Nonverbal Communication Essay

Theoretical The objective of this examination was to see whether instructors were showing nonverbal correspondence in their study hall, and furthermore in the event that it was critical to show nonverbal correspondence in the study hall. Educators have an assortment of showing styles, and methods. A few instructors utilizing nonverbals and some don't. Be that as it may, now and again class size, arrangement levels, and sexual orientation can make educators either utilize nonverbal correspondence or not. The members of this investigation were asked whether their instructor utilize various kinds of nonverbal correspondence in the study hall setting. The investigation found that understudies said most educators in their classes utilize nonverbal correspondence to instruct. This investigation additionally offers help of the significance nonverbal correspondence has when educating. Nonverbal correspondence in the homeroom: An examination about the significance of showing nonverbal correspondence Correspondence as a rule is the way toward sending and getting messages that empowers people to share information, mentalities, and aptitudes. In spite of the fact that we typically recognize correspondence with discourse, correspondence is made out of two measurements, which are verbal and nonverbal. Nonverbal correspondence has been characterized as correspondence, yet just with no words. Conveying isn't something we can simply manage without, nonverbal correspondence particularly considering it can never be stopped, not normal for verbal correspondence we are continually imparting nonverbally. One can't not impart. Nonverbal correspondence is consistently around you and difficult to overlook. Exploration, in numerous investigations, has demonstrated that nonverbal correspondence can serve a wide scope of capacities in human association. Nonverbal correspondence is a basic piece of consistently life. Regardless of if at work, school, or even at home, nonverbal correspondence assumes a gigantic job throughout everyday life. As Blatner (2002) says, â€Å"Often individuals can't comprehend the effect of nonverbal interchanges associated with a circumstance except if it is replayed and figured out† (pg.3). Instructors should practice and showing nonverbal correspondence in the homeroom regular, and that by doing so understudies will turn out to be greatly improved communicators. Nonverbal correspondence procedures are essential to the advancement of a viable instructive framework. Nonverbal correspondence ought to be drilled in a greater number of classes than just correspondence classes, on the grounds that regardless of what major of study you are in correspondence is continually going to be a basic thing to know. Numerous social researchers have led research in the field of nonverbal correspondence as it influences understudies and instructors. Ritchie (1977) found that seven percent of correspondence is nonverbal. Voice enunciation represents 38% of the message, and outward appearance, including â€Å"body language,† imparts 55% of the message. Speer (1972) states that on the grounds that 90% of the all out effect of a message can emerge out of nonverbal components, honing nonverbal relational abilities really want to make an individual a superior communicator. So for what reason are not all educators utilizing this technique for instructing in the homeroom setting? That is one of the inquiries I might want to reply in my exploration. This paper will work to decide whether nonverbal correspondence is fundamental to be educated in the study hall and the significance of the instructing of nonverbal correspondence. Writing Review Exploration has been examined, by a wide range of academic analysts, about nonverbal correspondence and the significance of why it ought to be instructed to understudies in their learning vocation. Nonverbal correspondence can be characterized as marking, images, hues, motions, rhythms, and substantially more. Those are only a couple of models that will be talked about (Ritchie 1977). Speer (1972) accepts that it is critical to realize all the various approaches to impart nonverbally and clarifies those routes in the book. Speer (1972) additionally underlines on the way that so as to impart, you should initially recognize what nonverbal correspondence really is. Pilner, Alloway, and Krames (1974) anyway look at how people and creatures impart distinctively nonverbally and the significance of knowing the various ways, and they additionally call attention to how people and creatures can convey likewise nonverbally too. Ethology is the method of considering conduct among individuals. We itz (1974) alludes to ethology as an approach to lead research, realizing how to examine various people groups conduct is fundamental to know before seeing how individuals act. Visual associations are additionally methods of contemplating nonverbal correspondence in the homeroom, as indicated by Weitz (1974). As indicated by Molcho (1985), nonverbal correspondence is basic in the study hall setting, particularly in relational correspondence. The most solid messages instructors produce are supposed to be nonverbal. Duggan (2012) talks about the entirety of the diverse nonverbal signs and why they are significant. For instance, he expresses the significance of outward appearances, motions, and appearance. Similarly Carli (1995), Mayo &Henley (1981) and Thompson (2012) have various articles about contrasts among people and the various musings they have on nonverbal correspondence. He likewise talks about various examination situations in which exploration has been directed to demonstrate the significance of nonverbal correspondence, and why people convey contrastingly here and there. Region of Study Nonverbal correspondence assumes an enormous job in the study hall, and how instructors ought to utilize nonverbal correspondence. (Pliner 1974) This paper is an examination planned to help comprehend why nonverbal correspondence is so significant in educating, and what those importance’s are. Instructors ought to utilize nonverbal correspondence regularly, in each course regardless of what the major of study is. I need to research to check whether instructors are utilizing nonverbal relational abilities in the homeroom condition, and if so how they are utilizing them. My theory is that yes I accept educators are utilizing nonverbal correspondence as a method of instructing in their study hall. In the event that the appropriate response is no in any case, I will explore why instructors are not utilizing nonverbal correspondence in their consistently showing strategies, and if there are explanations for why they are not utilizing it. I will lead reviews in class to check whether understudies accept instructors are showing enough nonverbal correspondence, and in the event that they trust it is critical to find out about. I would ask, does nonverbal correspondence assume a job in the study hall? For example, is nonverbal correspondence significant in the study hall setting, regardless of whether it be the manner by which the instructor dresses, addresses, stands, and so on. I likewise need to see whether instructors are showing enough nonverbal correspondence to their understudies. Are understudies increasing enough information about nonverbal correspondence while in the homeroom setting? Likewise, I might want to discover, what is the significance of nonverbal correspondence. For what reason should we study this and for what reason do we have to become familiar with this examination for our entire vocations. At last, what might a study hall setting resemble with zero nonverbal correspondence? This comprises of no eye to eye connection, appearance codes, signal, or some other sort of nonverbal correspondence conduct. The accompanying exploration questions and theories control the current investigation: H1: Students accept educators are utilizing nonverbal correspondence to speak with them consistently. H2: There is no distinction between what guys accept educators use in the study hall and what females accept. H3: All ages accept something very similar with regards to how frequently their educators convey nonverbally and how they are imparting along these lines. RQ1: Does nonverbal correspondence assume a job in the study hall? RQ2: Are educators showing enough nonverbal correspondence to their understudies? Procedure Instrument I utilized the comfort type inspecting technique. (see supplement A) This is a nonrandom sort testing; in which I utilized volunteers in my group to take my overview. The study contained nine inquiries. Members were posed nine inquiries about how their educators utilize diverse nonverbal relational abilities to speak with them. The understudies were approached to stamp yes or no in the event that the educator utilized those specific styles of nonverbals while instructing, Students were additionally posed some