18.1: Key Topics in Macroeconomics
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Defining Macroeconomics
Macroeconomics is a branch of economics that focuses on the behavior and decision-making of an economy as a whole.
learning objectives
- Define Macroeconomics.
Economics is comprised of many specializations; however, the two broad sub-groupings for economics are microeconomics and macroeconomics.
Macroeconomics
Macroeconomics is a branch of economics that focuses on the behavior and decision-making of an economy as a whole. In this manner it differs from the field of microeconomics, which evaluates the motivations of and relationships between individual economic agents.
Macroeconomics: Circular Flow of the Economy : Macroeconomics simplifies the complexities of the trading activities in an economy by distilling actions to primary participants and tracing the circular flow of activity between them.
Indicators
Macroeconomists study aggregated indicators such as GDP, unemployment rates, and price indices to understand how the whole economy functions and develop models that explain the relationship between such factors as national income, output, consumption, unemployment, inflation, savings, investment, government spending, and international trade. These variables taken as a whole comprise a grouping of variables that are referred to as economic indicators . These indicators, which are classified as leading, lagging and coincident relative to their predictive capability, in combination with one another provide economists with a directional attribution for the economy.
Macroeconomic Study
While macroeconomics is a broad field of study, there are two areas of research that are especially well publicized in the media: the evaluation of the business cycle and the growth rate of the economy. As a result, macroeconomics tends to be widely cited in discussions related to government intervention in economic expansion and contraction, as well as, with respect to the evaluation of economic policy.
Though macroeconomics encompasses a variety of concepts and variables, but there are three central topics for macroeconomic research on a national level: output, unemployment, and inflation. Outside of macroeconomic theory, these topics are also extremely important to all economic agents including workers, consumers, and producers.
The Importance of Aggregate Decisions about Consumption versus Saving and Investment
Money can either be consumed, invested, or saved (deferred consumption or investment).
learning objectives
- Explain the relationship between consumption, savings, and investment.
There are three choices that market actors can make with their money. They can consume it by spending it on goods and services. For example, buying a movie ticket is spending money on consumption. They can also invest money by lending it to a company or project with the hope of getting back more money in the future. Finally, they can save it by putting it in a bank account (or keeping cash under the bed). Savings is essentially deferred consumption or investment; it is intended for use in the future.
In order to understand the effects of aggregate decisions of consumption, savings, and investment, we must look at aggregate demand (AD). AD is the total demand for final goods and services in the economy at a given time and price level. It specifies the amounts of goods and services that will be purchased at all possible price levels and is the demand for the gross domestic product of a country.
Components of Aggregate Demand
It is often cited that the aggregate demand curve is downward sloping because at lower price levels a greater quantity is demanded. While this is correct at the microeconomic, single good level, at the aggregate level this is incorrect. The aggregate demand curve is downward sloping but in variation with microeconomics, this is as a result of three distinct effects: the wealth effect, the interest rate effect and the exchange-rate effect.
Basically individuals will consume or purchase more when they feel wealthier or have access to inexpensive funding.
The wealth effect is specifically related to the value of assets; market participants will adjust consumption in-line with their perception of the appreciation or depreciation of held assets (a home; equity investments, etc.). The interest rate effect has to do with access to inexpensive funding, which provides an incentive to increase current period expenditures; while the exchange-rate effect has to do with expenditure decisions related to imports or foreign related expenditures, as the exchange rate is perceived to be favorable to the domestic currency, expenditures on foreign items or imports will increase.
Consumption, Savings, and Investment
Aggregate demand met by the market is spending, be it on consumption, investment, or other categories.
Spending is related to income:
\[\text{Income} \; – \text{Spending} = \text{Net Savings}\]
Rearranging:
\[\mathrm{Spending = Income \; – Net \; Savings = Income \; + Net \; Increase \; in \; Debt}\]
In words: what you spend is what you earn, plus what you borrow: if you spend $110 and earned $100, then you must have net borrowed $10; conversely if you spend $90 and earn $100, then you have net savings of $10, or have reduced debt by $10, for net change in debt of –$10.
For the economy as a whole, aggregate savings is greater than or equal to investment, which is usually in the form of borrowed funds available as a result of savings. Through investment spending, savings influences aggregate demand.
Furthermore, since consumption and investment are components of GDP but saving is not, increased savings indirectly reduces GDP.
US Savings Rate : Savings have declined in the US on aggregate since the 1980s, which means that the proportion of income spent on consumption and investment increased.
The Role of the Financial System
A financial market or system is a market in which people and entities can trade financial securities, commodities, and other fungible items.
learning objectives
- Explain the importance of the financial system
Financial System
A financial market or system is a market in which people and entities can trade financial securities, commodities, and other fungible items. Securities include stocks and bonds, and commodities include precious metals or agricultural goods.
Equity Markets : Equity markets are the most closely followed of the financial markets. They provide transparent and active trading platforms that promote liquidity and access to funds to on a global scale.
There are both general markets (where many commodities are traded) and specialized markets (where only one commodity is traded). Markets work by placing many interested buyers and sellers, including households, firms, and government agencies, in one place, thus making it easier for them to find each other.
An economy that relies primarily on interactions between buyers and sellers to allocate resources is known as a market economy, in contrast either to a command economy or to a non-market economy such as a gift economy.
