The city of Tucson grew between Saguaro NP East and West, severing connectivity. No recolonization could occur from the eastern population. Solution: re-establish connectivity — the Oracle Road wildlife crossings documented over 4,400 crossings by 16 species in their first two years. Patch dynamics Patch size, shape, and connectivity change over time because of ecological processes — succession, disturbance (fire, flood, windthrow), and fragmentation — not random chance and not just geology. 3.2 Biomes and realms Biome: A large biological community defined by climate and dominant vegetation type (e.g., tropical rainforest, boreal forest, tundra, desert, savanna, temperate grassland). Biogeographic realm: A large area of the Earth's surface with a distinctive assemblage of taxa, reflecting shared evolutionary history (e.g., Nearctic, Neotropical, Palearctic, Afrotropical, Indomalayan, Australasian, Oceanic, Antarctic). Factors shaping where biomes are found: temperature and precipitation (the primary controls), seasonality, latitude, elevation, continental geography, and evolutionary history. Realms reflect plate tectonics — Pangaea split into Laurasia and Gondwana, then into the continents we have today, producing unique evolutionary trajectories in each realm (e.g., Australia's marsupials, Madagascar's lemurs). 3.3 Island Biogeography and the SLOSS debate MacArthur & Wilson's Theory of Island Biogeography: species richness on an island is set by the balance between the colonization rate (immigration) and the extinction rate. Size effect — larger islands have LOWER extinction rates (bigger populations). Distance effect — islands closer to the mainland have HIGHER colonization rates. Equilibrium species number occurs where colonization and extinction curves INTERSECT. SLOSS debate — Single Large Or Several Small? Originally framed: is a single large reserve or several small reserves of equal total area better for biodiversity? Large favors: lower extinction, room for interior species, bigger populations, full food webs. Several small favors: replication (insurance against one disaster), sampling more habitat types, potentially higher total diversity. Modern answer: it depends — on species' dispersal, the matrix, and whether you value diversity vs. viability. Connectivity (corridors) often matters more than the large/small question alone. Source population: Produces more offspring than can be supported locally — exports individuals to other patches. Population growth rate > 0. Sink population: Organisms arrive but do not reproduce enough to sustain the local population; persists only via immigration from sources. Population growth rate < 0. 4. Extinction and Climate 4.1 The 'Big Five' mass extinctions Term Definition Ordovician–Silurian (~439 Mya) ~85% marine species lost. Cause: rapid glaciation and sea-level drop, then warming. Late Devonian (~364 Mya) Prolonged event; major loss of marine invertebrates, especially reef builders. Probable causes include ocean anoxia and climate change. Permian–Triassic (~251 Mya) 'The Great Dying' — ~96% marine species and ~70% terrestrial vertebrates. THE most severe. Cause: Siberian Traps volcanism → CO₂ spike → warming, ocean acidification, and anoxia. Recovery took 5–10 million years. End Triassic (~199–214 Mya) ~50% of species lost; cleared the way for dinosaurs to dominate. Likely cause: CAMP volcanism and climate change. Cretaceous–Tertiary (K-Pg, ~65 Mya) ~76% of species, including non-avian dinosaurs. Cause: Chicxulub asteroid impact (plus Deccan Traps volcanism) → darkened skies, cooling, then warming. Why scientists are concerned now Current extinction rates are 100–1000× background rates — comparable to mass-extinction levels. Rate of change: current climate change is occurring more rapidly than almost any past episode — faster than many species can adapt or track. Humans have built roads, cities, and agricultural landscapes that BLOCK the range shifts species would otherwise use to follow their climate. Human societies are themselves adapted to current climate (agriculture, supply chains, coastlines) — disruption drives conflict. 4.2 Why climate change affects ecological systems Temperature, precipitation, seasonality, and extreme events all drive the distribution and performance of every species. Shifting climate disrupts energy balance, water balance, food availability, and reproduction; changes the timing of seasonal events; and alters disturbance regimes (fire, floods, storms). All of these cascade through communities and ecosystems. 5. Climate Change — Ecology, Climate, and the Carbon Cycle 5.1 The carbon cycle Term Definition Pool (reservoir) A place where carbon is stored and from which it can be released. Measured as a quantity (e.g., gigatons). Flux The amount of carbon exchanged between pools per unit time (gigatons/year). Measures MOVEMENT. Sink A pool that accumulates more carbon than it releases — net REMOVER of carbon from the active cycle. Source A pool that releases more carbon than it accumulates — net ADDER of carbon to the active cycle. Biggest/smallest pools & fluxes Major carbon pools (approximate, gigatons): Deep ocean: ~37,000 GtC — BY FAR the largest pool Fossil pool (oil, gas, coal): ~10,000 GtC — second largest Reactive ocean sediments: ~6,000 GtC Soils: ~2,300 GtC Surface ocean: ~1,000 GtC Atmosphere: ~800 GtC — this is the pool that drives climate Plant biomass: ~550 GtC (the largest LIVING pool) Major fluxes are photosynthesis and respiration (~120 GtC/yr terrestrial; ~90 GtC/yr ocean), which are normally nearly balanced. Fossil-fuel combustion and deforestation are the (smaller but crucial) fluxes currently unbalancing the system. Why atmospheric CO₂ is increasing Humans are burning fossil fuels — moving carbon from a long-term sink (the fossil pool) into the active atmospheric pool faster than natural sinks can remove it. Deforestation and land-use change also shift carbon from plant biomass and soils to the atmosphere. The balanced photosynthesis/respiration fluxes cannot keep up with the ~10 GtC/yr added by human activity. 5.2 Ocean acidification As atmospheric CO₂ rises, more CO₂ dissolves into the ocean. The chemistry: Step 1: The ocean is slightly alkaline; CO₂ is slightly acidic, so CO₂ dissolves into seawater. Step 2: CO₂ + H₂O → H₂CO₃ (carbonic acid). Step 3: H₂CO₃ dissociates → HCO₃⁻ (bicarbonate) + H⁺. Step 4: Some HCO₃⁻ dissociates → CO₃²⁻ (carbonate) + H⁺. Step 5: Bicarbonate and carbonate exist in equilibrium. Net result: more H⁺ ions → lower pH = acidification. Acidification also reduces carbonate availability, making it harder for corals, shellfish, and plankton to build calcium-carbonate skeletons. Warming and the ocean's ability to sequester carbon Warmer water holds LESS dissolved CO₂ (inverse solubility). As oceans warm, their ability to absorb atmospheric CO₂ decreases — a positive feedback loop that further increases atmospheric CO₂ and warming. 5.3 Important climate feedback loops Term Definition Ice-albedo feedback (POSITIVE) Warming melts polar ice → darker ocean/land replaces reflective white ice → lower albedo, more solar energy absorbed → more warming → more melting. Water vapor feedback (POSITIVE) Warming increases evaporation; water vapor is a greenhouse gas → more warming → more evaporation. Permafrost/methane feedback (POSITIVE) Thawing permafrost releases CO₂ and CH₄ long locked in frozen soils → more warming → more thawing. CO₂ fertilization (NEGATIVE, partially) Higher CO₂ can boost plant photosynthesis, pulling more C out of the atmosphere. Partially counteracts warming but is limited by water, nutrients, and heat stress. Ocean solubility feedback (POSITIVE) Warmer oceans hold less CO₂ → more stays in the atmosphere → more warming. Quiz-style example Melting polar ice caps → decreased albedo → further warming = POSITIVE feedback loop (amplifies the original change). 