segment inquiries: sex, characterization, and age. I utilized proof by Wilmont (1995), about exploration of nonverbal correspondence to think of my examination questions. I built up my inquiries cautiously before picking what the correct inquiries were to pose. I contemplated questions that could be valuable to my examination and that would assist me with building up the outcomes I required so as to demonstrate or refute my subject. I pick addresses that wouldn’t be hosti le to anybody, with the goal that everybody could take part. I was attempting to discover the hugeness of nonverbal correspondence being utilized and instructed in the study hall setting. Members I had twenty-five understudies in my exploration correspondence class partake in my overview. There were fourteen guys and eleven females who took an interest, anyway sexual orientation doesn’t have quite a bit of an effect on my examination. The ages for my review went from nineteen to twenty-three years of age. The entirety of the understudies who took my overview were in a correspondence field. I directed my overview and dispersed it during our group hour, alongside every other person. I dispersed my reviews on Thursday October eighteenth, 2012. I circulated my overview to every part in the class straight request. I just passed my review out line by column to each class part, and when everybody got my study they started taking it. At the point when the class was finished taking my review they continued to the front of the homeroom and put my studies in a heap for me to get. I at that point investigated the entirety of my outcomes soon thereafter. I caused a to exceed expectations report and experienced every individual paper and recorded my outcomes in to exceed expectations. I recorded the quantity of females and guys, class ra

Launching a New Product - Idioms in Context

Propelling a New Product - Idioms in Context This short story centers around the challenges of propelling another item, or presenting another thought. Gain from the definitions accommodated the figures of speech and articulations presented following the story and check your comprehension with a short test. Try to peruse for essence the clench hand time. Propelling a New Product - Story Attempting to dispatch another item can be an overwhelming assignment. Indeed, its so hard that the vast majority have no backbone and before long quit any pretense of understanding that theyll need to cut their misfortunes and acknowledge rout. There are numerous explanations behind these challenges, not least of which is that extremely new thoughts frequently go against most people groups desires. Simply recall the days prior to the wireless. Im sure the organization that made that first tremendous, substantial versatile telephone confronted a great deal of restriction to their item. Who at any point thought marry wind up conveying telephones in our pockets that have additionally serve as our own advanced assistants?!â So as to keep the ball rolling, a business visionary or anybody with another thought will most likely need to cause some disruption the push for progress. This capacity to attack imaginary enemies is like the capacity to totally disregard what, at that point, must appear evident exhortation. Its this skill for faith regardless of uncertainty that achievement relies on. Without a practically strict conviction, its difficult to proceed with the request for the day of promoting your item. This is particularly evident when a CEO or some other significant corporate smarty pants is looking blades at you as they put you through some serious hardship for regularly having idea of such an idiotic thought. At that point obviously, there are the individuals who toss a distraction into the discussion as you make your pitch to potential financial specialists. Be that as it may, at long last, you wont need to hard offer your item to the individuals who get it. Theyll perceive your motivation and go ahead despite any potential risks to get the train of your virtuoso! That is the day youll kick off your drive to progress. Definitions cut ones misfortunes - acknowledge that you have lost and quitfly even with something - be in opposition to what a few thoughts appear to provehard sell something - attempt to drive somebody into purchasing something by causing them to accept that they have to get it NOW!have no fortitude - not have the option to keep going a long timehinge on something - be needy after something different happeningkeep the ball rolling - keep supporting something by doing what is necessarykick off - start something, typically a business campaignlook blades at somebody - take a gander at somebody with serious hatredmake a pitch - acquaint a business thought with somebody, attempt to sell somethingorder of the day - the most significant thing that should be done on an agendarake somebody over the coals - firmly condemn somebody for accomplishing something wrongred herring - a contention which is acquainted into a conversation with abstain from looking at something more importantruffle someones plumes - affront someonethrow alert to the breeze - take a risk in spite of the risktilt at windmills - neutralize inconceivable chances, attempt to keep accomplishing something that is impeded by others Maxims Quiz Lets keep ______________ on this task. I dont figure we ought to stop just yet.Any craftsman will reveal to you that before progress comes youll regularly feel as though are ______________.He needed to acknowledge rout, ______________ his ______________ and close the business. She ______________ her significant other ______________ for his mix-ups that cost them thousands.Im apprehensive that thought has ______________. Itll never work out.Stop ______________ me! I didnt do anything incorrectly, and I didnt intend to annoy you.Peter realized that he was bringing a ______________ into the discussion, however he didnt need the venture to move forward.Im apprehensive that ______________ all that I know. It cannot be true. Our achievement ______________ getting an interest in this venture. Without reserves, were lost. Id like to ______________ at the following financial specialists meeting. Do you think theyll have the opportunity to tune in to my proposition? Test Answers the ball rollingtilting at windmillscut his lossesraked her significant other over the coalslooking blades atred herringflies in the face ofhinds onmake a pitch Learn more figures of speech in setting with further stories.

Mirror By Silvia Plath Essays - American People Of German Descent

Mirror By Silvia Plath Essays - American People Of German Descent Mirror By Silvia Plath By simply perusing the significant sonnet Mirror by Silvia Plath I am as of now in a snapshot of shortcoming. As clich as it may sound, it is completely evident. It is one of those pieces that will pull you in profound, however wont discharge until it is all set. It is that telling. It talks reality. By genuinely acknowledging what Sylvia has introduced, I will attempt to decipher each line. She initially portrays the mirror, it doesnt generalization, and whatever approaches is impartial. The picture rapidly shows up without a trace of re-thinking, the mirror doesn't excuse or like the picture, again it remains unbiased. It doesnt fuel the article just observes and regurgitates it back the manner in which it is. These last subtleties given by Plath are incredibly splendid. There is a dream of a lady twisting around, attempting to change her blemishes, some way or another creation them less obvious. Causing the mirror to appear to be an insidious, Plath recommends it resembles a simple light or moon, where there is riddle present, and no indication of truth is to be told. Again there is another straightforward picture, a picture effectively demonstrated honestly, and the effortlessness of a back of a lady. The sonnet says dependably provoking the discussing reality, prompting supreme disillusionment. Before long there are tears created, She compensates me scarcely. Sure the tears discuss compensating dependent on genuinely and honesty. Not founded on content with the picture. The most significant line of this piece is I am imperative to her. She travels every which way. This is perfectly put. This is very significant yet so natural to identify with. There is a need of having a mirror. It talks the brutal truth of society. It demonstrates what to address, what to excuse. I genuinely grasp the last two lines of this sonnet. Despite the fact that the mirror is the articulate adversary, the lady returns over and again. This shows the amount it is required. A long time pass by gazing at this article searching for answers. Obviously, the lady didnt take the genuineness smoothly; she subsequently matured to a horrendous fish. This was a very philosophical and profound piece. I end up identifying with each line somehow. The vast majority do. It was unfortunate, however ruthlessly legitimate.