Role of the Financial System
Financial markets are associated with the accelerated growth of an economy. A financial market helps to achieve the following non-comprehensive list of goals:
- Saving mobilization: Obtaining funds from the savers or surplus units such as household individuals, business firms, public sector units, central government, state governments, etc. is an important role played by financial markets. Borrowers (e.g. bond issuers) are connected with lenders (e.g. bond buyers) in financial markets.
- Investment: Financial markets play a crucial role in arranging to invest funds. Both firms and individuals can invest in companies through financial markets (e.g. by buying stock).
- National Growth: An important role played by financial market is that, they contribute to a nation’s growth by ensuring unfettered flow of surplus funds to deficit units. In other words, financial markets help shift money from industry to industry or firm to firm based on the supply and demand for their products.
- Entrepreneurship growth: Financial markets allow entrepreneurs (and established firms) to access the funds needed to invest in projects or companies.
The Business Cycle: Definition and Phases
The term business cycle refers to economy-wide fluctuations in production, trade, and general economic activity.
learning objectives
- Identify features of the economic business cycle
The Business Cycle
The term “business cycle” (or economic cycle or boom-bust cycle) refers to economy-wide fluctuations in production, trade, and general economic activity. From a conceptual perspective, the business cycle is the upward and downward movements of levels of GDP (gross domestic product) and refers to the period of expansions and contractions in the level of economic activities (business fluctuations) around a long-term growth trend.
Business Cycles : The phases of a business cycle follow a wave-like pattern over time with regard to GDP, with expansion leading to a peak and then followed by contraction leading to a trough.
Business Cycle Phases
Business cycles are identified as having four distinct phases: expansion, peak, contraction, and trough.
An expansion is characterized by increasing employment, economic growth, and upward pressure on prices. A peak is realized when the economy is producing at its maximum allowable output, employment is at or above full employment, and inflationary pressures on prices are evident. Following a peak an economy, typically enters into a correction which is characterized by a contraction, growth slows, employment declines (unemployment increases), and pricing pressures subside. The slowing ceases at the trough and at this point the economy has hit a bottom from which the next phase of expansion and contraction will emerge.
Business Cycle Fluctuations
Business cycle fluctuations occur around a long-term growth trend and are usually measured by considering the growth rate of real gross domestic product.
In the United States, it is generally accepted that the National Bureau of Economic Research (NBER) is the final arbiter of the dates of the peaks and troughs of the business cycle. An expansion is the period from a trough to a peak, and a recession as the period from a peak to a trough. The NBER identifies a recession as “a significant decline in economic activity spread across the economy, lasting more than a few months, normally visible in real GDP, real income, employment, industrial production. ” This is significantly different from the commonly cited definition of a recession being signaled by two consecutive quarters of decline in real GDP.
Recessions
A recession is a business cycle contraction; a general slowdown in economic activity.
learning objectives
- Explain the connection between a recession and other macroeconomic variables
In economics, a recession is a business cycle contraction; a general slowdown in economic activity. Macroeconomic indicators such as GDP (Gross Domestic Product), employment, investment spending, capacity utilization, household income, business profits, and inflation fall, while bankruptcies and the unemployment rate rise. Recessions generally occur when there is a widespread drop in spending (an adverse demand shock ). This may be triggered by various events, such as a financial crisis, an external trade shock, an adverse supply shock, or the bursting of an economic bubble.
Recessions and panic : Recessions are characterized as periods of fear and uncertainty; historically they also were a time of widespread panic. However, as confidence in the central bank and federal government increased, though fear and uncertainty remain, panic-conditioned “runs” as depicted in the photo above have become an element of the past.
Attributes of Recession
A recession has many attributes that can occur simultaneously, these include declines in component measures (economic indicators) of economic activity (GDP) such as consumption, investment, government spending, and net export activity. These indicators in turn, reflect underlying drivers such as employment levels and skills, household savings rates, corporate investment decisions, interest rates, demographics, and government policies.
Causes of Recession
Under ideal conditions, a country’s economy should have the household sector as net savers and the corporate sector as net borrowers, with the government budget nearly balanced and net exports near zero. When these relationships become imbalanced, recession can develop within a country or create pressure for recession in another country. Policy responses are often designed to drive the economy back towards this ideal state of balance.
Most mainstream economists believe that recessions are caused by inadequate aggregate demand in the economy, and favor the use of expansionary macroeconomic policy during recessions.
Policy Responses to Recession
Strategies favored for moving an economy out of a recession vary depending on which economic school the policymakers follow. Monetarists would favor the use of expansionary monetary policy, while Keynesian economists may advocate increased government spending to spark economic growth. Supply-side economists may suggest tax cuts to promote business capital investment. When interest rates reach the boundary of an interest rate of zero percent (zero interest-rate policy) conventional monetary policy can no longer be used and government must use other measures to stimulate recovery.
A severe (GDP down by 10%) or prolonged (three or four years) recession is referred to as an economic depression, although some argue that their causes and cures can be different. As an informal shorthand, economists sometimes refer to different recession shapes, such as V-shaped, U-shaped, L-shaped, and W-shaped recessions.
Managing the Business Cycle
When the economy is not at a steady state, the government and monetary authorities have policy mechanisms to move the economy back to consistent growth.
learning objectives
- Identify how changes in monetary and fiscal policy can manage the business cycle, and why that is desirable
The business cycle is comprised of the upward and downward movement in the level of Gross Domestic Product (GDP) over time. These fluctuations occur around a long-term growth trend, and typically involve shifts over time between periods of relatively rapid economic growth (an expansion or boom), and periods of relative stagnation or decline (a contraction or recession ).
