ACME Construction LTD Asbestos Awareness Procedure †Building Safety (200 Level Course)

ACME Construction LTD Asbestos Awareness Procedure – Building Safety (200 Level Course) Free Online Research Papers ACME Construction LTD Asbestos Awareness Procedure Legal Form Building Safety (200 Level Course) I.Pre- Construction Procedures Prior to taking an area, contractor to submit â€Å"Construction Clearance Request†. Consultants to review and respond to contractors request. Upon return from consultant, contractor to review any exceptions taken by consultants. Approved â€Å"Construction Clearance Request† is to be forwarded to all parties according to the law. participating subs, consultants etc.. for their review and record. Contractor to review contracted scope of work in relation to the asbestos abatement scope of work. Review to include Superintendent and Project Manager. After scope of work and coordination of contract documents are complete, area of work is released to jobsite Superintendent. Should contractor’s work interfere with Hazardous Materials, contractor to contact Consultant for clarification and directions on how to proceed. II.On-site Procedures Superintendent to conduct pre-construction review of area to work in. Attendance required by all subcontractors scheduled to work in designated area. Review to include: 1.Asbestos abatement scope of work. 2.Contractor’s scope of work. 3.Each sub’s procedures and planned routing of new work if not clearly defined on contract documents. 4.Hot Areas that are not to be disturbed. 5.Any changes in contract scope as affected by HazMat. All on-site personnel to receive copy of the Pre-construction Meeting Minutes for record. Superintendent to post a â€Å"Hot List† at the entrance to each room that contains hazardous materials. This list is to identify all materials that are to be undisturbed during construction. ( see attached form ) Asbestos Awareness Certificates to be kept on-site for each contractor’s employees for verification and approval to enter site. â€Å"Daily Sign-In Sheet† will be completed by each subcontractor’s foreman and turned in to the Superintendent each morning for confirmation of employee certification. ( see attached form ) Each certified employee will be issued a colored identification mark that will be attached to the employee’s identification badge. This will provide another means for the Superintendent to verify certification. Asbestos abatement status to be a topic at every weekly on-site sub-meeting. ACME CONSTRUCTION LTD ASBESTOS AWARENESS PROCEEDURES III.Reporting Procedures Any employee who suspects hazardous containing materials to be present in an area, and is not identified as such, is required to report the suspected materials to the jobsite Superintendent. Superintendent is to contact the program manager or consultant and request a review. Project Manager to follow up with a formal written Request for Information. Work should be suspended in the suspected area until a formal response is received from the program manager or consultant. Once a response is received from the program manager or consultant, Project Manager is to forward response to Superintendent and party requesting the information. Should a change in scope occur, request that the Architect prepare a formal Proposal Request. This is required for record, whether there is cost involved or not. Research Papers on ACME Construction LTD Asbestos Awareness Procedure - Building Safety (200 Level Course)The Project Managment Office SystemRiordan Manufacturing Production PlanMoral and Ethical Issues in Hiring New EmployeesOpen Architechture a white paperStandardized TestingArguments for Physician-Assisted Suicide (PAS)Analysis of Ebay Expanding into AsiaInfluences of Socio-Economic Status of Married MalesQuebec and CanadaIncorporating Risk and Uncertainty Factor in Capital

Police Powers of Control of Public Assemblies The WritePass Journal

Police Powers of Control of Public Assemblies Police Powers of Control of Public Assemblies Part1: Annotated Bibliography                             Part2: Police Powers of Control of Public AssembliesRelated [POLICE POWERS: BIBLIOGRAPHY] (a) you are required to complete a (part annotated) bibliography on the topic â€Å"Police Powers of Control of Public Assemblies† (annotated): you should describe the relevance of the contents of the materials you find and comment upon them).                                                                                                                                       (b) You must write a paragraph on Police Powers of Control of Public Assemblies which contains: one properly referenced quotation, one properly referenced paraphrase of material from one of your identified sources and one sentence of your own composition. Part1: Annotated Bibliography (a) You should identify and properly reference (to exact OSCOLA protocols) eight books – three of which should be annotated. AW Bradley and KD Ewing: Constitutional and Administrative Law (14th edition, Pearson Education 2007) This is the 14th edition of Bradley and Ewing’s authoritative work and deals with the unwritten constitution of the UK and the intricacies of administrative law in great detail. The authors deal with police powers and public assemblies in chapter 24 which includes discussion of the Human Rights Act. They point out that the influence of Human Rights in this area will not change the course of police powers but rather act as a means to prevent their further growth since 9/11. Hilaire Barnett: Constitutional and Administrative Law (7th edition, Routledge Cavendish 2008) This book is the 7th edition of another authoritative work on constitutional and administrative law in the United Kingdom. The author approaches the subject of police control and public assemblies in the second half of the book. Albert V.Dicey: Introduction to the Study of the Law of the Constitution (8th edition, Liberty Fund Inc 1982) A.V. Dicey was the foremost British constitutional jurist of his day. For Dicey, there was no specific right of freedom of assembly or association – it was a by-product of the freedom of the individual to do as they wished so far as it was not prohibited by law.   Dicey recognised, therefore, that there were limitations to an individuals’ freedom of assembly, but these were â€Å"grounded on the absolute necessity for preserving the King’s peace† (at p.174). Paul Craig: Administrative Law (6th edition, Sweet Maxwell 2008) Ewing, KD and Gearty, CA: The Struggle for Civil Liberties: Political Freedom and the Rule of Law in Britain (Oxford University Press 2001)    Helen Fenwick: Civil Liberties and Human Rights (3rd edition, Routledge-Cavendish 2002)       Richard Stone: Textbook on Civil Liberties and Human Rights (8th edition, Oxford University Press 2010) David Williams: Keeping the Peace: The Police and Public Order (1st edition, Hutchinson 1967) (b) You should identify and properly reference (to exact OSCOLA protocols) five journal articles three of which should be annotated. Neil Parpworth, ‘Public Assemblies and the Statutory Power to Impose Conditions’ in Justice of the Peace Local Government Law [2000] 164 (20), 376-378    This journal article examines the police powers to impose conditions on public processions and assemblies under the Public Order Act. The article is a case comment on Broadwith v Chief Constable of Thames Valley [2000] Crim.L.R.924 (DC) which concerned s.14(5) and whether a protestor was bound by a Police direction for a prior assembly he had not participated in. Gabrielle Moore, ‘Policing Protest’ in Criminal Law Justice Weekly [2011] 175 (1/2), 12 This journal article argues that individuals are being denied their right to protest with misapplication of the Public Order Act 1986 s.14 (which gives police officers the authority to impose conditions on individuals if they are of the opinion that criminal acts may result from an assembly). Sally Ramage, ‘The Right to Protest: Should Police Charge Demonstrators a Fee?’ in Criminal Lawyer [2009] 192, 1-3 This article looked at the issue of policing for the group of 20 economic summit in London on 1st April 2009 in London and considers the police tactics of â€Å"kettling† and whether this constitutes a deprivation of protestors civil liberties. Michael Connolly, ‘Freedom of Assembly, Freedom of the Person: Advance Notice Imposing Conditions on Public Assembly’ in Journal of Civil Liberties [2000] 5(2), 223-230    G.T Williams, ‘Processions, Assemblies and the Freedom of the Individual’ in Criminal Law Review [1987] March 167-179 (c) You should identify and properly reference (to exact OSCOLA protocols) twenty cases – the most recent of which should be annotated. 1.Carter v Crown Prosecution Service [2009] EWHC 2197 (Admin); [2010] 4 All E.R. 990; This case concerned s.30 of the Anti-Social Behaviour Act 2003 where a police officer with the rank of at least Superintendent has reasonable grounds to believe that members of the public have been intimidate, harassed, alarmed or distressed as a result of the behaviour of two or more members of the public in an area where anti-social behaviour is a problem then authorisation may be given for police officers in uniform to have extra powers. The facts of the case are that in August 2008 the appellant was with a group of other youths who were causing a public nuisance and behaving unacceptably. They were warned by a police patrol not to do so in accordance with a â€Å"dispersal order† but the group, after initially complying, got back together and flouted the order and the appellant was arrested and charged. The case at first instance was decided against the defendants: the magistrates had misinterpreted the legislation and thought that oral evidence of the â€Å"dispersal ord er† equated to authorisation under the 2003 Act. The appellate court overturned the conviction for lack of evidence of authorisation under s.30. 