5.4 Factors affecting Earth's surface temperature Three major controls: Energy arriving from the sun (solar radiation) Earth's albedo — how much of that energy is reflected back to space Greenhouse gases in the atmosphere — how much outgoing infrared is trapped Carbon dioxide is the LARGEST driver of current human-caused climate change (sheer volume, long atmospheric lifetime). Methane is more potent per molecule but far less abundant; water vapor amplifies change via feedback but is not itself a primary driver. 6. Climate Change — Ecological and Human Response 6.1 How climate change affects plants and animals Climate change disrupts performance in three main ways: Term Definition Energy balance Plants: respiration rates rise faster than photosynthesis with warming — net carbon gain (and growth) drops. Animals: thermoregulation costs rise; outside the thermal neutral zone, organisms burn more energy just to stay alive. Water balance Warmer temperatures and higher vapor-pressure deficit mean plants LOSE more water per unit of photosynthesis. Animals face greater dehydration risk; aquatic species face altered hydrology. Food acquisition & reproduction Changed phenology, drought, and heat reduce the resources available for growth and reproduction. Fewer seeds, fewer offspring, lower survival. Examples of species already affected Term Definition Pika Small alpine mammal restricted to cold, rocky talus. Warming pushes them to higher elevations — eventually they 'run out of mountain.' Already extirpated from lower-elevation sites in the Great Basin. Tuatara Reptile with temperature-dependent sex determination. Warming skews sex ratios toward males, threatening population persistence. Wolverine Depends on persistent spring snowpack for denning. Declining snowpack reduces suitable reproductive habitat. 6.2 Responses of species: MOVE, ADAPT, or DIE Move: shift range poleward or upslope to track suitable climate (classic response). Range shifts are highly variable across species — depends on dispersal ability, habitat specificity, and whether barriers (cities, roads, water bodies) intervene. Adapt: through plasticity (phenotypic change within a lifetime) or evolutionary change (genetic change across generations). Long-lived species with small populations adapt slowly. Die: local extirpation or global extinction if neither option is available fast enough. 6.3 Phenology Phenology: The timing of recurring biological events — bud burst, flowering, migration, breeding, hibernation. Climate change is advancing many spring phenological events (earlier bloom, earlier migration). Phenological mismatch occurs when interacting species shift their timing differently — e.g., a migratory bird arrives after its caterpillar prey has already peaked. Mismatches cascade through food webs. 6.4 Characteristics of climate-vulnerable species Narrow thermal tolerance (specialists) Poor dispersal ability (can't move to new climate) Long generation time, low reproductive rate (slow to adapt) Small, fragmented populations (low genetic variation, high stochastic risk) Dependence on climate-sensitive habitats (snowpack, sea ice, coral reefs, alpine tundra) Narrow geographic range, especially on islands or mountain tops (nowhere to go) Tightly tied to a specific phenological window or species interaction 6.5 Why current climate change is especially damaging Rate — change is occurring faster than most species can adapt or move Barriers — human land use has fragmented habitat, blocking the range shifts species used during past climate changes Cumulative stressors — climate change interacts with pollution, invasive species, overharvest, and habitat loss Interconnected systems — ecosystems, human agriculture, and global supply chains are all calibrated to current conditions 6.6 Mitigation vs. Adaptation Term Definition Climate MITIGATION Actions that reduce the magnitude of climate change itself — typically by lowering atmospheric greenhouse gases. Examples: switching to renewables, reforestation (sequestering carbon), reducing fossil-fuel use, more efficient buildings and transport. Climate ADAPTATION Actions that help humans and ecosystems COPE with the climate change that is already happening / unavoidable. Examples: creating migration corridors, building climate-resilient ecosystems through forest thinning, adjusting USDA seed zones, changing crop choices, updating hunting/fishing regulations, designing for sea-level rise. Quick quiz check Planting trees to sequester carbon = MITIGATION (reduces atmospheric CO₂). Thinning Southwest forests to make them more fire-resilient = ADAPTATION (copes with changing fire regime). Geoengineering proposals like stratospheric aerosol injection = a controversial form of mitigation (reduces incoming solar energy). Special cases of adaptation Managed (assisted) relocation: Actively moving species to areas outside their current range that are projected to become climatically suitable. Benefits: may be the only option for species that cannot disperse fast enough; can save species from extinction. Risks: recipient communities may experience novel interactions; potential to create invasive species; ethical questions about intervention. Assisted evolution: Human intervention to increase the rate of evolutionary adaptation — e.g., selective breeding for heat tolerance, or hybridization with warm-adapted populations. Benefits: keeps species in place; works for species that cannot move. Risks: may reduce genetic diversity; unintended consequences; can go wrong (outbreeding depression). 6.7 Corridors, climate refugia, and conservation design Climate refugium: A location whose physical or biological features allow species to persist despite regional climate change — e.g., high-elevation cool pockets, deep canyons, shaded slopes, coastal fog zones. Incorporating corridors (to enable range shifts) and refugia (places species can hold on) into reserve design is essential for climate-integrated conservation. A high-elevation forest that remains cool despite regional warming can serve as a seed source for recolonization — that's the textbook example of a refugium supporting resilience. Final thoughts: making an argument about climate-integrated conservation You should be able to give your own opinion on climate-integrated conservation and defend it. A solid answer acknowledges trade-offs: traditional 'protect what is there' approaches may fail under rapid change, but aggressive interventions (managed relocation, assisted evolution) carry real risks. Most conservation scientists argue for a portfolio approach — protect refugia, build corridors, and use active interventions only where the alternative is extinctionl

japan aging and shrinking

Iceberg demonstrates the relationship between direct and indirect costs of accidents, showing that on average, indirect costs exceed direct costs. Examples of indirect costs include: - a) Overhead costs - b) Schedule delays - c) **Medical costs** (DIRECT COST) - d) Cleanup time ## 7. Geometric Sequences - **Sequence Identification:** The proper arrangement of the following shapes by their complexity is: I. Quadrilateral II. Parallelogram III. Rectangle IV. Square. - a) II, IV, III, I - b) I, II, III, IV - c) IV, III, II, I - d) I, III, II, IV ## 8. Building Use Classification - The term **Occupancy** refers to a type of use of a building for interior space such as an office, restaurant, private residence, or school, grouped based on similar life-safety characteristics, fire hazards, and combustible contents. - a) Building elements - b) **Occupancy** - c) Building Code - d) Accommodation ## 9. Construction Pit Transport Fees - The maximum distance, as specified in the construction contract, which the contractor is expected to transport soil material without receiving additional payment, is known as **Freehaul distance**. - a) **Freehaul distance** - b) Overhaul distance - c) Haul distance - d) Baseline distance ## 10. Retarder Application Principles - **Fundamental Principles for Upper Retarders:** The retarder should be as near as possible to the warm side of the insulation or the warm face of the assembly. Moreover, it should be installed using a method appropriate