Cycles in the economy : The economy moves through expansion and contraction on a routine basis; policy mechanisms allow for smoother transitions and soften landings.
Policy Responses
When the economy is not at a steady state and instead is at a point of either overheating (growing to fast) or slowing, the government and monetary authorities have policy mechanisms, fiscal and monetary, respectively, at their disposal to help move the economy back to a steady state growth trajectory. If the economy needs to be slowed, these policies are referred to as contractionary and if the economy needs to be stimulated the policy prescription is expansionary.
Expansionary Policy
Expansionary fiscal policy involves government spending exceeding tax revenue, and is usually undertaken during recessions. Fiscal authorities will increase government spending in order to revive the economy.
Expansionary monetary policy relies on the central bank increasing availability of loanable funds through three mechanisms: open market operations, discount rate, and the reserve ratio. As the supply of loanable funds increases, the interest rate is expected to decrease and thereby increase the desire to borrow funds for consumption and investment purposes.
Contractionary Policy
Contractionary fiscal policy is opposite of the action taken in an expansionary purpose, and occurs when government spending is lower than tax revenue.
Similarly, contractionary monetary policy is the opposite of expansionary monetary policy and occurs when the supply of loanable funds is limited, to reduce the access and availability to relatively inexpensive credit.
Long Run Growth
Long run growth is the increase in the market value of the goods and services produced by an economy over time.
learning objectives
- Explain the impact of consistent long-run growth on an economy.
Long run growth is the increase in the market value of the goods and services produced by an economy over time. It is conventionally measured as the percentage of increase in real gross domestic product, or real GDP. Growth is usually calculated in real terms: it is inflation-adjusted to eliminate the distorting effect of inflation on the price of goods produced. In economics, economic growth or economic growth theory typically refers to growth of potential output, which is production at full employment.
Policymakers strive for steady, continued, and consistent growth because it is predictable and manageable for both policymakers and market participants. Over long periods of time even small rates of growth, like a 2% annual increase, have large effects. For example, the United Kingdom experienced a 1.97% average annual increase in its inflation-adjusted GDP between 1830 and 2008. In 1830, the GDP was £41,373 million. It grew to £1,330,088 million by 2008 (in 2005 pounds). A growth rate that averaged 1.97% over 178 years resulted in a 32-fold increase in GDP by 2008.
Long-run growth rates : Growth in GDP can be significant, especially when annual growth rates are fairly consistent.
The Power of Compounding
The large impact of a relatively small growth rate over a long period of time is due to the power of compounding. A growth rate of 2.5% per annum leads to a doubling of the GDP within 29 years, while a growth rate of 8% per annum (an average exceeded by China between 2000 and 2010) leads to a doubling of GDP within 10 years. Therefore, a small difference in economic growth rates between countries can result in very different standards of living for their populations if this small difference continues for many years.
Note: an easy way to approximate the doubling time of a number with a constant growth rate is to use the Rule of 72. Divide 72 by the percentage annual growth rate to get a rough estimate of the number of years until the number doubles. For example, at a 10%, divide 72 by 10 to get a doubling time of 7.2 years. The actual doubling time is 7.27 years, so the rule of 72 is a good rough approximation.
Key Points
- Macroeconomists study aggregated indicators such as GDP, unemployment rates, and price indices to understand how the whole economy functions.
- Macroeconomists develop models that explain the relationship between such factors as national income, output, consumption, unemployment, inflation, savings, investment, government spending and international trade.
- Though macroeconomics encompasses a variety of concepts and variables, but there are three central topics for macroeconomic research on the national level: output, unemployment, and inflation.
- Aggregate demand is downward sloping as a result of three consumption sensitivities: wealth effect, interest rate effect and foreign exchange effect.
- Spending is related to income: Income – Spending = Net Savings.
- For the economy as a whole, aggregate savings is equal to investment, which is usually in the form of borrowed funds available as a result of savings.
- An economy which relies primarily on interactions between buyers and sellers to allocate resources is known as a market economy.
- Markets work by placing many interested buyers and sellers, including households, firms, and government agencies, in one “place,” thus making it easier for them to find each other.
- Healthy financial systems are associated with the accelerated development of an economy.
- Business cycles are identified as having four distinct phases: expansion, peak, contraction, and trough.
- Business cycle fluctuations occur around a long-term growth trend and are usually measured by considering the growth rate of real gross domestic product.
- In the United States, it is generally accepted that the National Bureau of Economic Research (NBER) is the final arbiter of the dates of the peaks and troughs of the business cycle.
- Macroeconomic indicators such as GDP (Gross Domestic Product), employment, investment spending, capacity utilization, household income, business profits, and inflation fall, while bankruptcies and the unemployment rate rise.
- Most mainstream economists believe that recessions are caused by inadequate aggregate demand in the economy, and favor the use of expansionary macroeconomic policy during recessions.
- Strategies favored for moving an economy out of a recession vary depending on which economic school the policymakers follow.
- If the economy needs to be slowed, enacted policies are referred to as being contractionary and if the economy needs to be stimulated the policy prescription is expansionary.
- Central banks use monetary policy measures to facilitate consistent economic growth, while the government uses fiscal policy.
- The government policy measures are referred to as fiscal policy.
- Growth is usually calculated in real terms, meaning that it is inflation -adjusted to eliminate the distorting effect of inflation on the price of goods produced.
- Policymakers strive for continued and consistent growth.