Mattel Case Stusy - Free Essay Example

BUSINESS ETHICS ASSIGNMENT 1 STUDENT NAME: THUY LINH NGUYEN NOI3002 I. DO MANUFACTURES OF PRODUCTS FOR CHILDRENS HAVE SPECIAL OBLIGATIONS TO CONSUMERS AND SOCIETY? IF SO, WHAT ARE THESE RESPONSIBILITIES? Because of the company’s product and designs primary for children, it must be sensitive to social concern about children’s right: By assuring parents that their children’s privacy will be respected, Mattel demonstrated that it takes its responsibility of marketing to children seriously. In 2007, Mattel conduct entitled Global Manufacturing principles. In this principle, Mattel’s business partners must ensure high standard for product safety and quality, adhering to practices that meet Mattel’s safety and quality standards, make sure that the entire product will not be harmful to the children. Partners must also comply with all import and export regulation and they must strictly adhere to local and international customs law. An example of Mattel r esponsibility to the children is the Mattel children foundation which is found in 1998. The gift was mean to support the existing hospital and provide for a new state-of-art-facility. To the society, the company is not using any child labor, forced labor or uses any type of that labor itself. The company stated that it does not tolerate discrimination, the employee should be hire according to their ability to complete the job, not their believe or characteristics II. HOW EFFECTIVE HAS MATTEL BEEN AT ENCOURAGING ETHICAL AND LEGAL CONDUCT BY ITS MANUFACTURERS? WHAT CHANGES AND ADDITIONS WOULD YOU MAKE TO THE COMPANY’S GLOBAL MANUFACTURING PRINCIPLE? All partners must respect the intellectual property of the company, and support Mattel in the protection of asset. Mattel always required its business partner s to commit with their high ethical standards for product safety and quality. But in recent years, some standards have been seriously violated, such as using child labor in some overseas company. Those companies were later on asked to change their operation or risk losing Mattel’s business or being punished by legal department or suited by Mattel or the customers. In order to encourage their partner, they also conducted the Global Manufacturing Principles. Here are some of my recommendations for Mattel’s Global Manufacturing Principles: 1. Make sure the contractors and subcontractor use the right facilities for Mattel’s products. 2. Maintain the supervisor 3. All the products must be tested carefully to make sure that they not violated to any cultural ethic and ensure their safety III. TO WHAT EXTENT IS MATTEL RESPONSIBLE FOR ISSUES RELATED TO ITS PRODUCTION OF TOYS IN CHINA? HOW MIGHT HAVE MATTEL ADVOID THESE ISSUES? 007 was a bad year for Mattel. Despite Mattel’s best effort, not all oversea manufactures have faithfully adhered to its high standard, forcing Mattel to make two huge toys recall. The re called toys sol d by Mattel was for various health hazards. Among them were toys that contained magnets and lead paint Small magnets used in toys can fall out and be swallowed or aspirated. Intestinal or blockage can occur, if more than on magnet is swallowed. Lead is extremely toxic and can create numerous health problems when swallowed or inhaled in large level. The paint used in recalled products was not certified for use according to Mattel standards. In my opinion, the Chinese contractors had violated the commitment between two companies by using lead paint. But, we cannot say that Mattel is not responsible for this issue. Firstly we should talk about its three points paint check system: 1. Mattel only use paint from certificated suppliers. Every batch from every vendor is tested. Any batches not passing the test will not be used. 2. The production process controls are for vendors and random unannounced inspections are implemented. . All finished toy produced are tested before they get to t he customers. As we can see, that a very strict check system but why those harmful toys could still pass through and went to the market? It’s clearly that using lead paint is bad but let those toys get to the customer isn’t it worst? If I own a car toy factory and I allow my neighbor to produce my car and my neighbor use toxic paint to paint them then we are both in the wrong. So both Mattel and the Chinese contractor are equally to blame. Mattel also have problems with their design, the magnet fall out too easy. As they are losing their reputation and subcontractors, Mattel should really do something to avoid these issues. In my opinion, firstly, Mattel should improve its design and carefully exam the toy before launch them out. Secondly, they should also improve their supervisor over the products and make sure all of them pass the high standards request. Thirdly, Mattel should investigate contractors and audit the subcontractor and if necessary, provide them the i nformation about their product high standard and safety. IV. SHOULD MATTEL RECEIVE CONTROL OF MGA’S BRAZT DOLLS? IF SO, WHAT ACTIONS SHOULD MATTEL TAKE REGARDING BRAZT? Brazt is really the first doll to successfully compete against the massively successful Barbie franchise in ages. The Brazt ranges of doll have affected the sale of Mattel’s leading product: Barbie and decreased by %6 The battle began when Mattel had an investigation and found out that: Carter Bryant, the designer of the Brazt range, who was then working for MGA, had conceived the ideas of Brazt while he was at Mattel. Matte then suited MGA to gain the control over Brazt. A judge earlier judged that MGA had develop the doll from the intellectual property that belonged to Mattel and so, he ordered that Mattel take over the manufacture and sale of the doll after the Christmas season. In my opinion, even if you state that the concept of the doll was created at Mattel, at best you could make an argume nt that Mattel had some right to an injunction and profit from the first generation of the doll. The judge not only ruled MGA to stop selling and manufacturing Brazt but also have to hand over all sort of confident info includes: all related product, customers’ info and especially the 2010 plan†¦ That is difficult to see any fairness at all for forcing them hand over the future plan that have nothing to do with the created while at Mattel. MGA was then faced a critical situation: they are forced to collect and destroy all Brazt dolls that are in the market. MGA had investigated it would have to spent about $10 million or $20 million to do so. But in December 9, the Ninth Circuit Court of Appeals essentially stopped the process. The court ruled the MGA can continue to sell their Brazt dolls that are currently on the market until the next judgment is made. The court also indicated that the order transferring ownership of the Bratz trademark and copyright from MGA to Mattel was drastic, and questioned why Mattel wasnt simply given a royalty or ownership stake in MGAs Bratz franchise. The appellate judges also ordered Mattel and MGA to mediation. In other words, the two companies should try to sort it out themselves. MGA then paid US $100 million (instead of US$500 million as Mattel sued MGA for) in damages, citing that only the first generation of Bratz had infringed on Mattel property and that MGA had innovated and evolved the product significantly enough that subsequent generations of Bratz could not be conclusively found to be infringing. I think that would be the best solution for both Mattel and MGA because Brazt has been in the market for a long time and is going to celebrate its 10th anniversary. Customers love Brazt and they don’t want to lose them or changed them. After this affair some customers say they don’t want Barbie anymore because Mattel was just being selfish and it seems like they simply trying to stop comp etition. As so, in my opinion, Mattel should work out a deal with MGA in which MGA can continue sell Brazt dolls as long as Mattel share in some of the profits. REFENRENCES: Case study 6, â€Å"Mattel responds to Ethical Challenges†, p3, 4,5,6,7. Mike Masnick, 2009, â€Å"Why Mattel Get Future Should Plans For New Bratz Dolls? †Accessed 1 May 5, 2010. ( https://www. techdirt. com/articles/20090527/0143345018. shtml) Bonnie Fitzgerald, â€Å"Made in China: Mattel Recalls toys for safety issues â€Å"accessed 1 May 5, 2010 (https://www. helium. com/items/608895-made-in-china-mattel-recalls-toys-for-safety-issues)