for the specific condensation hazard. ## 11. Material Characteristics - **Hardness**: A measure of a material's ability to resist indentation or penetration. - a) **Hardness** - b) Ductility - c) Toughness - d) Resilience ## 12. Soil Density Changes - **Consolidation**: An increase in the soil density of cohesive soil resulting from the expulsion of water from the soil's void spaces. - a) Segregation - b) **Consolidation** - c) Compaction - d) Soil Stabilization ## 13. Concrete Finishing Process - The correct step-by-step process of finishing standard weight concrete slabs is as follows: 1. Bleeding 2. Screeding 3. Leveling 4. Edging 5. Jointing 6. Floating 7. Troweling 8. Broom finishing ## 14. Safety Oversight Authority - The entity given authority to review reports of inspection, accident investigations, and the implementation of the program is the **Health and Safety Committee**. - a) **Health and Safety Committee** - b) DOLE - c) DPWH - d) BFP ## 15. Soil Grouting Process - The process of injecting any agent into soil or rock to increase its strength or stability, protect foundations, or reduce groundwater is termed **Grouting**. - a) **Grouting** - b) Pumping - c) Bleeding - d) Screeding ## 16. Construction Safety Program Requirements - Every construction project must have a suitable **Construction Safety and Health Program**, which adheres to the rules and orders issued by the DOLE. - a) **Construction Safety and Health Program** - b) Occupational Health and Safety Program - c) Occupational Safety and Health Administration - d) Workplace Safety and Procedures ## 17. Safety Sight Distance and Vehicle Characteristics - One of the provisions for safety sight distance is dependent on the characteristics of the vehicle, including: - I. Type of vehicle (car or truck) - II. Friction between the tire and road - III. Eye height of the driver - IV. Speed of the vehicle - a) I only - b) II and III only - c) IV only - d) **All of the above** ## 18. Concrete Leveling Technique - **Screeding** is the process to level a floor or layer of concrete with a straight edge using a back and forth motion while moving across the surface. - a) Troweling - b) **Screeding** - c) Floating - d) Finishing ## 19. Structural Support Types - A structure driven into the soil to support construction by transferring building loads to a deeper and stronger layer of soil or rock is referred to as a **Pile**. - a) Caisson - b) Pier - c) Shoring - d) **Piles** ## 20. Road User Guidance Signs - **Guide signs** inform and advise road users of directions, distances, routes, and the location of services. - a) Cross road sign - b) **Guide signs** - c) Advance direction signs - d) Traffic instruction signs ## 21. Delay Concept in Transportation - The **Delay** refers to the difference between the actual travel time and the ideal travel time for a segment of the transportation system. - a) Queue time - b) Travel time - c) **Delay** - d) Service time ## 22. Construction Instructions - **Specifications** are written instructions detailing how a facility is to be constructed. - a) **Specifications** - b) Estimates - c) Bid documents - d) Plans ## 23. Tidal Wave Phases - The interval referring to the time delay in highest tide for each location due to cosmic forces and friction is called the **Age of Tides**. - a) **Age of Tides** - b) Lunar tide - c) Diurnal tide - d) Semi-diurnal tide ## 24. Road Environment Factors and Safety Sight Distance - The provision for safety sight distance is influenced by the following characteristics of the road environment: - I. Road geometry - II. Road surface - III. Road illumination at night - IV. Road topography - a) I and IV only - b) I, II, and III only - c) II and IV only - d) **All of the above** ## 25. Pavement Cracking Types - **Transverse cracking** occurs at right angles to the pavement centerline due to shrinkage or differential thermal stress of the asphalt concrete or reflective cracks. - a) Alligator cracking - b) Block cracking - c) **Transverse cracking** - d) Longitudinal cracking ## 26. Pavement Surface Wear - **Raveling** refers to the wearing away of the pavement surface caused by dislodging of aggregated particles and binder, often a result of insufficient asphalt binder in the mix. - a) Joint or crack spalling - b) Flushing - c) Bleeding - d) **Raveling** ## 27. Surveying Procedures - **Double centering** is a procedure in a horizontal angle layout that involves turning the angle twice and creating a line of sight for critical points. Not used on every point. ## 28. Fatigue Resistance Measure - **Fatigue resistance** is the measure of a material's ability to withstand cyclic (repeated) stresses, with the risk of fracture occurring without warning, even below yield strength. ## 29. Screeding Definition - **Screeding** is defined as the method of moving a straight-edge back and forth with a saw-like motion across the forms to finish concrete surfaces. ## 30. Hazard Definition - A **Hazard** is defined as a source or situation that poses a potential risk for harm, injury, or damage to health, property, or the environment. ## 31. Risk Definition - **Risk** is defined as a human action that deviates from commonly accepted safe procedures that may result in an accident; it requires adherence to a suitable Construction Safety and Health Program, per DOLE requirements. ## 32. Loading Zones - **Loading and unloading zone markings** must be red in color. ## 33. Project Definition - A **Project** is a series of activities with specified objectives that have defined start and end dates, monitored planning, and resource consumption, including money, labor, and equipment. - a) **All of the above** - b) I, II, IV, and V - c) I, II, and IV - d) I, III, and V ## 34. Contract Changes - The following reasons may cause a contract change, except for: - a) Unforeseen conditions - b) **Poor jobsite productivity** - c) A change in owner requirements - d) Designer omission or error ## 35. Road Condition Characteristics - Factors affecting safety sight distance based on the road environment include: - I. Road geometry-grade and curvature sight limitations - II. Road surface-sealed or unsealed, and its smoothness - III. Road illumination at night - IV. Road topography - a) I, II, and III only - b) **All of the above** - c) I, III, and IV only - d) II, III, and IV only ## 36. Structural Properties in Coastal Construction - Key structural properties vital for material selection in harbor and coastal construction include: - I. Specific gravity - II. Material strength - III. Resistance to cyclical impact loading - IV. Resistance to seismic forces - V. Material flexibility - VI. Structural size - a) I, II, and III only - b) IV, V only - c) I, III, and IV only - d) **All of the above** ## 37. Piling Definition - **Piles** are structural components driven into the soil transferring building loads to deeper and stronger soil or rock layers. ## 38. Trip Definition - A **Trip** is defined as the basic unit of travel behavior, involving movement from a single origin to a single destination, characterized by origins, destinations, purposes, and travel modes. ## 39. Signal Coordination - **Signal coordination** involves timing signals in relation to one another, allowing vehicles traveling at a determined speed to pass through successive green lights. ## 40. Rumble Strip Purpose - A **Rumble strip** is a type of thermoplastic lane marking that provides motorists with visual, audio, and motion warnings on the road. ## 41. Grade Resistance - **Grade resistance** represents the component of vehicle weight that acts parallel to an inclined surface. ## 42. Hazard Circumstances - **Hazard** refers to circumstances that deviate from standard conditions, permitting occurrences of accidents or incidents. ## 43. Demolition Area Restrictions - During demolition, no one except workers directly engaged in demolition shall enter an area within a distance equal to 1.5 times the height of the structure being demolished. ## 44. Logistic Definition - **Logistics** refers to the strategic management of resources, materials, and information to ensure efficient movement and delivery of goods and services. ## 45. Design Speed - **Design speed** refers to the maximum safe speed that can be maintained over a specified section of highway under favorable conditions governed by design features. ## 46. Bid Bond Valid Statement - A valid statement regarding a **bid bond** is that it represents costs incurred by the owner if the bidder fails to enter into a contract. - a) It pays for costs incurred by the bid deadline is mixed. - b) **It represents the costs that the owners incur if the bidder fails to enter into a contract.