- The large impact of a relatively small growth rate over a long period of time is due to the power of compounding.
- A small difference in economic growth rates between countries can result in very different standards of living for their populations if this small difference continues for many years.
Key Terms
- Macroeconomics : The study of the entire economy in terms of the total amount of goods and services produced, total income earned, the level of employment of productive resources, and the general behavior of prices.
- microeconomics : That field that deals with the small-scale activities such as that of the individual or company.
- aggregate demand : The total demand for final goods and services in the economy at a given time and price level.
- investment : A placement of capital in expectation of deriving income or profit from its use.
- entrepreneurship : The art or science of innovation and risk-taking for profit in business.
- saving : the act of storing for future use
- expansion : The act or process of expanding.
- trough : The lowest turning point of a business cycle
- peak : The highest value reached by some quantity in a time period.
- contraction : A period of economic decline or negative growth.
- recession : A period of reduced economic activity
- fiscal policy : Government policy that attempts to influence the direction of the economy through changes in government spending or taxes.
- monetary policy : The process by which the central bank, or monetary authority manages the supply of money, or trading in foreign exchange markets.
- economic growth : The increase of the economic output of a country.
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8.4B: Nerve and Blood Supply
Synovial joints are highly innervated but vascularized indirectly by nearby tissues.
- Identify the nerve and blood supply of synovial joints
Key Points
- Although the articular capsule is innervated with the nerves necessary for movement, it lacks blood vessels because the arteries wrap around the joint in an anastomosis, bypassing direct capillary contact with the capsule.
- The articular and epiphyseal branches given off by the neighboring arteries form a periarticular arterial plexus.
- Exchange of gases (oxygen and carbon dioxide) and nutrients is achieved, albeit slowly, via diffusion or more efficiently during exercise via convection.
Key Terms
- convection : The movement of groups of molecules within fluids such as liquids or gases.
- osteomyelitis : An infection of the bone and bone marrow characterized by inflammation.
- anastomosis : A cross-connection between two blood vessels.
Elbow Joint : Diagram of the anastomosis around the elbow joint.
The blood supply of a synovial joint comes from the arteries sharing in anastomosis around the joint. The articular and epiphyseal branches of the neighboring arteries form a periarticular arterial plexus. The articular capsule is highly innervated but avascular (lacking blood and lymph vessels), and receives nutrition from the surrounding blood supply via either the slow process of diffusion or convection, a far more efficient process.
Numerous vessels from this plexus pierce the fibrous capsule and form a rich vascular plexus in the deeper part of the synovial membrane. The blood vessels of the synovial membrane terminate around the articular margins in a fringe of looped anastomoses termed the circulus vasculosus (circulus articularis vasculosus). It supplies the capsule, synovial membrane, and the epiphyses. After epiphyseal fusion in the growth of long bones, communication between the circulosus vasculosus and the end arteries of the metaphysis is established. This minimizes the chances of osteomyelitis in the metaphysis.
The synovial cartilage in the capsule acts somewhat like a sponge. A sponge will absorb fluid, but it will release little of that fluid unless it is squeezed. Exercising the joint, in effect, squeezes the synovial “sponge,” allowing gas exchange to occur and nutrients to flow into the cartilage. Flexing and extending the joint alternately squeezes the sponge and releases it to reabsorb more fluid.


22.6: Modifications in Respiratory Functions
Learning Objectives
- Define the terms hyperpnea and hyperventilation
- Describe the effect of exercise on the respiratory system
- Describe the effect of high altitude on the respiratory system
- Discuss the process of acclimatization
At rest, the respiratory system performs its functions at a constant, rhythmic pace, as regulated by the respiratory centers of the brain. At this pace, ventilation provides sufficient oxygen to all the tissues of the body. However, there are times that the respiratory system must alter the pace of its functions in order to accommodate the oxygen demands of the body.
Hyperpnea
Hyperpnea is an increased depth and rate of ventilation to meet an increase in oxygen demand as might be seen in exercise or disease, particularly diseases that target the respiratory or digestive tracts. This does not significantly alter blood oxygen or carbon dioxide levels, but merely increases the depth and rate of ventilation to meet the demand of the cells. In contrast, hyperventilation is an increased ventilation rate that is independent of the cellular oxygen needs and leads to abnormally low blood carbon dioxide levels and high (alkaline) blood pH.
Interestingly, exercise does not cause hyperpnea as one might think. Muscles that perform work during exercise do increase their demand for oxygen, stimulating an increase in ventilation. However, hyperpnea during exercise appears to occur before a drop in oxygen levels within the muscles can occur. Therefore, hyperpnea must be driven by other mechanisms, either instead of or in addition to a drop in oxygen levels. The exact mechanisms behind exercise hyperpnea are not well understood, and some hypotheses are somewhat controversial. However, in addition to low oxygen, high carbon dioxide, and low pH levels, there appears to be a complex interplay of factors related to the nervous system and the respiratory centers of the brain.
First, a conscious decision to partake in exercise, or another form of physical exertion, results in a psychological stimulus that may trigger the respiratory centers of the brain to increase ventilation. In addition, the respiratory centers of the brain may be stimulated through the activation of motor neurons that innervate muscle groups that are involved in the physical activity. Finally, physical exertion stimulates proprioceptors, which are receptors located within the muscles, joints, and tendons, which sense movement and stretching; proprioceptors thus create a stimulus that may also trigger the respiratory centers of the brain. These neural factors are consistent with the sudden increase in ventilation that is observed immediately as exercise begins. Because the respiratory centers are stimulated by psychological, motor neuron, and proprioceptor inputs throughout exercise, the fact that there is also a sudden decrease in ventilation immediately after the exercise ends when these neural stimuli cease, further supports the idea that they are involved in triggering the changes of ventilation.