2.Kay v Commissioner of Police of the Metropolis [2008] UKHL 69; [2008] 1 W.L.R. 2723; 3.R. (on the application of Laporte) v Chief Constable of Gloucestershire [2006] UKHL 55; [2007] 2 A.C. 105; [2007] 2 W.L.R. 46; 4.R. (on the application of Singh) v Chief Constable of the West Midlands [2005] EWHC 2840 (Admin); [2006] Po. L.R. 1; 5.R. (on the application of W) v Commissioner of Police of the Metropolis [2006] EWCA Civ 458; [2007] Q.B. 399; [2006] 6.University of Oxford v Broughton [2006] EWHC 1233 (Admin); (2006) 103(25) L.S.G. 28 (QBD (Admin)) 7.Austin v Commissioner of Police of the Metropolis [2007] EWCA Civ 989; [2008] Q.B. 660;))   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   8. Brogan v United Kingdom (1988) 11 EHRR 117 9. Brown v Stott [2003] 1 AC 681; [2001] 2 WLR 817; [2001] 2 All ER 97, PC 10. Chief Constable of Cleveland Police v McGrogan [2002] EWCA Civ 86; [2002] 1 FLR 707 11. De Jong, Baljet and Van den Brink  v The Netherlands (1984) 8 EHRR 20 12. Guzzardi v Italy (1980) 3 EHRR 333 13. McQuade v Chief Constable Humberside Police [2001] EWCA Civ 1330; [2002] 1 WLR 1347 A 14. McVeigh, ONeill and Evans v United Kingdom (1981) 5 EHRR 71 15. Maguire v Chief Constable of Cumbria Constabulary [2001] EWCA Civ 619, CA 16. Osman v United Kingdom (1998) 29 EHRR 245 17. R v Jones (Margaret) [2006] UKHL 16; [2007] 1 AC 136; [2006] 2 WLR 772; 18. R v Kamara [1974] AC 104; [1973] 3 WLR 198; [1973] 2 All ER 1242, HL(E) 19. Thomas v Sawkins [1935] 2 KB 249 20. Duncan v Jones [1936] 1 KB 218                              Part2: Police Powers of Control of Public Assemblies The control of public assemblies is becoming an ever more contentious issue in light of recent protests against the Coalition Government and their unpopular austerity measures. The Human Rights Act is beginning to filter into our system of protest and assembly but it cannot yet be said to be presenting a challenge to laws which have long held sway[1]. As Bradley and Ewing observe: â€Å"The same vigorous approach to freedom of assembly has not always been adopted in other cases – such as those involving noisy anti-globalisation or angry anti-war protestors. In these cases Convention rights have yielded to other concerns, notably the need to maintain public order under common law rules created long before the enactment of the Human Rights Act 1998†[2]. The student protests of 2010 were another recent example of kettling and the inability of the human rights act to stop the police using excessive force on public demonstrations. [1] AW Bradley and KD Ewing: Constitutional and Administrative Law (14th edition, Pearson Education 2007) at p.598 [2] Ibid at p.598

Koran as a Message of Peace Essay Example | Topics and Well Written Essays - 750 words - 1

Koran as a Message of Peace - Essay Example Not only this that the diction and mythology narrated in these Scriptures are very similar to one another, but also they also lay stress upon one and the same teachings. Since it gives glad tidings to the humans in the afterlife on performing good,  escaping evil, and complying with the commands of Almighty Allah and his last Prophet Hazrat Muhammad (peace and blessings of Almighty Allah be upon him) during their stay in this world. Moreover, its teachings vehemently forbid its followers from hurting, harming and killing anyone, either Muslim or non-Muslim altogether, without any just reason. Similarly, it also provides complete shelter and protection to the non-believers even, which do not have any nefarious designs to harm the Muslims or the cause of Islam, as Chapter 65 Verse 2 of the Scripture clearly states: And whosoever fears Allah and keeps his duty to Him, He will make a way for him to get out (of every difficulty). It is, therefore, Koran is regarded as the message of pea ce. Koran and Bible maintain several issues and beliefs in common. For instance, Leviticus 19: 1-33 of the Hebrew Bible manifestly commands its followers (as well as all humans at large) to worship One God, respect the parents, observe honesty, integrity, chastity and avoid fornication, theft, cheating, adultery, homosexuality and disobedience of God. Almost the same teachings have been stressed in Chapter 17 of the Holy Koran (i.e. Children of Israel), where its verses from 41 to 52 glorify the attributes and blessings of Almighty Allah upon all the creatures, which in return say His hymns and praises subsequently.