Welfare Policy - 845 Words

Description According to the US Census Bureau, about 274,000 people, or 10 percent of the population in Chicago, Illinois are living in deep poverty (Emmanuel, 2015). Despite its high poverty rates, welfare in Chicago has always been small by any measure. At its peak in the 1990s, only 5 million families received assistance, averaging less than $400 a family (Piven, 2002). Frances Fox Piven believes that â€Å"changes in welfare were related to shifts that were occurring in a range of American social policies† (Piven, 2002). In July 1996, current welfare policies were replaced with Temporary Assistance to Needy Families (TANF) which provided block grants to the states for cash assistance (Piven, 2002). The goal of this policy was to â€Å"end†¦show more content†¦McDonald believes that this is due to the spatial concentration of urban poverty, and is a serious social problem. He discusses the reasons to believe that it’s worse to have the population in povert y concentrated in a few locations rather than in a general, dispersed pattern. He states that the economic and social environments of high-poverty areas are harmful to the residents. The social environment consists of ghetto culture, lack of role models, underfunded schools, and several more issues. The second reason he suggests is that high-poverty areas lead to decline as middle-class residents move elsewhere, which harms the neighborhood and the central city. The final reason he states is that the quality of life for residents of poor neighborhoods is dreadful (McDonald, 2003). 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The Role of the Teacher in Reporting Cases of Child Abuse...

Child abuse is a growing problem that affects children of all genders, ages, races, religions, and classes. It generally can be defined as â€Å"the non-accidental physical, sexual or mental injury or neglect caused by basic omissions of the child’s parents or caretakers†(Colorado State Department of Education, 1998). Narrowing the causes of child abuse to one in particular would be impossible, due to the wide range of factors that contribute. Today, teachers hold an important and unique position, for they are required to have an understanding of the laws and regulations in which to detect and report any suspected cases of child abuse. In Baltimore County, there have been recent efforts to train and educate public school employees on the†¦show more content†¦The DSS has outlined warning signs of physical abuse as follows: â€Å"bruises on the face in an unusual pattern, black eyes with no injury to the nose, burns from hot implements such as: a curling ir on, rope, hot liquid, cigarettes (crater shaped on hands), welts, cuts, abrasions, fractures, internal injuries, combined with other warning signs, or any injury that does not seem likely to have resulted from normal activity† (BC DSS, 2000). A teacher would have extreme suspicion that a child has been abused if one or more of the warning signs are present combined with abnormal behavior. Children who are physically abused will often be overly shied, obedient, or aggressive. They tend to avoid physical parental contact, and will change their story about reasons for their injury. 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The topic I have selected for this paper is child abuse and neglect. In this paper I will provide information of the findings for four different articles, I will include results provided by each article, finding similarities or dissimilarities. TheRead MoreMandated Reporting Laws : The Most Vulnerable Individuals Are Found Within The Elderly And Children Population1322 Words   |  6 PagesMandated Reporting Laws The most vulnerable individuals are found within the elderly and children population. Children can be impacted tremendously when experiencing situations that may affect their emotional, physical, and mental stage. Abuse can be seen in different forms such as sexual, emotional, physical abuse, and neglect. If any child is exposed to any of these abuse, it is the law to reach out to the proper authorities in order to protect the child’s life. Each state has its own mandatedRead MoreChild Abuse And Its Effects On Children1708 Words   |  7 Pagesaverage between four and seven children every day to child abuse and neglect (childhelp.org). Child abuse is a problem that can prevented with treatment programs and education for schools where teachers and administration can learn how to detect abuse. They may not be able to tell if a child is being physically, emotionally, sexually abused, or neglected but can be instrumental in alerting authorities if they suspect mistreatment. Child abuse and neglect is commonly passed down through generations; thereforeRead MorePreventing Child Abuse And Maltreatment1293 Words   |  6 Pagespreventing child abuse and maltreatment. In a child’s ecological system, the microsystem is important because it has direct contact with the child. 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The homework consisted of mathematical problems, a short reading and answer question, and memorizing the 50 Capitals of the United States. All the assignments for homework were due on Friday morning, so he quickly finished his homework so he could get to bed. Around 10:00 pm, David’s father came home from work, checked his son’s homework and saw many errors. He immediately went up toRead MoreChild Abuse- a Child Called It1727 Words   |  7 PagesUnfortunately, child abuse is one of the major issues that our country is plagued with, yet we neglect to bring this to the attention of the entire nation. It is often over looked because everyone has a different view of what exactly defines child abuse. The International Child Abuse Network (ICAN) uses four basis catigories to docunment the child abuse cases. They are: emotional abuse, neglect, physical abuse, and sexual abuse. I will be describing the first three. Emotional Abuse, (also knownRead MoreEssay Child Abuse in A Child Called It by Dave Pelzer1710 Words   |  7 PagesUnfortunately, child abuse is one of the major issues that our country is plagued with, yet we neglect to bring this to the attention of the entire nation. It is often over looked because everyone has a different view of what exactly defines child abuse. The International Child Abuse Network (ICAN) uses four basis categories to docunment the child abuse cases. They are: emotional abuse, neglect, physical abuse, and sexual abuse. I will be describing the first three. Emotional Abuse, (also knownRead MoreCritical Incident Scenario Essay1429 Words   |  6 Pagesthat her uncle was touching her in her private parts when no one was watching. The teacher was so confused to what to do when he read Bianca’s journal, especially because he was wondering if it was appropriate for him to ask her questions about it. The teacher was concern that due to being a male that the student was going to feel uncomfortable if he were to ask her about what she had wrote in her journal. The teacher did know what to do and he was so confused because he was reading and grading the

Nursing Care Plan free essay sample