High Altitude Effects
An increase in altitude results in a decrease in atmospheric pressure. Although the proportion of oxygen relative to gases in the atmosphere remains at 21 percent, its partial pressure decreases (Table \(\PageIndex{1}\)). As a result, it is more difficult for a body to achieve the same level of oxygen saturation at high altitude than at low altitude, due to lower atmospheric pressure. In fact, hemoglobin saturation is lower at high altitudes compared to hemoglobin saturation at sea level. For example, hemoglobin saturation is about 67 percent at 19,000 feet above sea level, whereas it reaches about 98 percent at sea level.
Table \(\PageIndex{1}\)
| Partial Pressure of Oxygen at Different Altitudes | |||
|---|---|---|---|
| Example location | Altitude (feet above sea level) | Atmospheric pressure (mm Hg) | Partial pressure of oxygen (mm Hg) |
| New York City, New York | 0 | 760 | 159 |
| Boulder, Colorado | 5000 | 632 | 133 |
| Aspen, Colorado | 8000 | 565 | 118 |
| Pike’s Peak, Colorado | 14,000 | 447 | 94 |
| Denali (Mt. McKinley), Alaska | 20,000 | 350 | 73 |
| Mt. Everest, Tibet | 29,000 | 260 | 54 |
As you recall, partial pressure is extremely important in determining how much gas can cross the respiratory membrane and enter the blood of the pulmonary capillaries. A lower partial pressure of oxygen means that there is a smaller difference in partial pressures between the alveoli and the blood, so less oxygen crosses the respiratory membrane. As a result, fewer oxygen molecules are bound by hemoglobin. Despite this, the tissues of the body still receive a sufficient amount of oxygen during rest at high altitudes. This is due to two major mechanisms. First, the number of oxygen molecules that enter the tissue from the blood is nearly equal between sea level and high altitudes. At sea level, hemoglobin saturation is higher, but only a quarter of the oxygen molecules are actually released into the tissue. At high altitudes, a greater proportion of molecules of oxygen are released into the tissues. Secondly, at high altitudes, a greater amount of BPG is produced by erythrocytes, which enhances the dissociation of oxygen from hemoglobin. Physical exertion, such as skiing or hiking, can lead to altitude sickness due to the low amount of oxygen reserves in the blood at high altitudes. At sea level, there is a large amount of oxygen reserve in venous blood (even though venous blood is thought of as “deoxygenated”) from which the muscles can draw during physical exertion. Because the oxygen saturation is much lower at higher altitudes, this venous reserve is small, resulting in pathological symptoms of low blood oxygen levels. You may have heard that it is important to drink more water when traveling at higher altitudes than you are accustomed to. This is because your body will increase micturition (urination) at high altitudes to counteract the effects of lower oxygen levels. By removing fluids, blood plasma levels drop but not the total number of erythrocytes. In this way, the overall concentration of erythrocytes in the blood increases, which helps tissues obtain the oxygen they need.
Acute mountain sickness (AMS) , or altitude sickness, is a condition that results from acute exposure to high altitudes due to a low partial pressure of oxygen at high altitudes. AMS typically can occur at 2400 meters (8000 feet) above sea level. AMS is a result of low blood oxygen levels, as the body has acute difficulty adjusting to the low partial pressure of oxygen. In serious cases, AMS can cause pulmonary or cerebral edema. Symptoms of AMS include nausea, vomiting, fatigue, lightheadedness, drowsiness, feeling disoriented, increased pulse, and nosebleeds. The only treatment for AMS is descending to a lower altitude; however, pharmacologic treatments and supplemental oxygen can improve symptoms. AMS can be prevented by slowly ascending to the desired altitude, allowing the body to acclimate, as well as maintaining proper hydration.
Acclimatization
Especially in situations where the ascent occurs too quickly, traveling to areas of high altitude can cause AMS. Acclimatization is the process of adjustment that the respiratory system makes due to chronic exposure to a high altitude. Over a period of time, the body adjusts to accommodate the lower partial pressure of oxygen. The low partial pressure of oxygen at high altitudes results in a lower oxygen saturation level of hemoglobin in the blood. In turn, the tissue levels of oxygen are also lower. As a result, the kidneys are stimulated to produce the hormone erythropoietin (EPO), which stimulates the production of erythrocytes, resulting in a greater number of circulating erythrocytes in an individual at a high altitude over a long period. With more red blood cells, there is more hemoglobin to help transport the available oxygen. Even though there is low saturation of each hemoglobin molecule, there will be more hemoglobin present, and therefore more oxygen in the blood. Over time, this allows the person to partake in physical exertion without developing AMS.
Chapter Review
Normally, the respiratory centers of the brain maintain a consistent, rhythmic breathing cycle. However, in certain cases, the respiratory system must adjust to situational changes in order to supply the body with sufficient oxygen. For example, exercise results in increased ventilation, and chronic exposure to a high altitude results in a greater number of circulating erythrocytes. Hyperpnea, an increase in the rate and depth of ventilation, appears to be a function of three neural mechanisms that include a psychological stimulus, motor neuron activation of skeletal muscles, and the activation of proprioceptors in the muscles, joints, and tendons. As a result, hyperpnea related to exercise is initiated when exercise begins, as opposed to when tissue oxygen demand actually increases.