Identify time management techniques Essay Example | Topics and Well Written Essays - 500 words

Identify time management techniques - Essay Example In addition, one needs to incorporate a motivational factors within the goal setting activity that would enable the generation of a rewards for fulfilling or accomplishing the goals that were set within the identified time frame. One affirms that by looking forward to availing of a benefit or reward, the achievement of goals are facilitated since one’s focus would be re-directed to the positive outcome, and not on the challenges that could be encountered on the way to attaining the identified goal. Another important aspect of goal setting and time management is learning the skill of prioritization. One’s score in this area is 24 out of 35 or 69%. Given a set of activities or endeavors, one must be able to identify and classify the tasks according to urgency: which needs to be done within the shortest possible time frame. As such, making a list of the activities for the day, or for the week, would assist in developing prioritization skills. Likewise, one must also recognize which tasks are more tedious and comprehensively encompassing in details. If there are endeavors that require much preparation and planning, the strategies for prioritization should include accurately identifying tasks in minute details, or broken down into sub-tasks, so that one would not perceive the activity as burdensome in holistic form. In addition, tasks that entail prior research, collection of data, or extensive studying could be scheduled intermittently, as one’s spare time would allo w. The third relevant aspect in time management is managing interruptions. The score generated in this area is 12 out of 20 or 60%. It could be deduced that there are more rooms for improvement in this aspect. One must be able to discern which types of interruptions prevent me from completing scheduled tasks or responsibilities in an effective manner according to prescribed time frame. The interruptions in one’s daily routine

Research paper Example | Topics and Well Written Essays - 250 words

Research Paper Example Our subject belongs to the last stage, teenager. The physical size is normal for the Asian race. His vital signs are presumed normal since he was dancing with his friends at the park. Their group is composed of dance enthusiasts. I cannot assume about his organ development. But looking at his physically, nothing seemed to be abnormal. He dances well and this shows that his vision and hearing are refined. The subject’s developmental stage showed his capability to function normally. Piaget’s Stages of Cognitive Development The Swiss biologist and psychologist Jean Piaget observed his children and in the end developed a four-stage model of how the mind processes new information met. He speculated that children improve through 4 stages and they all do in the same order. The four stages of Piaget’s cognitive development include sensorimotor stage, preoperational stage, concrete operations, and formal operations. Our subject belongs to the formal operations stage which includes ages 11 to 15. The cognition is in its final form. Our subject no longer needs concrete objects to make reasonable and logical judgments. He is already competent of hypothetical and deductive reasoning.

Urbanisation Essay Example for Free

Urbanisation Essay London in the 18th century brought about a revolution in urbanisation and the expansion of an urbanised city began in England and spread rapidly all around Europe. Urbanisation brought a dramatic and radical change to London, significantly in the impact of the Industrial Revolution which was effected urban society. There were both general and particular reasons why the eighteenth century was a century of urban growth and amoung the general reasons were the rise in national population, the expansion of industry and commerce, and the displacement of growing numbers of country-dwellers by an agricultural revolution. [1] At the beginning of the 18th century, Britain was primarily an agricultural country with most people living in rural areas and the majority of workers and industires operated within a domestic system. 2] This involved people working in their own homes to produce goods and also to cultivate food on their own farm or piece of land. During the 18th centuy, there was a gradual move away from this way of working and the growth of urbanisation changed the domestic system to improve the lives of the British public. Urbanisation brough together all the manpower it required, whether for manual work or for the tertiary sector where the new age was creating more and more jobs, especially once London became more urbanised. 3] A further indicator of the abundance of the labour supply was the enormous number of domestic servants and at the end of the 18th century, domestic servants made up over 15% of the population of London and ultimately, England had no labour shortage as it was being urbanised. [4] The invention of machines after the industrial revolution led to a transformation in the ways in which goods could be produced and the speed and scale of the process of the 18th century, saw significant changes in the size, location and lifestyle of the British population. 