While various mechanisms may cause TBI, the most common causes include motor vehicle accidents (eg, collisions between vehicles, pedestrians struck by motor vehicles, bicycle accidents), falls, assaults, sports-related injuries, and penetrating trauma. Motor vehicle accidents account for almost half of the TBIs in the United States, and in suburban/rural settings, they account for most TBIs. In cities with populations greater than 100,000, assaults, falls, and penetrating trauma are more common etiologies of head injury. The male-to-female ratio for TBI is nearly 2:1, and TBI is much more common in persons younger than 35 years. Diagnostic Procedures: The physical examination and the history of the exact details of the injury are the first steps in caring for a patient with head injury. The patients past medical history and medication usage will also be important factors in deciding the next steps. Plain skull X-rays are rarely done for the evaluation of head injury. It is more important to assess brain function than to look at the bones that surround the brain. Plain X-ray films may be considered in infants to look for a fracture, depending upon the clinical situation. Computerized tomography (CT) scan of the head allows the brain to be imaged and examined for bleeding and swelling in the brain. It can also evaluate bony injuries to the skull and look for bleeding in the sinuses of the face associated with basilar skull fractures. CT does not assess brain function, and patients suffering axonal shear injury may be comatose with a normal CT scan of the head. Numerous guidelines exist to give direction as to when a CT should be completed in patients who present awake after sustaining a minor head injury. The Ottawa CT head rules apply to patients age 2 to 65. High Risk †¢Glasgow Coma Scale less than 15, two hours after injury ? †¢Suspect open or depressed skull fracture ? †¢Sign of basilar skull fracture ? †¢Vomiting more than once ? †¢Older than 65 years of age Medium Risk †¢Amnesia before impact greater than 30 minutes? †¢Dangerous mechanism of injury Signs, Symptoms, and Course of the Disease/Disorder: It is important to remember that a head injury can have different symptoms and signs, ranging from a patient experiencing no initial symptoms to coma. A high index of suspicion that a head injury may exist is important, depending upon the mechanism of injury and the initial symptoms displayed by the patient. Being unconscious, even for a short period of time is not normal. Prolonged confusion, seizures, and multiple episodes of vomiting should be signs that prompt medical attention is needed. In some situations, concussion-type symptoms can be missed. Patients may experience difficulty concentrating, increased mood swings, lethargy or aggression, and altered sleep habits among other symptoms. Medical evaluation is always wise even well after the injury has occurred. Treatment and Prognosis: The treatment of head injury may be divided into the treatment of closed head injury and the treatment of penetrating head injury. While significant overlap exists between the treatments of these 2 types of injury, some important differences are discussed. Closed head injury treatment is divided further into the treatment of mild, moderate, and severe head injuries. Mild head injury Most head injuries are mild head injuries. Most people presenting with mild head injuries will not have any progression of their head injury; however, up to 3% of mild head injuries progress to more serious injuries. Mild head injuries may be separated into low-risk and moderate-risk groups. Patients with mild-to-moderate headaches, dizziness, and nausea are considered to have low-risk injuries. Many of these patients require only minimal observation after they are assessed carefully, and many do not require radiographic evaluation. These patients may be discharged if a reliable individual can monitor them. Patients who are discharged after mild head injury should be given an instruction sheet for head injury care. The sheet should explain that the person with the head injury should be awakened every 2 hours and assessed neurologically. Caregivers should be instructed to seek medical attention if patients develop severe headaches, persistent nausea and vomiting, seizures, confusion or unusual behavior, or watery discharge from either the nose or the ear. Patients with mild head injuries typically have concussions. A concussion is defined as physiologic injury to the brain without any evidence of structural alteration. Concussions are graded on a scale of I-V. A grade I concussion is one in which a person is confused temporarily but does not display any memory changes. In a grade II concussion, brief disorientation and anterograde amnesia of less than 5 minutes duration are present. In a grade III concussion, retrograde amnesia and loss of consciousness for less than 5 minutes are present, in addition to the 2 criteria for a grade II concussion. Grade IV and grade V concussions are similar to a grade III, except that in a grade IV concussion, the duration of loss of consciousness is 5-10 minutes, and in a grade V concussion, the loss of consciousness is longer than 10 minutes. As many as 30% of patients who experience a concussion develop postconcussive syndrome (PCS). PCS consists of a persistence of any combination of the following after a head injury: headache, nausea, emesis, memory loss, dizziness, diplopia, blurred vision, emotional lability, or sleep disturbances. Fixed neurologic deficits are not part of PCS, and any patient with a fixed deficit requires careful evaluation. PCS usually lasts 2-4 months. Typically, the symptoms peak 4-6 weeks following the injury. On occasion, the symptoms of PCS last for a year or longer. Approximately 20% of adults with PCS will not have returned to full-time work 1 year after the initial injury, and some are disabled permanently by PCS. PCS tends to be more severe in children than in adults. When PCS is severe or persistent, a multidisciplinary approach to treatment may be necessary. This includes social services, mental health services, occupational therapy, and pharmaceutical therapy. After a mild head injury, those displaying persistent emesis, severe headache, anterograde amnesia, loss of consciousness, or signs of intoxication by drugs or alcohol are considered to have a moderate-risk head injury. These patients should be evaluated with a head CT scan. Patients with moderate-risk mild head injuries can be discharged if their CT scan findings reveal no pathology, their intoxication is cleared, and they have been observed for at least 8 hours. Moderate and severe head injury The treatment of moderate and severe head injuries begins with initial cardiopulmonary stabilization by ATLS guidelines. The initial resuscitation of a patient with a head injury is of critical importance to prevent hypoxia and hypotension. In the Traumatic Coma Data Bank study, patients with head injury who presented to the hospital with hypotension had twice the mortality rate of patients who did not present with hypotension. The combination of hypoxia and hypotension resulted in a mortality rate 2. 