** - c) It represents costs incurred by subcontractors if the project is underbid. - d) It pays for office overhead costs related to a bid ## 47. Hygroscopic Material Definition - **Hygroscopic** refers to a substance that tends to absorb water from the air. ## 48. Safe Pile Capacity Data - The safe capacity of piles driven by powered hammers is based on data comprising: - I. Average penetration per blow (last six blows) - II. Energy of hammer - III. Weight of hammer - IV. Weight of pile including appurtenances - V. Coefficient of restitution based on pile weight - VI. **All of the above** ## 49. Berth Structure Definition - A **Pier** is a berth structure projecting out from the shoreline. - a) Groin - b) Wharf - c) Breakwater - d) **Pier** ## 50. Road Alignment Signs - **Chevron signs** are used to guide drivers through a change in the horizontal alignment of the road. - a) **Chevron signs** - b) Supplementary signs - c) Guide post signs - d) Delineators ## 51. Road Delineation Devices - Delineation of road alignment includes: - I. Pavement Markings - II. Signs - III. Guide Posts - IV. Reflective delineators - V. Lighting - VI. Curb or other physical devices - a) I, II, II, and IV only - b) I, II, IV, and VI only - c) I, V, V, and VI only - d) **All of the above** ## 52. Properties of Queuing Diagrams - Important properties in queuing diagrams include: - I. The slope of D(t) is the departure rate; the slope of A(t) is the arrival rate. - II. The departure rate cannot exceed the service rate or capacity of the server. It may be less. - III. Cumulative departures can never exceed cumulative arrivals. D(t) can never be above A(t) in the queuing diagram. - IV. When a queue exists, the departure rate equals the service rate. In the absence of a queue, the same rate equals the arrival rate. - V. **All of the above** ## 53. Scaffolding Capacity Brackets - Capacity requirements for all scaffolding must be: - a) At least four times its own weight - b) At least 6 times its own weight - c) At most 6 times its own weight - d) At most 5 times its own weight ## 54. Highway Driver Elements - The essential elements of highway driving are referred to as **Driving Task**, encompassing navigation, guidance, and control. - a) **Driving task** - b) Ergonomics - c) Engineering psychology - d) Range index ## 55. Protective Systems in Excavation - **Protective systems** include methods for protecting workers from cave-ins during excavations, consisting of support systems, sloping, benching systems, and shield systems. - a) **Protective system** - b) Personnel protective system - c) Fall arrest system - d) Level arrest system ## 56. Bucket Volume Definitions - **Bucket load capacity** refers to the volume contained within the bucket outline as determined by the bucket sides. - a) Plate line capacity - b) Water line capacity - c) Heap volume - d) **Bucket load capacity** ## 57. Contract Definition - A **Contract** is defined as a formal or legally binding agreement between two parties. ## 58. Toolbox Meeting Definition - A **Toolbox Meeting** is an informal group discussion that focuses on a specific safety issue, facilitating health and safety culture discussions on job sites. ## 59. Road User Directional Signs - **Guide signs** inform road users about the directions and distances to destinations on their route or intersecting roads. - a) Supplementary signs - b) **Guide signs** - c) Warning signs - d) Stack signs ## 60. Specifications Definition - **Specifications** provide detailed requirements for materials, equipment, and workmanship for projects. - a) **Specifications** - b) Bid documents - c) Estimates - d) Plans ## 61. Damping Capacity - **Damping capacity** is the measure of a material’s ability to absorb or dissipate mechanical vibrations. ## 62. Profile Drawing Definition - A **Profile** is a drawing with elevation as the vertical axis and horizontal distance measured along the centerline as the horizontal axis. ## 63. PERT CPM Network Preparation - When preparing a report on the PERT CPM network in construction, one should consider: - a) Pessimistic time network - b) Optimistic time - c) Probable time - d) **All of the above** ## 64. Post-Construction Resolution - This occurs after completion of construction and the resolution of the majority of punchlist and commissioning issues, known as the **Profile**. ## 65. Concrete Formwork Concept - **Formwork** is necessary for concrete placement to maintain shape before the concrete sets. ## 66. Benching Technique in Excavation - **Benching** is a method of protecting workers from cave-ins by creating a series of horizontal levels or steps in excavated areas. - a) **Benching** - b) Shoring - c) Shielding - d) Fall arrest system ## 67. Concrete Surface Leveling - The process of leveling a concrete surface with enough mortar after screeding is termed **Floating**. - a) **Floating** - b) Edging - c) Leveling - d) Bleeding ## 68. Control Joint Placement in Concrete - **Jointing** involves placing premolded inserts in concrete slabs to control cracking due to shrinkage, immediately after or during edging. - a) Jointing - b) Troweling - c) Leveling - d) Edging ## 69. Safety Barrier Considerations - Reasons to establish a need for safety barriers include: - I. Fore slope and back slope steepness and height - II. Unforgiving hazards within the clear zone - III. Water hazards within the clear zone - a) II only - b) I only - c) II and III only - d) **All of the three** ## 70. Limits on Road Messages - Messages painted on pavement should be limited to **six words or less**. - a) **six words or less** - b) five words or less - c) four words or less - d) three words or less ## 71. Types of Pavement Markings - The four types of pavement and curb markings include: - a) **longitudinal lines, transverse lines, lane lines, and center lines** - b) longitudinal lines, transverse lines, stop lines, & center lines - c) longitudinal lines, transverse lines, transition lines, & stop lines - d) longitudinal lines, transverse lines, other lines, & other markings ## 72. Overtaking Lane Design Considerations - Design considerations for overtaking and climbing lanes include: - I. Initial diverge taper - II. Auxiliary lane length - III. End or merge taper - a) **I, II, & III** - b) I & II only - c) II & III only - d) I & III only ## 73. Road Density Definition - **Density** is defined as the number of vehicles per unit distance occupying a roadway section at a given instant in time, measured in vehicles per mile or kilometer. - a) flow - b) **density** - c) capacity - d) volume ## 74. Continuous Waterfront Structure - A **Wharf** is a continuous structure built parallel to the shoreline for loading and unloading ships. - a) pier - b) **wharf** - c) port - d) lighthouse ## 75. Vertical Design Factors - The minimum **K value** for sag vertical should be based on the following factors: - I. Safety sight distance for drivers - II. Appearance in low fill and flat areas - III. Riding comfort, especially at floodway approaches - IV. Vertical alignment fitting into natural terrain. - a) I, II, & III only - b) I, III, & IV only - c) I, II, & IV only - d) II, III, & IV only ## 76. Rumble Strip Definition - A **Rumble strip** is a thermoplastic lane marking designed for visual, audio, and motion warnings for motorists on the road. - a) regulatory signs - b) diagonal marking - c) chevron marking - d) **rumble strip** ## 77. Lane Line Continuation Rules - Lane lines must not be continued in the following scenarios: - I. Across signalized intersections, where low priority road lines must be discontinued. - II. Across side street entrances, except for one-way streets. - III. Past the start of the taper at multi-lane road narrows. - IV. On roads with more than two lanes without median islands. - a) I, II, & IV - b). I, II, & IV - c) II, III, & IV - d) I, II, and III ## 78. Directional Information Signs - **Guide signs** serve to inform road users about directions, distances to destinations, and service locations. - a) **guide signs** - b) warning signs - c) regulatory sign - d) traffic sign ## 79. Benefits of Shoulder Paving - **Shoulder paving** offers: - I. Integrity of the pavement - II. Width for edge line pavement markings - III. Enhanced safety to prevent vehicle skidding - IV. Lower maintenance costs compared to paved shoulders - a) I, III, & IV only - b) **all of the above** - c) I, II, & III only - d) II, III, & IV only ## 80. Structures Built into the Sea - A **Pier** is defined as a structure built into the sea but not aligned parallel to the coastline, which serves various purposes for vessels. - a) lighthouse - b) port - c) **pier** - d) wharf ## 81. Navigable Water Definitions - A navigable body of water leading to a harbor is referred to as a **Channel**. - a) fairway - b) **channel** - c) shoal - d) significant depth ## 82. Types of Curves in Roads - **Vertical curves** are typically parabolas centered around the point of intersection of vertical tangents they connect. - a) **vertical curve** - b) vertical tangent - c) spiral curve - d) grade ## 83. Wind-Generated Waves - Waves under wind influence are referred to as **Sea waves**. - A. Wakes - B. **Sea** - C. Swells - D. Seiching ## 84. Traffic Flow Rate - The **Capacity** refers to the maximum sustained rate of flow for vehicles (passenger cars per hour per lane) under uniform conditions on a freeway segment. - A. Density - B. Traffic flow - C. **Capacity** - D. Design hourly volume ## 85. Hazardous Condition Warnings - **Warning signs** inform road users about hazardous or unexpected road conditions. - A. Roadwork signs - B. **Warning signs** - C. Traffic signs - D. Guide signs ## 86. Purpose of Edge Lines - The purpose of **edge lines** includes discouraging shoulder travel, enhancing safety at night, guiding past hazards, and delineating the edge of the traveled way from the shoulder. - A. I - B. IV - C. V - D. II ## 87. Road Capacity Measurement - **Road capacity** is the maximum number of vehicles expected to pass over a given section of a roadway in one direction during one hour. - A. **Road capacity** - B. Flow of traffic - C. Density - D. Free flow ## 88. High-Rise Building Cleaners - For window cleaners of high-rise buildings, **Slung Scaffold** is most appropriate for providing a suspended working platform. - a) Birdcage Scaffold - b) **Slung Scaffold** - c) Cantilever Scaffold - d) Trestle Scaffold ## 89. Leading Workplace Fatalities - **Falls** are the leading cause accounting for more than 50% of workplace fatalities. - a) Slips - b) Trips - c) **Falls** - d) Electrocution ## 90. Excavation Material Placement - Excavated material should be kept from the excavation edge at a distance not less than **1/4** of the excavation depth. - a) **1/4** - b) 1/3 - c) 1/2 - d) 2/3 ## 91. Temporary Vertical Support Definition - **Dead Shore** refers to temporary vertical support installed directly beneath structural elements while repairs or foundation work is conducted. - A. **Dead Shore** - B. Lateral Bracing - C. Cantilever Prop - D. Raking Shore ## 92. Building Information Modeling - **Building Information Modeling** (BIM) is a 3D model-driven process generating a digital representation of facility features, supporting informed decision-making throughout its lifecycle. - A. CAD Drafting - B. **Building Information Modeling** - C. GIS Mapping - D. Structural Analysis Software ## 93. Operating Costs in Contracting - **Operating Cost** refers to expenses incurred while using equipment for project execution, including repair costs, parts replacement, fuels, labor, and storage. - A. I, II, III, IV - B. I, II, III, IV, V - C. I, II, III - D. II, III, IV ## 94. Water Supply Pipe Terminology - In a water supply system, the vertical pipes are referred to as **risers**, and the horizontal pipes as **branches**. - A. branches and risers respectively - B. **risers and branches respectively** - C. roughing ins and connections respectively - D. connections and roughing ins respectively ## 95. Joint Sealant Definition - A **Joint Sealant** is a rubber or rubber-like material used to fill and seal joints or openings, either alone or with other materials. - A. Grout - B. **Joint Sealant** - C. Adhesive - D. Mortar ## 96. Demolition Area Entry Restriction - During demolition, no one except those engaged in the work shall enter an area within a distance of **1.5 times the height** of the structure being demolished. - A. 1.2 times the height of the structure - B. 2.0 times the height of the structure - C. **1.5 times the height of the structure** - D. 3.0 times the height of the structure ## 97. Vertical Pipe Definition - A **Riser** is a vertical pipe used to transport fluids between different floors of a building. - A. Drain - B. Conduit - C. **Riser** - D. Vent ## 98. Plan View Definition - A **Plan View** is a scaled drawing representing the layout of a structure as seen from above, detailing the arrangement of spaces, walls, and features. - A. **Plan View** - B. Section View - C. Isometric View - D. Elevation View ## 99. Corrosion-Resistant Coating - **Epoxy** is a common protective coating for enhancing corrosion resistance and durability of pipes and appliances. - A. **Epoxy** - B. Latex - C. Polyurethane - D. Acrylic ## 100. Surveying Type Acknowledgment - **Geodetic Surveying** is the type of surveying that takes the curvature of the Earth into account. - A. **Geodetic Surveying** - B. Plane Surveying - C. Topographic Surveying - D. Hydrographic Surveying ## 101. Competency Standards Defined - **Competency Standards** define the required skills, knowledge, and attitudes necessary for effective job performance in the workplace. - A. Work Ethics - B. **Competency Standards** - C. Training Manuals - D. Job Description ## 102. Concrete Retarder Example - A commonly used chemical compound as a retarder in concrete is **Calcium lignosulphonate**. - A. Calcium chloride - B. Aluminum powder - C. Potassium carbonate - D. **Calcium lignosulphonate** ## 103. Sub-base Thickness Determination - The minimum thickness for one layer of compacted granular sub-base should be **20 cm**. - A. 10 cm - B. **20 cm** - C. 15 cm - D. 12 cm ## 104. Hazard Control Classification - The type of hazard control that involves replacing a toxic or hazardous material with a less harmful one is termed **Substitution**. - A. **Substitution** - B. Elimination - C. Engineering Control - D. Administrative Control ## 2. Substitution - B. Elimination - C. Engineering Control - D. Administrative Control ## 2. Substitution - B. Elimination - C. Engineering Control - D. Administrative Control