5] Industrialisation was a very important influence in stimulating the movement to urbanisation and the growth of factories and the availibility of work in them attracted people from rural areas and sustained higher densities of people in London. Industrialisation was a majour factor in the population growth and urbanisation in London in the 1700s and although it initially created a new urban poverty, the living standards of the working cla ss rose from the mid-18th century onwards as new employment opportunities became vailable. [6] During the 18th century, major improvements occurred whilst London was being urbanised, especially in agricultural prodoction. Modern scientific farming methods brought about new tools and farming machines, new methods, improved crops and employment rose. [7] In 1702, 1757, 1769 and 1773 Parliament passed legislation, liberalizing the economy and this led many to conclude that libralization significantly contributed to accelerate growth, due to urbanisation. 8] The vast majority of economic historians do not believe that any of these variables alone was responsible for the boom in the British economy, although many believe that urbanisation was essential for the Londons improvement in its economy beause it is frequently asserted that it was the concomitant effect of all of them that delivered the improved performance. [9] Farming was modernised through the use of enclosure, the enlargement of farms, the use of new methods, new crops and the population grew, commerce expanded, and Lon don promoted exports. 10] Due to urbanisation and the industrial revolution, the English countryside intergrated into the islands national market; as a component part of this network, English farms fed the population of the towns and industrial conurbations; they were the essential component in a domestic market which provided London to continue to develop in its early days. [11] It also had colonies, and London enjoyed the same stock of natural resources as it did a century later, all because of London becoming urbanised and it brought London into political stability as it also liberalised the economy. 12] Within the industrial revolution as a whole, Britian went through a series of individual revolutions once London became more urbanised and the British public revolutionised in its agriculture, demography, inland transport, technoloy, trade and industry. [13] As Europes commetial and finantial centre of gravity shifted to London in the early 18th century, a strong territorial state and an intefrated national economy provided the resources for a new type of commercial metropolis, the modern â€Å"world city. [14] Although urbanisation brought prosperity to London, the social consequences of urbanisation left a huge social upheaval in the 18th century which had a majour effect on the physical and social conditions in which people had to live. The consequences of a large mass of people moving to live around new factories in a relatively short space of time included – housing shortages and squalor, sanitation problems, public health problems and regular utbreaks of disease and exploytation of workers and widespread poverty. [15] As the population increased in Britain, people moved from the countryside to the unrestrainedly frowing towns, which faced serious public health problems. The poor physical conditions in urban areas in the 18t h century led to majour public health problems and rapidly growing cities experienced majour outbreaks of disease, epidemics and other problems of : overcrowded, damp, and poorly ventilated housing. 16] Urbanisation also contributed to the lack of an effective sewerage system, industrial pollution, the lack of a clean water supply and a lack of undertanding about how infectious diseases were spread and so, many people living in the 18th century died at a relatively young age of infectious diseases that were contracted because of the public health condition, a lack of servises and multiple disease epidemics at the time. 17] As London became larger, the disposal of residential and industrial wastes became even more of a challenge, partly as a result of the mountening pressure for people to migrate to cities; the growth in urban populations stripped the availibility of basic servises such as – water, transportation and electricity. [18] As a result, life in London in the 18th Century in the urban shantytownes was plagued by poverty, pollution, congestion, homelessness and unemployment. The rapid expansion also led to problems of overcrowding and insanitary conditions, bringing desease, high death rates and it was therefore only through substantial migration from the countryside that London could continue to grow. [19] Whilst England had its small though rapidly expanding population, it became the most urbanisted country in Europe in the sense that the larger proportion of its citizens lived in a directly urban environment than anywhere else. Although there were many positire reactions to London being urbanised, many critics gave cynical views on the dramatic changes of the city. As David Landers has said, â€Å"Industrialisation in England had the effect of concentrating larger numbers of weavers and spinners in manufactoring districts which, thought still rural and not yet urban, became densely packed: full of people as Defoe wrote of the country around the Halifax in the West Riding. †[20] As Jacques Bertin said, I admit I am still completely in the dark about what industrilisation means. Does it mean railways? Cotton? Coal? Metals? So, even at the time of the industrial revolution, urbanisation wasnt highly liked and many were bemused by the act that London was evolving. [21] Since urbnisation meant everything – society, economy, political structures and public opinion, the most ambitious