5 times greater than if neither of these factors was present. Once a patient has been stabilized from the cardiopulmonary standpoint, evaluation of their neurologic status may begin. The initial GCS score provides a classification system for patients with head injuries but does not substitute for a neurologic examination. After assessment of the coma score, a neurologic examination should be performed. If a patient has received muscle relaxants, the only neurologic response that may be evaluated is the pupillary response. After a thorough neurologic assessment has been performed, a CT scan of the head is obtained. The results of the CT scan help determine the next step. If a surgical lesion is present, arrangements are made for immediate transport to the operating room. Fewer than 10% of patients with TBI have an initial surgical lesion. Although no strict guidelines exist for defining surgical lesions in persons with head injury, most neurosurgeons consider any of the following to represent indications for surgery in patients with head injuries: extra-axial hematoma with midline shift greater than 5 mm, intra-axial hematoma with volume greater than 30 mL, an open kull fracture, or a depressed skull fracture with more than 1 cm of inward displacement. In addition, any temporal or cerebellar hematoma that is larger than 3 cm in diameter is considered a high-risk hematoma because these regions of the brain are smaller and do not tolerate additional mass as well as the frontal, parietal, and occipital lobes. These high-risk temporal and cerebellar hematomas are usually evacuated immediately If no surgical lesion is present on the CT scan image, or following surgery if one is present, treatment of the head injury begins. The first phase of treatment is to institute general measures. Once appropriate fluid resuscitation has been completed and the volume status is determined to be normal, intravenous fluids are administered to maintain the patient in a state of euvolemia or mild hypervolemia. A previous tenet of head injury treatment was fluid restriction, which was believed to limit the development of cerebral edema and increased ICP. Fluid restriction decreases intravascular volume and, therefore, decreases cardiac output. A decrease in cardiac output often results in decreased cerebral flow, which results in decreased brain perfusion and may cause an increase in cerebral edema and ICP. Thus, fluid restriction is contraindicated in patients with TBI. Another supportive measure used to treat patients with head injuries is elevation of the head. When the head of the bed is elevated to 20-30 °, the venous outflow from the brain is improved, thus helping to reduce ICP. If a patient is hypovolemic, elevation of the head may cause a drop in cardiac output and CBF; therefore, the head of the bed is not elevated in hypovolemic patients. In addition, the head should not be elevated (1) in patients in whom a spine injury is a possibility or (2) until an unstable spine has been stabilized. Sedation is often necessary in patients with traumatic injury. Some patients with moderate head injuries have significant agitation and require sedation. In addition, patients with multisystem trauma often have painful systemic injuries that require pain medication, and many intubated patients require sedation. Short-acting sedatives and analgesics should be used to accomplish proper sedation without eliminating the ability to perform periodic neurologic assessments. This requires careful titration of medication doses and periodic weaning or withholding of sedation to allow periodic neurologic assessment. Intravenous lidocaine administered along with rapid sequence induction before endotracheal intubation is not associated with significant hemodynamic changes in traumatic brain injury patients. [9] The use of anticonvulsants in patients with TBI is a controversial issue. No evidence exists that the use of anticonvulsants decreases the incidence of late-onset seizures in patients with either closed head injury or TBI. Temkin et al demonstrated that the routine use of Dilantin in the first week following TBI decreases the incidence of early-onset (within 7 d of injury) seizures but does not change the incidence of late-onset seizures. [10] In addition, the prevention of early posttraumatic seizures does not improve the outcome following TBI. Therefore, the prophylactic use of anticonvulsants is not recommended for more than 7 days following TBI and is considered optional in the first week following TBI. After instituting general supportive measures, the issue of ICP monitoring is addressed. ICP monitoring has consistently been shown to improve outcome in patients with head injuries. ICP monitoring is indicated for any patient with a GCS score less than 9, any patient with a head injury who requires prolonged deep sedation or pharmacologic relaxants for a systemic condition, or any patient with an acute head injury who is undergoing extended general anesthesia for a nonneurosurgical procedure. ICP monitoring involves placement of an invasive probe to measure the ICP. Unfortunately, noninvasive means of monitoring ICP do not exist, although they are under development. ICP may be monitored by means of an intraparenchymal monitor, an intraventricular monitor (ventriculostomy), or an epidural monitor. These devices measure ICP by fluid manometry, strain-gauge technology, or fiberoptic technology. Intraparenchymal ICP monitors are devices that are placed into the brain parenchyma to measure ICP by means of fiberoptic, strain-gauge, or other technologies. The intraparenchymal monitors are very accurate; however, they do not allow for drainage of CSF. Epidural devices measure ICP via a strain-gauge device placed through the skull into the epidural space. This is an older form of ICP measurement and is rarely used today because the other technologies available are more accurate and more reliable. A ventriculostomy is a catheter placed through a small twist drill hole into the lateral ventricle. The ICP is measured by transducing the pressure in a fluid column. Ventriculostomies allow for drainage of CSF, which can be effective in decreasing the ICP. A risk of symptomatic hemorrhage exists with entriculostomy placement, and Bauer et al report from a retrospective study that an international normalized ratio (INR) of 1. 2-1. 6 is an acceptable range for emergent ventriculostomy placement in patients with TBI. [11] Once an ICP monitor has been placed, ICP is monitored continuously. No absolute value of ICP exists for which treatment is implemented automatically. In adults, the reference range of ICP is 0-15 mm Hg. The normal ICP wavef orm is a triphasic wave, in which the first peak is the largest peak and the second and third peaks are progressively smaller. When intracranial compliance is abnormal, the second and third peaks are usually larger than the first peak. In addition, when intracranial compliance is abnormal and ICP is elevated, pathologic waves may appear. Lundberg described 3 types of abnormal ICP waves, A, B, and C waves. [12] Lundberg A waves, known as plateau waves, have a duration of 5-20 minutes and an amplitude of 50 mm Hg over the baseline ICP. After an episode of A waves dissipates, the ICP is reset to a baseline level that is higher than when the waves began. Lundberg A waves are a sign of severely compromised intracranial compliance. The rapid increase in ICP caused by these waves can result in a significant decrease in CPP and may lead to herniation. Lundberg B waves have a duration of less than 2 minutes, and they have an amplitude of 10-20 mm Hg above the baseline ICP. B waves are also related to abnormal intracranial compliance. Because of their smaller amplitude and shorter duration, B waves are not as deleterious as A waves. C waves, known as Hering-Traube waves, are low-amplitude waves that may be superimposed on other waves. They may be related to increased ICP; however, C waves can also occur in the setting of normal ICP and compliance. When treating elevated ICP, remember that the goal of treatment is to optimize conditions within the brain to prevent secondary injury and to allow the brain to recover from the initial insult. Maintaining ICP within the reference range is part of an approach designed to optimize both CBF and the metabolic state of the brain. Treatment of elevated ICP is a complex process that should be tailored to each particular patients situation and should not be approached in a cookbook manner. Many potential interventions are used to lower ICP, and each of these is designed to improve intracranial compliance, which results in improved CBF and decreased ICP. Acute treatment of increased intracranial pressure The Monro-Kellie doctrine provides the framework for