In contrast, acute exposure to a high altitude, particularly during times of physical exertion, does result in low blood and tissue levels of oxygen. This change is caused by a low partial pressure of oxygen in the air, because the atmospheric pressure at high altitudes is lower than the atmospheric pressure at sea level. This can lead to a condition called acute mountain sickness (AMS) with symptoms that include headaches, disorientation, fatigue, nausea, and lightheadedness. Over a long period of time, a person’s body will adjust to the high altitude, a process called acclimatization. During acclimatization, the low tissue levels of oxygen will cause the kidneys to produce greater amounts of the hormone erythropoietin, which stimulates the production of erythrocytes. Increased levels of circulating erythrocytes provide an increased amount of hemoglobin that helps supply an individual with more oxygen, preventing the symptoms of AMS.
Review Questions
Q. Increased ventilation that results in an increase in blood pH is called ________.
A. hyperventilation
B. hyperpnea
C. acclimatization
D. apnea
Answer: A
Q. Exercise can trigger symptoms of AMS due to which of the following?
A. low partial pressure of oxygen
B. low atmospheric pressure
C. abnormal neural signals
D. small venous reserve of oxygen
Answer: D
Q. Which of the following stimulates the production of erythrocytes?
A. AMS
B. high blood levels of carbon dioxide
C. low atmospheric pressure
D. erythropoietin
Answer: D
Critical Thinking Questions
Q. Describe the neural factors involved in increasing ventilation during exercise.
A. There are three neural factors that play a role in the increased ventilation observed during exercise. Because this increased ventilation occurs at the beginning of exercise, it is unlikely that only blood oxygen and carbon dioxide levels are involved. The first neural factor is the psychological stimulus of making a conscious decision to exercise. The second neural factor is the stimulus of motor neuron activation by the skeletal muscles, which are involved in exercise. The third neural factor is activation of the proprioceptors located in the muscles, joints, and tendons that stimulate activity in the respiratory centers.
Q. What is the major mechanism that results in acclimatization?
A. A major mechanism involved in acclimatization is the increased production of erythrocytes. A drop in tissue levels of oxygen stimulates the kidneys to produce the hormone erythropoietin, which signals the bone marrow to produce erythrocytes. As a result, individuals exposed to a high altitude for long periods of time have a greater number of circulating erythrocytes than do individuals at lower altitudes.
Glossary
- acute mountain sickness (AMS)
- condition that occurs a result of acute exposure to high altitude due to a low partial pressure of oxygen
- acclimatization
- process of adjustment that the respiratory system makes due to chronic exposure to high altitudes
- hyperpnea
- increased rate and depth of ventilation due to an increase in oxygen demand that does not significantly alter blood oxygen or carbon dioxide levels
- hyperventilation
- increased ventilation rate that leads to abnormally low blood carbon dioxide levels and high (alkaline) blood pH


7.8B: Shared Features of Bacteria and Archaea
Most of the metabolic pathways, which comprise the majority of an organism’s genes, are common between Archaea and Bacteria.
LEARNING OBJECTIVES
Describe the evidence for the evolution of the Archaea from Bacteria
Key Takeaways
The relationship between the three domains is of central importance for understanding the origin of life. Most of the metabolic pathways, which comprise the majority of an organism ‘s genes, are common between Archaea and Bacteria, while most genes involved in genome expression are common between Archaea and Eukarya. Within prokaryotes, archaeal cell structure is most similar to that of Gram-positive bacteria, largely because both have a single lipid bilayer and usually contain a thick sacculus of varying chemical composition. In phylogenetic trees based upon different gene/ protein sequences of prokaryotic homologs, the archaeal homologs are more closely related to those of Gram-positive bacteria. Archaea and Gram-positive bacteria also share conserved indels in a number of important proteins, such as Hsp70 and glutamine synthetase I.
R.S. Gupta has proposed that the Archaea evolved from Gram-positive bacteria in response to antibiotic selection pressure. This is suggested by the observation that archaea are resistant to a wide variety of antibiotics that are primarily produced by Gram-positive bacteria, and that these antibiotics primarily act on the genes that distinguish Archaea from Bacteria. His proposal is that the selective pressure towards resistance generated by the Gram-positive antibiotics was eventually sufficient to cause extensive changes in many of the antibiotics’ target genes, and that these strains represented the common ancestors of present-day Archaea. The evolution of Archaea in response to antibiotic selection, or any other competitive selective pressure, could also explain their adaptation to extreme environments (such as high temperature or acidity) as the result of a search for unoccupied niches to escape from antibiotic-producing organisms; Cavalier-Smith has made a similar suggestion. Gupta’s proposal is also supported by other work investigating protein structural relationships and studies that suggest that Gram-positive bacteria may constitute the earliest branching lineages within the prokaryotes.
Key Points
- Within prokaryotes, archaeal cell structure is most similar to that of Gram-positive bacteria, largely because both have a single lipid bilayer and usually contain a thick sacculus of varying chemical composition.
- It has been proposed that the Archaea evolved from Gram-positive bacteria in response to antibiotic selection pressure.
- The evolution of Archaea in response to antibiotic selection, or any other competitive selective pressure, could also explain their adaptation to extreme environments (such as high temperature or acidity).