kind of history could not embrace it because the industrial revolution along with the urbanisation of London – it threw Britain into upheaval and it was not a netely-definable phenomenon. [22]There were also pessimists who, seeing its expansion, bel ieved that urbanisation was sucking in the life-blood of the nation, among them was Dr. Richard Price, who wrote gloomingly in 1783 that the inhabitants of the cottages thrown down in the country fly to London, there to be corrupted and perished. [23] This already is a strong indication that urbanisation was not the majour element in the onset of revolutionising London; this conclusion is reinforced by the analysis of urbanisation trends and it was not the traditional network of cities which was the basis of the new industrialisation process and this process was essentially located in very small towns or villages, which obviously later became big cities. 24] Urbanisation strengthened the political power of workers and of those engaged in business, with a middle class, the bourgeoisie, formed out of managers, suppliers of services, investors, bankers, industrialists, engineers and others whose well-being depended on industrialisation and urbanisation. [25] Although urbanisation did bring prosperity to London, H.  Shmal has suggesed that high levels of urbanisation actually limited the possiblities of productive investement, especially in the new sectors and consumption demanded from the cities and even the construction needed to be absorbed to a large share of resources, that ultimately resulted in poor living and unhealthy living conditions. [26] High levels of urbanisation in London created urban under-employment, and therefore, lowered productivity on the whole economy and this under-employment also lead to a too large tertiary sector, and to rigidity in the offer and mobility of the labour force. [27]

The Glasgow Coma Scale Health And Social Care Essay

The Glasgow Coma Scale Health And Social Care Essay There are three types of cord syndromes related to spinal cord injury. These are the central cord syndrome, anterior cord syndrome, and brown-sequard syndrome or the lateral cord syndrome. The central cord syndrome is caused by injury or edema in the central cord usualy in the cervical area due to hyperextension injuries. This results to motor weakness of the upper extremities than the lower extremities. The anterior cord syndrome is caused by disk herniation or compression of the artery that runs along the front of the spinal cord. This causes loss of sensory, loss of pain and temperature but sensitivity to position and vibrations are preserved. The brown-sequard syndrome or lateral cord syndrome may be a result of penetrating injury in the spine or hemisection of the cord. This causes ipsilateral hemiplegia with loss of touch, pressure and vibration also contralateral pain and temperature sensation deficits. Discuss how the Glasgow Coma Scale is utilized in determining neurological status. The Glasgow coma scale is used widely in hospitals to give a reliable, objective way of recoding the level of consciousness of a patient. The GCS has three elements, the eye response, verbal response and motor response. Each has their own grades. For the eye response 4pts for open spontaneously, 3pts to open to non-verbal command, 2pts on open in response to pain and 1pt to no response. For verbal response 5pts for talking/oriented, 4pts for confused speech/disoriented, 3pts on inappropriate words, 2pts for incomprehensible sounds and 1pt for no response. Last for motor response 6pts for obey commands, 5pts to localizes to pain, 4pts for flexion/ withdrawal from painful stimuli, 3pts to flexion in response to pain, 2pts for extension in response to pain and 1pt to no response. 15pts is the perfect score and 3 as the lowest score which indicates that the patient is in deep coma. Discuss nursing interventions related to prevention of injury in the brain-injured patient. To prevent injury for patient that has brain injury the patient must be assessed to ensure adequate oxygenation and that the bladder is not distended. Dressings and casts mast be check for constriction. The side rails must be raised and padded to avoid falling. The bed must also be lowered. Reducing environmental stimuli and to have an adequate lighting. Minimize disturbances during sleep to provide adequate rest for the patient. Medications can be given as prescribed to prevent restlessness. For incontinence catheter can be used. Written assignment Identify risk factors for spinal cord injury. Spinal cord injury is an injury due to an unexpected accident. In short everyone can have a spinal cord injury. Still there are some risk factors. One risk factor is if you are engage in active sports or into jobs that requires lifting heavy loads. Another risk factor is for the people who are in the 16-30yrs of age because in these years people are active and many people at these age bracket is now driving and one of the leading cause of spinal cord injury is vehicular accidents. And if you have bone disorder like osteoporosis, this can cause spinal cord injury. List three clinical features of the patient with neurogenic shock. Neurogenic shock is caused by injury in the central nervous system that causes vasodilation as a result of loss of balance between the sympathetic and parasympathetic stimulation. This causes low blood pressure (hypotension), decrease heart rate (bradycardia), and reduce venous return which gives a dry, warm skin. Why is autonomic dysreflexia an acute