understanding and organizing the various treatments of elevated ICP. In patients with head injuries, the total intracranial volume is composed of the total volume of the brain, the CSF, intravascular blood volume, and any intracranial mass lesions. The volume of one of these components must be reduced to improve intracranial compliance and to decrease ICP. The discussion of the different treatments of elevated ICP is organized according to which component of intracranial volume they affect. The first component of total intracranial volume to consider is the blood component. This includes all intravascular blood, both venous and arterial, and comprises approximately 10% of total intracranial volume. Elevation of the head increases venous outflow and decreases the volume of venous blood within the brain. This results in a small improvement in intracranial compliance and, therefore, has only a modest effect on ICP. The second component of intracranial vascular volume is the arterial blood volume. Hypocapnia is capable of reducing cerebral blood flow 4% for each mm Hg change in PaCO2. The control mechanism is probably extravascular pH changes in fluid bathing cerebral resistor vessels, which alter smooth muscle intracellular calcium concentrations. This may be reduced by mild-to-moderate hyperventilation, in which the PCO2 is reduced to 30-35 mm Hg. This decrease in PCO2 causes vasoconstriction at the level of the arteriole, which decreases blood volume enough to reduce ICP. The effects of hyperventilation have a duration of action of approximately 48-72 hours, at which point the brain resets to the reduced level of PCO2. This is an important point because once hyperventilation is used, the PCO2 should not be returned to normal rapidly. This may cause rebound vasodilatation, which can result in increased ICP. Below a PaCO2 of 25-30 Torr, CBF falls much less rapidly, presumably because of severe enough vasoconstriction to induce hypoxemia in brain tissues, limiting oxygen delivery. PaCO2 tensions less than 25 Torr are sufficient to change brain metabolism into anaerobic, which increases acidosis. Low arterial O2 tensions influence CBF but to a lesser degree than PaCO2. No measurable changes in CBF occur during hypoxemia until the PaO2 drops below 50 Torr, at which time CBF gradually increases. In addition to reducing CBF, the resultant respiratory alkalosis may reverse local tissue acidosis, which develops in cerebral edema, benefiting cellular respiration and restoring autoregulation. Within 48-72 hours, renal mechanisms for handling bicarbonate excretion compensate for altered PaCO2 tensions, thereby normalizing cerebral pH and returning CBF to baseline values. There are 3 paradoxes to hyperventilation therapy for the control of ICP. †¢Since cerebral vasospasm is a serious concern in subarachnoid hemorrhage (SAH), attempts to create further vessel constriction by hyperventilation in order to decrease concomitant cerebral edema are rarely indicated unless the amount of edema is clinically emergent. †¢Vessels in the damaged area of the brain have lost their autoregulatory control. While unaffected brain regions would vasoconstrict normally to the stimulus of decreased PaCO2, damaged areas might vasodilate in response to diminished cerebral blood flow. This can create a â€Å"reverse steal† phenomenon, where blood and nutrients are diverted away from â€Å"normal† areas of the brain and into â€Å"damaged† areas. This diversion would feed the increased metabolic requirement of damaged tissues, but the sum total effect may cause more harm to the rest of the brain. In addition, the increased hydrostatic pressure combined with the capillary permeability damage might, in some cases, paradoxically increase ICP in damaged areas. †¢Sudden increases in PaCO2, as a result of ventilator changes, often result in dramatic increases in CBF, and rapid deteriorations in the patient’s condition. During hyperventilation, the cerebral bicarbonate level gradually adjusts to offset the lower level of CO2, maintaining normal pH. If the pCO2 is allowed to rise suddenly, the excess CO2 rapidly crosses the blood-brain barrier, but the bicarbonate level in the brain increases much less rapidly. The result is cerebral acidosis, with attendant cerebral vascular dilatation, increased cerebral blood volume, and elevated ICP, usually resistant to further hyperventilation. Unfortunately, little objective evidence exists that treatment by hypocapnia has significantly improved mortality or survival. At best, it seems to be a temporary stop-gap measure until some other curative measure, such as surgery, might be attempted. Patients with the most prompt response to hyperventilation generally have the best prognosis for recovery. No evidence exists that hyperventilation therapy produces benefit in hypoxemic-anoxic encephalopathy. CSF represents the third component of total intracranial volume and accounts for 2-3% of total intracranial volume. In adults, total CSF production is approximately 20 mL/h or 500 mL/d. In many patients with TBI who have elevated ICP, a ventriculostomy may be placed and CSF may be drained. Removal of small amounts of CSF hourly can result in improvements in compliance that result in significant improvements in ICP. The fourth and largest component of total intracranial volume is the brain or tissue component, which comprises 85-90% of the total intracranial volume. When significant brain edema is present, it causes an increase in the tissue component of the total intracranial volume and results in decreased compliance and increased ICP. Treatments of elevated ICP that reduce total brain volume include diuretics, perfusion augmentation (CPP strategies), metabolic suppression, and decompressive procedures. Diuresis and brain edema Diuretics are powerful in their ability to decrease brain volume and, therefore, to decrease ICP. Mannitol, an osmotic diuretic, is the most common diuretic used. Mannitol is a sugar alcohol that draws water out from the brain into the intravascular compartment. It has a rapid onset of action and a duration of action of 2-8 hours. Mannitol is usually administered as a bolus because it is much more effective when given in intermittent boluses than when used as a continuous infusion. The standard dose ranges from 0. 25-1 g/kg, administered every 4-6 hours. Because mannitol causes significant diuresis, electrolytes and serum osmolality must be monitored carefully during its use. In addition, careful attention must be given to providing sufficient hydration to maintain euvolemia. The limit for mannitol is 4 g/kg/d. At daily doses higher than this, mannitol can cause renal toxicity. Mannitol should not be given if the patients serum sodium level is greater than 145 or serum osmolality is greater than 315 mOsm. Other diuretics that sometimes are used in patients with TBI include furosemide, glycerol, and urea. Mannitol is preferred over furosemide because it tends to cause less severe electrolyte imbalances than a loop diuretic. Interestingly, mannitol and furosemide have a synergistic effect when combined; however, this combination tends to cause severe electrolyte disturbances. Urea and glycerol have also been used as osmotic diuretics. Both of these compounds are smaller molecules than mannitol and, as a result, tend to equilibrate within the brain sooner than mannitol; therefore, they have a shorter duration of action than mannitol. Urea has the additional problem that it can cause severe skin sloughing if it infiltrates into the skin. Hypertonic saline (3%) has generated some interest in the treatment of intracranial hypertension secondary to brain edema because it is thought to be less disruptive to fluid and electrolyte balance than other diuretic agents. Boluses of mannitol can generate a dramatic diuresis, resulting in rapid intravascular depletion and potential kidney damage. Mannitol can cause as much as 1500 cc of fluid to diurese in the space of 2 hours, as intravascular fluid depletion occurs, hematocrit can rise, blood viscosity can increase, and cloning is enhanced. This makes the area of brain irritation much more amenable to stroke. Saline 3% or 7. 