Key Terms
- prokaryotes : ( /proʊkæri.oʊts/, pro-kah-ree-otes or /proʊkæriəts/, pro-kah-ree-əts) a group of organisms whose cells lack a cell nucleus (karyon), or any other membrane-bound organelles. Most prokaryotes are unicellular organisms, although a few such as myxobacteria have multicellular stages in their life cycles.
- archaea : a taxonomic domain of single-celled organisms lacking nuclei that are fundamentally from bacteria.
- bacteria : Bacteria constitute a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals. Bacteria were among the first life forms to appear on Earth, and are present in most habitats on the planet.


1.9: “Volunteers Required-” Newspaper Articles on Spanish Flu from Wausau, Wisconsin 64
“Volunteers Required:” Newspaper Articles on Spanish Flu from Wausau, Wisconsin
Introduction:
More than 8,000 Wisconsin residents died in the 1918-1919 influenza epidemic. These articles from the Wausau, Wisconsin newspaper show how the community coped with the epidemic and the efforts of civic organizations to mitigate the spread of the disease. Public health officials educated people on the use of quarantine, masks, hand-washing, social distancing and provided help for citizens stricken with influenza.
The women’s committees of the World War I era were a federally organized effort to put women’s labor and domestic skills to use while the men were away at war. The work of the women’s committees was portrayed as the “home-front defense.” They addressed issues such as women’s and children’s health, food and nutrition, and other social welfare needs. Interestingly enough, the relationships, organization, and leadership skills developed during the war years laid the foundation of the women’s suffrage movement that followed in the 1920s.
HOMES CANVASSED FOR “FLU” CENSUS
Women Visit Households to Determine Number of Cases in the City
VOLUNTEERS REQUIRED
Conditions in Many Homes Indicate Need of Emergency Workers
Seventy women under the direction of the city health officer today began visiting homes in allotted districts to ascertain the number of cases of influenza in the city, to determine whether each case is in charge of a physician and to note the number of persons afflicted in each home, the condition of the sick, also the condition of the household as to cleanliness and ventilation, the need of help and the kind of assistance required. Circulars were distributed by the women which read as follows:
Caution:
Oftentimes it is impossible to tell a cold from mild influenza. Therefore if you get a cold go to bed in a well ventilated room. Keep warm. Keep away from the other people. Do not kiss any one . Use individual basins and knives, forks, spoons, towels, handkerchiefs, soap, wash plates and cups.
Every case of influenza should go to bed at once under the care of a physician. The patient should stay in bed at least three days after fever has disappeared and until convalescence is well established.
The patient must not cough or sneeze except when a mask or handkerchief is held before the face.
He should be in a warm, well ventilated room.
There is no specific [treatment] for the disease. Symptoms should be met as they arise.
The great danger is from pneumonia. Avoid it by staying in bed while actually ill and until convalescence is fully established.
The after-effects of influenza are worse than the disease. Take care of yourself. Strictly observe the state and city rules and regulations for the control of influenza.
Home Workers Needed
The woman’s committee of the Council of Defense is assisting the health department in this work. The urgent need of help in homes where there are several persons ill was announced today by Mrs. W.H. Nablo, chairman of the women's committee, and also by Mrs. E. F. Stockum, field worker for the Federated Charities. Persons who can prepare food, wash dishes, keep the home clean, etc. are required and if necessary, they will be paid by the city and Federated Charities. Visiting nurses will call at the homes, but there are not sufficient nurses to permit that the nurses do work about the household. They will attend to the needs of the patient.
Poster distributed by the American Red Cross in 1917-1918
"Influenza Wear Your Mask It May Save Your Life" by American National Red Cross is in the Public Domain
The conditions in a large majority of homes are bad according to nurses and volunteer workers who have visited these households. In many instances the home fires are burning at a high pitch and all windows and sources of ventilation are closed. The volunteer workers have been forced to remedy these conditions by shutting off the stove draft and opening windows. Many of the mothers are exhausted from overwork and it is feared that unless more volunteer workers offer their assistance, these mothers may themselves become ill and owing to their already weakened condition, may develop pneumonia. It is therefore imperative that more offer their services as volunteer workers. Women aged from twenty-five to forty are preferred for this work.
The Woman’s Motor Squad, of which Mrs. D.C. Everest is captain, and many other women who have automobiles at their disposal, aided the woman’s committee of the Council of Defense today in getting the volunteer workers to the various sections of the city in which they are assigned to work, also in transporting visiting nurses, etc. to and from homes afflicted with influenza.
American Red Cross Volunteer nurses making surgical dressings while wearing masks in Oakland, California.
"American Red Cross volunteers of 1917-1918 preparing surgical dressings [picture]." by Edward A. "Doc" Rogers is in the Public Domain .
Will Make Reports
The women who visited the homes today for information will send in reports this evening to the city health officer. They are instructed to handle all cases with diplomacy, keep a certain distance from those afflicted without arousing any ill-feeling, teach the members of the households the use of the face mask whenever attending the family and use it themselves whenever required. The face mask, they were told, should be thrown in boiling water whenever necessary to be cleaned.  All dishes should be thoroughly cleaned, all rooms kept clean and well ventilated and handkerchiefs, towels and linens used about the sick boiled or destroyed. Also not to spread or contract the disease from their neighbors by unnecessary calls or neighborly visits, nor by allowing children from various households to mingle on the streets or the premises.
Patrolling Streets
The police have been ordered to keep a close lookout for all children found playing on streets or on premises other than at their own homes.