emergency situation? Autonomic dysreflexia is the over activity of the autonomic nervous system. The nerve impulses that are being send to the brain are blocked by a lesion in the spinal cord (at the t-5 level or above) which causes the brain to increase activity of the sympathetic system that results to a rise in blood pressure. The heart then sends impulse to the brain that causes the heart to slow down and the blood vessels above the spinal injury to dilate. But the brain cannot send impulse below the level of injury due to the lesion therefore blood pressure cannot be regulated. This is an acute emergency situation because if not treated immediately this may lead to seizures, stroke and even death. Develop a matrix identifying concussion, contusion, and diffuse axonal injury. Identify clinical manifestations and associated diagnostic testing. Definition Clinical manifestation Diagnostic testing Concussion Injury to the brain that is a result from an impact to the head. Ranges from mild to severe concussion Mild concussion Slightly dazed Brief loss of consciousness Severe concussion Longer loss of consciousness Longer recovery time Other manifestations Nausea and vomiting Blurred vision Confusion Fatigue Short-term memory loss Neurological function tests CT scan Contusion Traumatic brain injury or bruising of the brain because of sever acceleration-deceleration force or blunt trauma Loss of consciousness Lack of motor coordination Memory problems CT scan MRI Diffuse axonal injury This is a diffuse brain injury cause by severe head traumas. As tissue slides over tissue, a shearing injury occurs. This causes the lesions that are responsible for unconsciousness, as well as the vegetative state that occurs after a severe head injury Lack of consciousness No lucid interval Immediate coma MRI CT scan EEG electroencephalogram Discuss the long-term rehabilitation needs of the spinal cord injured patient. Within a group, ask questions regarding nursing care in the rehabilitative phase. For patients who suffered spinal cord injury rehabilitation is needed to restore as much function to the patient. The patient must understand his condition and reduce assistance with activities and let the patient be independent to improve motor function and also to increase the patients self-esteem. Discuss nursing management for the head-injured patient related to nursing applicable nursing diagnoses. Ineffective airway clearance Assess the respiratory status Check the patency of the airway Ensure airway clearance Ineffective tissue perfusion (cerebral) Assess the visual, sensory and motor functions Note for headache, dizziness, altered mental status and personality changes Elevate HOB (10 degrees) and maintain head/neck in midline or neutral position to promote circulation and venous drainage Decrease intracranial adaptive capability Monitor patients neurological vital signs (GCS) Monitor ICP Assess the patients reflexes Decrease environmental stimuli Risk for injury Provide safe environment Raise side rails Lower bed Web output NURSING MANAGEMENT OF ADULTS WITH SEVERE TRAUMATIC BRAIN INJURY http://www.dvbic.org/images/pdfs/AANN08_TBIGuide_2-13-09_update.aspx Base on the study that I have read, the neuroscience nurse is the one who intervenes to maintain and manage intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patience with traumatic brain injury (TBI). The prevention of complications commonly associated with TBI is also involved in the management of care for TBI patients such as deep vein thrombosis (DVT), hyperglycemia, and excessive protein loss. In maintaining or decreasing of ICP, this study recommended guidelines. First, an uncontrolled intracranial hypertension leads to an absence of cerebral perfusion and results in brain death thus, the recommended ICP according to the original Guidelines for the Management of Severe head Injury should be at less than 20mmHg (Bullock, Chestnut, Clifton, 1995), as stated in the study. Second, the draining of cerebrospinal fluid (CSF) -this decreases ICP. As stated in the study, according to the Brain Trauma Foundation, American Association of Neurological Surgeons, the Joint Section on Neurotrauma and Critical Care (2000), the first step to reduce intracranial hypertension is through ventricular drainage. As early as 1960, Lund demonstrated that removal of CSF via ventriculostomy temporarily decreases ICP (Lund, 1960). Draining as little as 3ml of CSF was found to decrease ICP by 10.1% relative to the baseline value of 10 minutes in 58 patients with severe TBI (Kerr, Weber, Sereika, Wi lberger, Marion, 2001). Protocols for CSF diversion range from time- dependent (leave drainage open for 5 minutes, then close), CSF-volume-dependent (drain 5cc then close), to continuous drainage (open all the time, closed at intervals to obtain an accurate ICP reading). This is supported by Monroe- Kellie hypothesis stating that a normal ICP can be maintained as one component in the cranial compartment (brain, blood and CSF) increases as long as there is a corresponding decrease of another component- therefore, decrease of one component decreases ICP. Third is not inducing hyperventilation to decrease ICP. Hyperventilation was routinely used to manage severe TBI. Studies done in the 1990s demonstrated the vasoconstriction associated with hyperventilation also resulted in decrease cerebral blood flow (CBF), thus, it is recommended to maintain normocapnia in most patients with severe TBI (Brain Trauma Foundation et al., 2007). Fourth is administering sedation- it