Iceberg demonstrates the relationship between direct and indirect costs of accidents, showing that on average, indirect costs exceed direct costs. Examples of indirect costs include: - a) Overhead costs - b) Schedule delays - c) **Medical costs** (DIRECT COST) - d) Cleanup time ## 7. Geometric Sequences - **Sequence Identification:** The proper arrangement of the following shapes by their complexity is: I. Quadrilateral II. Parallelogram III. Rectangle IV. Square. - a) II, IV, III, I - b) I, II, III, IV - c) IV, III, II, I - d) I, III, II, IV ## 8. Building Use Classification - The term **Occupancy** refers to a type of use of a building for interior space such as an office, restaurant, private residence, or school, grouped based on similar life-safety characteristics, fire hazards, and combustible contents. - a) Building elements - b) **Occupancy** - c) Building Code - d) Accommodation ## 9. Construction Pit Transport Fees - The maximum distance, as specified in the construction contract, which the contractor is expected to transport soil material without receiving additional payment, is known as **Freehaul distance**. - a) **Freehaul distance** - b) Overhaul distance - c) Haul distance - d) Baseline distance ## 10. Retarder Application Principles - **Fundamental Principles for Upper Retarders:** The retarder should be as near as possible to the warm side of the insulation or the warm face of the assembly. Moreover, it should be installed using a method appropriate for the specific condensation hazard. ## 11. Material Characteristics - **Hardness**: A measure of a material's ability to resist indentation or penetration. - a) **Hardness** - b) Ductility - c) Toughness - d) Resilience ## 12. Soil Density Changes - **Consolidation**: An increase in the soil density of cohesive soil resulting from the expulsion of water from the soil's void spaces. - a) Segregation - b) **Consolidation** - c) Compaction - d) Soil Stabilization ## 13. Concrete Finishing Process - The correct step-by-step process of finishing standard weight concrete slabs is as follows: 1. Bleeding 2. Screeding 3. Leveling 4. Edging 5. Jointing 6. Floating 7. Troweling 8. Broom finishing ## 14. Safety Oversight Authority - The entity given authority to review reports of inspection, accident investigations, and the implementation of the program is the **Health and Safety Committee**. - a) **Health and Safety Committee** - b) DOLE - c) DPWH - d) BFP ## 15. Soil Grouting Process - The process of injecting any agent into soil or rock to increase its strength or stability, protect foundations, or reduce groundwater is termed **Grouting**. - a) **Grouting** - b) Pumping - c) Bleeding - d) Screeding ## 16. Construction Safety Program Requirements - Every construction project must have a suitable **Construction Safety and Health Program**, which adheres to the rules and orders issued by the DOLE. - a) **Construction Safety and Health Program** - b) Occupational Health and Safety Program - c) Occupational Safety and Health Administration - d) Workplace Safety and Procedures ## 17. Safety Sight Distance and Vehicle Characteristics - One of the provisions for safety sight distance is dependent on the characteristics of the vehicle, including: - I. Type of vehicle (car or truck) - II. Friction between the tire and road - III. Eye height of the driver - IV. Speed of the vehicle - a) I only - b) II and III only - c) IV only - d) **All of the above** ## 18. Concrete Leveling Technique - **Screeding** is the process to level a floor or layer of concrete with a straight edge using a back and forth motion while moving across the surface. - a) Troweling - b) **Screeding** - c) Floating - d) Finishing ## 19. Structural Support Types - A structure driven into the soil to support construction by transferring building loads to a deeper and stronger layer of soil or rock is referred to as a **Pile**. - a) Caisson - b) Pier - c) Shoring - d) **Piles** ## 20. Road User Guidance Signs - **Guide signs** inform and advise road users of directions, distances, routes, and the location of services. - a) Cross road sign - b) **Guide signs** - c) Advance direction signs - d) Traffic instruction signs ## 21. Delay Concept in Transportation - The **Delay** refers to the difference between the actual travel time and the ideal travel time for a segment of the transportation system. - a) Queue time - b) Travel time - c) **Delay** - d) Service time ## 22. Construction Instructions - **Specifications** are written instructions detailing how a facility is to be constructed. - a) **Specifications** - b) Estimates - c) Bid documents - d) Plans ## 23. Tidal Wave Phases - The interval referring to the time delay in highest tide for each location due to cosmic forces and friction is called the **Age of Tides**. - a) **Age of Tides** - b) Lunar tide - c) Diurnal tide - d) Semi-diurnal tide ## 24. Road Environment Factors and Safety Sight Distance - The provision for safety sight distance is influenced by the following characteristics of the road environment: - I. Road geometry - II. Road surface - III. Road illumination at night - IV. Road topography - a) I and IV only - b) I, II, and III only - c) II and IV only - d) **All of the above** ## 25. Pavement Cracking Types - **Transverse cracking** occurs at right angles to the pavement centerline due to shrinkage or differential thermal stress of the asphalt concrete or reflective cracks. - a) Alligator cracking - b) Block cracking - c) **Transverse cracking** - d) Longitudinal cracking ## 26. Pavement Surface Wear - **Raveling** refers to the wearing away of the pavement surface caused by dislodging of aggregated particles and binder, often a result of insufficient asphalt binder in the mix. - a) Joint or crack spalling - b) Flushing - c) Bleeding - d) **Raveling** ## 27. Surveying Procedures - **Double centering** is a procedure in a horizontal angle layout that involves turning the angle twice and creating a line of sight for critical points. Not used on every point. ## 28. Fatigue Resistance Measure - **Fatigue resistance** is the measure of a material's ability to withstand cyclic (repeated) stresses, with the risk of fracture occurring without warning, even below yield strength. ## 29. Screeding Definition - **Screeding** is defined as the method of moving a straight-edge back and forth with a saw-like motion across the forms to finish concrete surfaces. ## 30. Hazard Definition - A **Hazard** is defined as a source or situation that poses a potential risk for harm, injury, or damage to health, property, or the environment. ## 31. Risk Definition - **Risk** is defined as a human action that deviates from commonly accepted safe procedures that may result in an accident; it requires adherence to a suitable Construction Safety and Health Program, per DOLE requirements. ## 32. Loading Zones - **Loading and unloading zone markings** must be red in color. ## 33. Project Definition - A **Project** is a series of activities with specified objectives that have defined start and end dates, monitored planning, and resource consumption, including money, labor, and equipment. - a) **All of the above** - b) I, II, IV, and V - c) I, II, and IV - d) I, III, and V ## 34. Contract Changes - The following reasons may cause a contract change, except for: - a) Unforeseen conditions - b) **Poor jobsite productivity** - c) A change in owner requirements - d) Designer omission or error ## 35. Road Condition Characteristics - Factors affecting safety sight distance based on the road environment include: - I. Road geometry-grade and curvature sight limitations - II. Road surface-sealed or unsealed, and its smoothness - III. Road illumination at night - IV. Road topography - a) I, II, and III only - b) **All of the above** - c) I, III, and IV only - d) II, III, and IV only ## 36. Structural Properties in Coastal Construction - Key structural properties vital for material selection in harbor and coastal construction include: - I. Specific gravity - II. Material strength - III. Resistance to cyclical impact loading - IV. Resistance to seismic forces - V. Material flexibility - VI. Structural size - a) I, II, and III only - b) IV, V only - c) I, III, and IV only - d) **All of the above** ## 37. Piling Definition - **Piles** are structural components driven into the soil transferring building loads to deeper and stronger soil or rock layers. ## 38. Trip Definition - A **Trip** is defined as the basic unit of travel behavior, involving movement from a single origin to a single destination, characterized by origins, destinations, purposes, and travel modes. ## 39. Signal Coordination - **Signal coordination** involves timing signals in relation to one another, allowing vehicles traveling at a determined speed to pass through successive green lights. ## 40. Rumble Strip Purpose - A **Rumble strip** is