5% administered in continuous infusion generates a more predictable and gentle osmotic flow of brain intracellular water into the interstitial space. The maximum effect occurs after the end of infusion and is visible over 4 hours. Hypertonic saline hydroxyethyl starch (HS-HES) seems to effectively lower ICP but does not increase CPP as much as does mannitol. Therapeutically, the limits of serum sodium and osmolality are in the range of 155-320. More research is needed to elucidate the exact method of action of hypertonic saline and the contraindications. Other supportive treatments While awaiting possible operative therapy, other supportive treatments are as follows: †¢Early extraventricular drainage of CSF is sometimes of value in controlling brain edema if there is a suspicion that the ventricles will progressively diminish in size because edema cannot be cannulated from a burr hole. †¢Coughing and straining increase venous pressure, restricting drainage and backing up blood into the head, thereby increasing ICP. Neuromuscular paralysis may decrease ICP by preventing sudden changes related to coughing or straining and by promoting systemic venous pooling that increases venous drainage from the head. Any other restrictions to jugular blood drainage, such as a kinked neck from positioning in bed, increase ICP by retarding jugular drainage, transmitting pressure back into the brain. †¢Trying to differentiate a drug-induced coma from an increased ICP–induced coma with a trial of naloxone (Narcan) is contraindicated, as it invariably induces agitation if the stupor is narcotic induced. Agitation increases catecholamine response, increases cardiac output, and increases blood flow to the head, thereby increasing hydrostatic pressure and ICP. Decreased serum protein (albumin) from malnutrition causes a decreased serum osmolality compared to the osmolality in the surrounding tissues. This allows intravascular water to flow along the increased osmotic gradient into the tissues, increasing edema. Hyperalimentation should be initiated as soon as possible if the course is likely to be protracted. †¢Boutique intravenous stabilizing cocktails have been said to maintain homeost asis of intravascular and extravascular fluid compartments, avoiding rapid fluid shifts that might adversely affect cerebral metabolism and edema. Composed of an albumin, bicarbonate, and Lasix solution, the albumin increases intravascular colloid content, resisting fluid flow into the brain substance, the bicarbonate buffers pH changes, and the Lasix tends to promote a stable, consistent urine output, resisting intravascular fluid changes from renal compensations. This may be useful in diffuse brain edema to protect against further damage from vascular compartment shifts, but body physiology probably adapts to it rapidly, thereby limiting its effect. These cocktails have not been proven to be effective as a treatment of SAH since they tend to promote diuresis and intravascular depletion. †¢Use of positive end-expiratory pressure (PEEP) for mechanical ventilation is controversial in TBI patients with acute lung injury/acute respiratory distress syndrome. Zhang et al found that PEEP can have a varied impact on blood, intracranial, and cerebral perfusion pressure in patients with cerebral injury. When applying this technique, mean arterial and intracranial pressure monitoring appears beneficial. [13] Management of cerebral perfusion pressure CPP management involves artificially elevating the blood pressure to increase the MAP and the CPP. Because autoregulation is impaired in the injured brain, pressure-passive CBF develops within these injured areas. As a result, these injured areas of the brain often have insufficient blood flow, and tissue acidosis and lactate accumulation occur. This causes vasodilation, which increases cerebral edema and ICP. When the CPP is raised to greater than 65-70 mm Hg, the ICP is often lowered because increased blood flow to injured areas of the brain decreases the tissue acidosis. This often results in a significant decrease in ICP. Metabolic therapies are designed to decrease the cerebral metabolic rate, which decreases ICP. Metabolic therapies are powerful means of reducing ICP, but they are reserved for situations in which other therapies have failed to control ICP. This is because metabolic therapies have diffuse systemic effects and often result in severe adverse effects, including hypotension, immunosuppression, coagulopathies, arrhythmias, and myocardial suppression. Metabolic suppression may be achieved through drug therapies or induced hypothermia. Barbiturates are the most common class of drugs used to suppress cerebral metabolism. Barbiturate coma is typically induced with pentobarbital. A loading dose of 10 mg/kg is administered over 30 minutes, and then 5 mg/kg/h is administered for 3 hours. A maintenance infusion of 1-2 mg/kg/h is begun after loading is completed. The infusion is titrated to provide burst suppression on continuous electroencephalogram monitoring and a serum level of 3-4 mg/dL. Typically, the barbiturate infusion is continued for 48 hours, and then the patient is weaned off the barbiturates. If the ICP again escapes control, the patient may be reloaded with pentobarbital and weaned again in several days. Hypothermia may also be used to suppress cerebral metabolism. The use of mild hypothermia involves decreasing the core temperature to 34-35 °C for 24-48 hours and then slowly rewarming the patient over 2-3 days. Patients with hypothermia are also at risk for hypotension and systemic infections. Another treatment that may be used in patients with TBI with refractory ICP elevation is decompressive craniectomy. In this surgical procedure, a large section of the skull is removed and the dura is expanded. This increases the total intracranial volume and, therefore, decreases ICP. Which patients benefit from decompressive craniectomy has not been established. Some believe that patients with refractory ICP elevation who have diffuse injury but do not have significant contusions or infarctions will benefit from decompressive craniectomy. Management of elevated ICP involves using a combination of treatments. Each patient represents a slightly different set of circumstances, and treatment must be tailored to each patient. Although no rigid protocols have been established for the treatment of head injury, many published algorithms provide treatment schemas. The American Association of Neurologic Surgeons published a comprehensive evidence-based review of the treatment of TBI, called the Guidelines for the Management of Severe Head Injury. In these guidelines, 3 different categories of treatments, standards, guidelines, and options are outlined. Standards are the accepted principles of management that reflect a high degree of clinical certainty. Guidelines are a particular strategy or a range of management options that reflect a high degree of clinical certainty. Options are strategies for patient management for which clinical certainty is unclear. Prognosis: The outcome of TBI is related to the initial level of injury. While the initial GCS score provides a description of the initial neurologic condition, it does not correlate tightly with outcome. Various methods have been used in an attempt to predict the outcome of TBI, and these are beyond the scope of this discussion. However, one simplified model uses 3 factors, that is, age, motor score of the GCS, and pupillary response (ie, normal, unilateral unresponsive pupil, bilateral unresponsive pupils), to provide a probability of outcome.