prevents ICP increa ses. A study of 17 patients with severe TBI found ICP was significantly higher and there was a significant decrease in CPP with endotracheal suctioning among patients who were inadequately sedated compared to those patients who were well- sedated with proforol (Gemma et al., 2002) According to the study, a randomized controlled trial of 42 patients with TBI found the use of Proforol (rather than morphine) resulted in significantly lower ICPs by post- injury day 3, with less use of neuromuscular blockers, benzodiazepines, and barbiturates and less CSF drainage was required ( Kelly et al., 1999). Fifth is administration of Mannitol is effective in decreasing ICP. Guidelines for Management of Severe TBI, 3rd Edition states, mannitol is effectice for control of raised ICP at doses of 0.25 gms/kg to 1.0 gm/kg body weight (Brain Trauma Foundation et al., 2007). The diuretic effect of mannitol can cause increase Na+ and serum osmolarity levels, this should be monitored at regular intervals . Mannitol is infused via IV bolus through a filter. Mannitol 20% contains 20g of mannitol in 100cc. 80% of 100g dose appears in the urine within 3 hrs. of infusion. Sixth is to elevate head of bed (HOB) 30 degrees to maintain or decrease ICP- this is thought to promote intracranial venous return and increase CSF drainage from the head, resulting in decreased ICP (Fan, 2004). Four controlled studies with sample sizes ranging from 5- 38 patients with severe TBI found significant decreases in ICP with HOB elevations of 30 degrees (Moraine, Berrà ©, and Mà ©lot, 2000; Ng, Lim, Wong, 2004; Schulz- Subner Thiex, 2006; Winkleman, 2000). Seventh is removing or loosening rigid cervical collars- according to the study, it may decrease ICP. These collars may hold back venous blood flow and cause pain and discomfort, elevating ICP. Eight is administering intensive insulin therapy- it may reduce ICP. Hyperglycemia is common in severe TBI and has a negative effect on outcome. A study was con ducted with a result of lower mean and minimal ICPs to those treated with intensive insulin therapy to maintain glucose levels lower than 110 mg/dl than in subjects treated with insulin only when their glucose levels exceeded 220 mg/dl. The ninth is maintenance of normothermia- it may prevent ICP increases. Hyperthermia is prevalent in the TBI population, as high as 68% within 72 hours of injury (Rumana, Gopinath, Uzura, Valadka, Robertson, 1998). There have been no long- term outcome studies in the effect of normothermia in TBI, but a study found an increase in brain temperature was associated with significant increase in ICP; as fever ebbed, there was significant decrease in ICP. In controversial treatments for refractory intracranial hypertension, first is the inducing of moderate hypothermia- it may decrease ICP in refractory intracranial hypertension. There are multiple human studies that have demonstrated decreased ICP with the induction of moderate hypothermia (33-36 degrees Celsius) in patients with severe TBI (Clifton, Miller et al., 2001; Marion, Obrist, carlier, Penrod, Darby, 1993; Polderman, Tjong Tjin, Peerdeman, Vandertop Girbes 2002; Tokutomi, Miyagi, Morimoto, karukay, Shigemori, 2004; Tokutomi et al., 2003). Second is admistering hypertonic saline. Third is the administration of high- dose barbiturates- are thought to suppress cerebral metabolism, reducing cerebral metabolic demand and cerebral blood volume. In maintaining adequate CPP or increasing CPP, first is maintaining CP b/w 50- 70mmHg- optimized cerebral perfusion (Brain Trauma Foundation et al., 2007). Second is administering norepinephrine, it may maintain adequate CPP or increase CPP. Third is elevating HOB 30 degrees- not only it increases venous drainage from head, it also can decrease perfusion. Fourth is CSF drainage- the decreasing volume of CSF decreases total intracranial volume. In preventing DVT, pharmacologic treatment may be safe for DVT prophylaxis. Agency for healthcare Research and Quality recommends use of prophylaxis to prevent venous thromboembolism for at- risk patients. In adequate nutrition, first initiating nutrition within 72 hours of injury- according to the study, it may improve outcomes. It is recommended that patients be fed so that full caloric requirements are met by post injury day 7 (Brain Trauma Foundation et al., 2007). Second is providing continuous intragastric feeding- it may improve tolerance. According to the study, continuous feeding was better tolerated and achieved 75% of nutritional goals faster than bolus feeding in 152 consecutive patients admitted to neurosurgical intensive care units (20% of whom had sustained severe TBI; Rhoney, Parker, Formean, yap, Coplin, 2002). In preventing seizures, administering antiepileptic drugs decreases incidence of early posttraumatic seizures. Guidelines for the Management of Severe TBI, 3rd Edition recommends the use of anticonvulsants to decrease the incidence of post traumatic seizure within the fisrt 7 days of injury when the brain is particularly vulnerable to secondary injury- involves multiple metabolic mechanisms that result from interruption of blood flow and oxygen to undamaged cells, producing anaerobic metabolism, inadequate synthesis of ATP, or cellular acidosis. Then continuous EEG monitoring has been used to identify a 20% seizure incidence with 50% of patients identified as non-convulsive (Vespa Nuwer, 2000) Reference: Nursing Management of Adults with Severe Traumatic Brain Injury, AANN Clinical Practice Guidelines Series