a type of thermoplastic lane marking that provides motorists with visual, audio, and motion warnings on the road. ## 41. Grade Resistance - **Grade resistance** represents the component of vehicle weight that acts parallel to an inclined surface. ## 42. Hazard Circumstances - **Hazard** refers to circumstances that deviate from standard conditions, permitting occurrences of accidents or incidents. ## 43. Demolition Area Restrictions - During demolition, no one except workers directly engaged in demolition shall enter an area within a distance equal to 1.5 times the height of the structure being demolished. ## 44. Logistic Definition - **Logistics** refers to the strategic management of resources, materials, and information to ensure efficient movement and delivery of goods and services. ## 45. Design Speed - **Design speed** refers to the maximum safe speed that can be maintained over a specified section of highway under favorable conditions governed by design features. ## 46. Bid Bond Valid Statement - A valid statement regarding a **bid bond** is that it represents costs incurred by the owner if the bidder fails to enter into a contract. - a) It pays for costs incurred by the bid deadline is mixed. - b) **It represents the costs that the owners incur if the bidder fails to enter into a contract.** - c) It represents costs incurred by subcontractors if the project is underbid. - d) It pays for office overhead costs related to a bid ## 47. Hygroscopic Material Definition - **Hygroscopic** refers to a substance that tends to absorb water from the air. ## 48. Safe Pile Capacity Data - The safe capacity of piles driven by powered hammers is based on data comprising: - I. Average penetration per blow (last six blows) - II. Energy of hammer - III. Weight of hammer - IV. Weight of pile including appurtenances - V. Coefficient of restitution based on pile weight - VI. **All of the above** ## 49. Berth Structure Definition - A **Pier** is a berth structure projecting out from the shoreline. - a) Groin - b) Wharf - c) Breakwater - d) **Pier** ## 50. Road Alignment Signs - **Chevron signs** are used to guide drivers through a change in the horizontal alignment of the road. - a) **Chevron signs** - b) Supplementary signs - c) Guide post signs - d) Delineators ## 51. Road Delineation Devices - Delineation of road alignment includes: - I. Pavement Markings - II. Signs - III. Guide Posts - IV. Reflective delineators - V. Lighting - VI. Curb or other physical devices - a) I, II, II, and IV only - b) I, II, IV, and VI only - c) I, V, V, and VI only - d) **All of the above** ## 52. Properties of Queuing Diagrams - Important properties in queuing diagrams include: - I. The slope of D(t) is the departure rate; the slope of A(t) is the arrival rate. - II. The departure rate cannot exceed the service rate or capacity of the server. It may be less. - III. Cumulative departures can never exceed cumulative arrivals. D(t) can never be above A(t) in the queuing diagram. - IV. When a queue exists, the departure rate equals the service rate. In the absence of a queue, the same rate equals the arrival rate. - V. **All of the above** ## 53. Scaffolding Capacity Brackets - Capacity requirements for all scaffolding must be: - a) At least four times its own weight - b) At least 6 times its own weight - c) At most 6 times its own weight - d) At most 5 times its own weight ## 54. Highway Driver Elements - The essential elements of highway driving are referred to as **Driving Task**, encompassing navigation, guidance, and control. - a) **Driving task** - b) Ergonomics - c) Engineering psychology - d) Range index ## 55. Protective Systems in Excavation - **Protective systems** include methods for protecting workers from cave-ins during excavations, consisting of support systems, sloping, benching systems, and shield systems. - a) **Protective system** - b) Personnel protective system - c) Fall arrest system - d) Level arrest system ## 56. Bucket Volume Definitions - **Bucket load capacity** refers to the volume contained within the bucket outline as determined by the bucket sides. - a) Plate line capacity - b) Water line capacity - c) Heap volume - d) **Bucket load capacity** ## 57. Contract Definition - A **Contract** is defined as a formal or legally binding agreement between two parties. ## 58. Toolbox Meeting Definition - A **Toolbox Meeting** is an informal group discussion that focuses on a specific safety issue, facilitating health and safety culture discussions on job sites. ## 59. Road User Directional Signs - **Guide signs** inform road users about the directions and distances to destinations on their route or intersecting roads. - a) Supplementary signs - b) **Guide signs** - c) Warning signs - d) Stack signs ## 60. Specifications Definition - **Specifications** provide detailed requirements for materials, equipment, and workmanship for projects. - a) **Specifications** - b) Bid documents - c) Estimates - d) Plans ## 61. Damping Capacity - **Damping capacity** is the measure of a material’s ability to absorb or dissipate mechanical vibrations. ## 62. Profile Drawing Definition - A **Profile** is a drawing with elevation as the vertical axis and horizontal distance measured along the centerline as the horizontal axis. ## 63. PERT CPM Network Preparation - When preparing a report on the PERT CPM network in construction, one should consider: - a) Pessimistic time network - b) Optimistic time - c) Probable time - d) **All of the above** ## 64. Post-Construction Resolution - This occurs after completion of construction and the resolution of the majority of punchlist and commissioning issues, known as the **Profile**. ## 65. Concrete Formwork Concept - **Formwork** is necessary for concrete placement to maintain shape before the concrete sets. ## 66. Benching Technique in Excavation - **Benching** is a method of protecting workers from cave-ins by creating a series of horizontal levels or steps in excavated areas. - a) **Benching** - b) Shoring - c) Shielding - d) Fall arrest system ## 67. Concrete Surface Leveling - The process of leveling a concrete surface with enough mortar after screeding is termed **Floating**. - a) **Floating** - b) Edging - c) Leveling - d) Bleeding ## 68. Control Joint Placement in Concrete - **Jointing** involves placing premolded inserts in concrete slabs to control cracking due to shrinkage, immediately after or during edging. - a) Jointing - b) Troweling - c) Leveling - d) Edging ## 69. Safety Barrier Considerations - Reasons to establish a need for safety barriers include: - I. Fore slope and back slope steepness and height - II. Unforgiving hazards within the clear zone - III. Water hazards within the clear zone - a) II only - b) I only - c) II and III only - d) **All of the three** ## 70. Limits on Road Messages - Messages painted on pavement should be limited to **six words or less**. - a) **six words or less** - b) five words or less - c) four words or less - d) three words or less ## 71. Types of Pavement Markings - The four types of pavement and curb markings include: - a) **longitudinal lines, transverse lines, lane lines, and center lines** - b) longitudinal lines, transverse lines, stop lines, & center lines - c) longitudinal lines, transverse lines, transition lines, & stop lines - d) longitudinal lines, transverse lines, other lines, & other markings ## 72. Overtaking Lane Design Considerations - Design considerations for overtaking and climbing lanes include: - I. Initial diverge taper - II. Auxiliary lane length - III. End or merge taper - a) **I, II, & III** - b) I & II only - c) II & III only - d) I & III only ## 73. Road Density Definition - **Density** is defined as the number of vehicles per unit distance occupying a roadway section at a given instant in time, measured in vehicles per mile or kilometer. - a) flow - b) **density** - c) capacity - d) volume ## 74. Continuous Waterfront Structure - A **Wharf** is a continuous structure built parallel to the shoreline for loading and unloading ships. - a) pier - b) **wharf** - c) port - d) lighthouse ## 75. Vertical Design Factors - The minimum **K value** for sag vertical should be based on the following factors: - I. Safety sight distance for drivers - II. Appearance in low fill and flat areas - III. Riding comfort, especially at floodway approaches - IV. Vertical alignment fitting into natural terrain. - a) I, II, & III only - b) I, III, & IV only - c) I, II, & IV only - d) II, III, & IV only ## 76. Rumble Strip Definition - A **Rumble strip** is a thermoplastic lane marking designed for visual, audio, and motion warnings for motorists on the road. - a) regulatory signs - b) diagonal marking - c) chevron marking - d) **rumble strip** ## 77. Lane Line Continuation Rules - Lane lines must not be continued in the following scenarios: - I. Across signalized intersections, where low priority road lines must be discontinued. - II. Across side street entrances, except for one-way streets. - III. Past the start of the taper at multi-lane road narrows. - IV. On roads with more than two lanes without median islands. - a) I, II, & IV - b). I, II, & IV - c) II, III, & IV - d) I, II, and III ## 78. Directional Information Signs - **Guide signs** serve to inform road users about directions, distances to destinations, and service locations. - a) **guide signs** - b) warning signs - c) regulatory sign - d) traffic sign ## 79. Benefits of Shoulder Paving - **Shoulder paving** offers: - I. Integrity of the pavement - II. Width for edge line pavement markings - III. Enhanced safety to prevent vehicle skidding - IV. Lower maintenance costs compared to paved shoulders - a) I, III, & IV only - b) **all of the above** - c) I, II, & III only - d) II, III, & IV only ## 80. Structures Built into the Sea - A **Pier** is defined as a structure built into the sea but not aligned parallel to the coastline, which serves various purposes for vessels. - a) lighthouse - b) port - c) **pier** - d) wharf ## 81. Navigable Water Definitions - A navigable body of water leading to a harbor is referred to as a **Channel**. - a) fairway - b) **channel** - c) shoal - d) significant depth ## 82. Types of Curves in Roads - **Vertical curves** are typically parabolas centered around the point of intersection of vertical tangents they connect. - a) **vertical curve** - b) vertical tangent - c) spiral curve - d) grade ## 83. Wind-Generated Waves - Waves under wind influence are referred to as **Sea waves**. - A. Wakes - B. **Sea** - C. Swells - D. Seiching ## 84. Traffic Flow Rate - The **Capacity** refers to the maximum sustained rate of flow for vehicles (passenger cars per hour per lane) under uniform conditions on a freeway segment. - A. Density - B. Traffic flow - C. **Capacity** - D. Design hourly volume ## 85. Hazardous Condition Warnings - **Warning signs** inform road users about hazardous or unexpected road conditions. - A. Roadwork signs - B. **Warning signs** - C. Traffic signs - D. Guide signs ## 86. Purpose of Edge Lines - The purpose of **edge lines** includes discouraging shoulder travel, enhancing safety at night, guiding past hazards, and delineating the edge of the traveled way from the shoulder. - A. I - B. IV - C. V - D. II ## 87. Road Capacity Measurement - **Road capacity** is the maximum number of vehicles expected to pass over a given section of a roadway in one direction during one hour. - A. **Road capacity** - B. Flow of traffic - C. Density - D. Free flow ## 88. High-Rise Building Cleaners - For window cleaners of high-rise buildings, **Slung Scaffold** is most appropriate for providing a suspended working platform. - a) Birdcage Scaffold - b) **Slung Scaffold** - c) Cantilever Scaffold - d) Trestle Scaffold ## 89. Leading Workplace Fatalities - **Falls** are the leading cause accounting for more than 50% of workplace fatalities. - a) Slips - b) Trips - c) **Falls** - d) Electrocution ## 90. Excavation Material Placement - Excavated material should be kept from the excavation edge at a distance not less than **1/4** of the excavation depth. - a) **1/4** - b) 1/3 - c) 1/2 - d) 2/3 ## 91. Temporary Vertical Support Definition - **Dead Shore** refers to temporary vertical support installed directly beneath structural elements while repairs or foundation work is conducted. - A. **Dead Shore** - B. Lateral Bracing - C. Cantilever Prop - D. Raking Shore ## 92. Building Information Modeling - **Building Information Modeling** (BIM) is a 3D model-driven process generating a digital representation of facility features, supporting informed decision-making throughout its lifecycle. - A. CAD Drafting - B. **Building Information Modeling** - C. GIS Mapping - D. Structural Analysis Software ## 93. Operating Costs in Contracting - **Operating Cost** refers to expenses incurred while using equipment for project execution, including repair costs, parts replacement, fuels, labor, and storage. - A. I, II, III, IV - B. I, II, III, IV, V - C. I, II, III - D. II, III, IV ## 94. Water Supply Pipe Terminology - In a water supply system, the vertical pipes are referred to as **risers**, and the horizontal pipes as **branches**. - A. branches and risers respectively - B. **risers and branches respectively** - C. roughing ins and connections respectively - D. connections and roughing ins respectively ## 95. Joint Sealant Definition - A **Joint Sealant** is a rubber or rubber-like material used to fill and seal joints or openings, either alone or with other materials. - A. Grout - B. **Joint Sealant** - C. Adhesive - D. Mortar ## 96. Demolition Area Entry Restriction - During demolition, no one except those engaged in the work shall enter an area within a distance of **1.5 times the height** of the structure being demolished. - A. 1.2 times the height of the structure - B. 2.0 times the height of the structure - C. **1.5 times the height of the structure** - D. 3.0 times the height of the structure ## 97. Vertical Pipe Definition - A **Riser** is a vertical pipe used to transport fluids between different floors of a building. - A. Drain - B. Conduit - C. **Riser** - D. Vent ## 98. Plan View Definition - A **Plan View** is a scaled drawing representing the layout of a structure as seen from above, detailing the arrangement of spaces, walls, and features. - A. **Plan View** - B. Section View - C. Isometric View - D. Elevation View ## 99. Corrosion-Resistant Coating - **Epoxy** is a common protective coating for enhancing corrosion resistance and durability of pipes and appliances. - A. **Epoxy** - B. Latex - C. Polyurethane - D. Acrylic ## 100. Surveying Type Acknowledgment - **Geodetic Surveying** is the type of surveying that takes the curvature of the Earth into account. - A. **Geodetic Surveying** - B. Plane Surveying - C. Topographic Surveying - D. Hydrographic Surveying ## 101. Competency Standards Defined - **Competency Standards** define the required skills, knowledge, and attitudes necessary for effective job performance in the workplace. - A. Work Ethics - B. **Competency Standards** - C. Training Manuals - D. Job Description ## 102. Concrete Retarder Example - A commonly used chemical compound as a retarder in concrete is **Calcium lignosulphonate**. - A. Calcium chloride - B. Aluminum powder - C. Potassium carbonate - D. **Calcium lignosulphonate** ## 103. Sub-base Thickness Determination - The minimum thickness for one layer of compacted granular sub-base should be **20 cm**. - A. 10 cm - B. **20 cm** - C. 15 cm - D. 12 cm ## 104. Hazard Control Classification - The type of hazard control that involves replacing a toxic or hazardous material with a less harmful one is termed **Substitution**. - A. **Substitution** - B. Elimination - C. Engineering Control - D. Administrative Control ## 2. Substitution - B. Elimination - C. Engineering Control - D. Administrative Control ## 2. Substitution - B. Elimination - C. Engineering Control - D. Administrative Control

Operative Lecture 8: Polymerization Shrinkage

Operative Lecture 8: Polymerization Shrinkage

Lecture 4: Shrinkage Methods

L5: Subset selection and shrinkage methods