This work ([Policeman warning citizen to don flu mask], by Dobbin, Hamilton Henry, 1856-1930.), identified by Calisphere , is free of known copyright restrictions.
Glossary:
- Circulars - letters or advertisements which are distributed to a large number of people.
- Council of Defense - The Council of National Defense was a United States government organization formed during World War I to coordinate resources and industry in support of the war effort, including the coordination of transportation, industrial and farm production, financial support for the war, and public morale. States formed their own Councils of Defense to coordinate local efforts.
Questions:
- Compare this community’s approach to the epidemic to your own. What services did the community provide to victims of the illness? How did the city government intervene?
- What do we learn about attitudes toward gender and women from this document?
Sources:
“Council of National Defense.” Wikipedia, Wikimedia Foundation, 3 Apr. 2020, en.Wikipedia.org/wiki/Council_of_National_Defense.
Newspaper articles on Spanish flu. Capital Times and Wausau Record Herald (1918); online facsimile at http://www.wisconsinhistory.org/turningpoints/search.asp?id=1553
VanOrsdal, Anita Anthony. "There Shall Be No Woman Slackers": The Woman's Committee of the Council of National Defense and Social Welfare Activism As Home Defense, 1917-1919 . MIchigan State University Doctoral Dissertation. file:///home/chronos/u-527091bbda2ca...128D_14489.pdf
“When The 1918 Influenza Pandemic Struck Wisconsin.” WisContext , 1 May 2020, www.wiscontext.org/when-1918-influenza-pandemic-struck-wisconsin .
This work (HOMES CANVASSED FOR “FLU” CENSUS, by Wausau Record Herald ), identified by Wisconsin Historical Society , is free of known copyright restrictions.


21.3A: Vaccines and Immunity
- Explain how vaccination protects vaccinated individuals and the community
Vaccines for Prevention
While we do have limited numbers of effective antiviral drugs, such as those used to treat HIV and influenza, the primary method of controlling viral disease is by vaccination, which is intended to prevent outbreaks by building immunity to a virus or virus family. Vaccines may be prepared using live viruses, killed viruses, or molecular subunits of the virus. The killed viral vaccines and subunit viruses are both incapable of causing disease.
Live viral vaccines are designed in the laboratory to cause few symptoms in recipients while giving them protective immunity against future infections. Polio was one disease that represented a milestone in the use of vaccines. Mass immunization campaigns in the 1950s and 1960s significantly reduced the incidence of the disease, which caused muscle paralysis in children and generated great fear in the general population when regional epidemics occurred. The success of the polio vaccine paved the way for the routine dispensation of childhood vaccines against measles, mumps, rubella, chickenpox, and other diseases.
The danger of using live vaccines, which are usually more effective than killed vaccines, is low, but significant since the possibility that these viruses will revert to their disease-causing form by back mutations is still present. Live vaccines are usually made by attenuating (weakening) the “wild-type” (disease-causing) virus by growing it in the laboratory in tissues or at temperatures different from what the virus is accustomed to in the host. Adaptations to these new cells or temperatures induce mutations in the genomes of the virus, allowing it to grow better in the laboratory while inhibiting its ability to cause disease when reintroduced into conditions found in the host. These attenuated viruses still cause infection, but since they do not grow very well, they allow the immune response to develop in time to prevent major disease. Back mutations occur when the vaccine undergoes mutations in the host such that it readapts to the host and can again cause disease, which can then be spread to other humans in an epidemic. This type of scenario happened as recently as 2007 in Nigeria where mutations in a polio vaccine led to an epidemic of polio in that country.
Some vaccines are in continuous development because certain viruses, such as influenza and HIV, have a high mutation rate compared to other viruses and normal host cells. With influenza, mutations in the surface molecules of the virus help the organism evade the protective immunity that may have been obtained in a previous influenza season, making it necessary for individuals to get vaccinated every year. Other viruses, such as those that cause the childhood diseases measles, mumps, and rubella, mutate so infrequently that the same vaccine is used year after year.
Key Points
- Vaccinations are prepared with live viruses, killed viruses, or molecular subunits of the virus.
- A live vaccine consists of a small dose of the active virus.
- A killed vaccine contains the inactivated virus.
- It is possible, though rare, for live vaccines to cause the disease they’re used to prevent.
- Live vaccines are made by growing the virus in a lab, which causes mutations that allow them to grow better in the lab than in the host, thereby inhibiting their ability to cause disease.
- Even though live vaccines are designed to cause few symptoms, back mutations can occur and cause the virus to readapt to the host and the disease to spread.
Key Terms
- vaccination : inoculation in order to protect against a particular disease or strain of disease; causes a primary immune response without illness, allowing the secondary response to destroy subsequent infection
- live vaccine : consists of an active microbe (virus or bacteria)
- killed vaccine : (inactivated vaccine) consists of virus particles which are grown in culture and then killed using a method such as with heat or formaldehyde


11.5A: Parts of the Cerebellum
The cerebellum, which looks like a separate structure attached to the bottom of the brain, plays an important role in motor control.
- Describe the parts of the cerebellum
Key Points
- The cerebellum can be separated into three lobes: the flocculonodular lobe, anterior lobe, and posterior lobe.
- The medial zone of the anterior and posterior lobes constitutes the spinocerebellum, or paleocerebellum.
-
There are about 3.6 times as many neurons in
the cerebellum as in the neocortex. -
Based on surface appearance, three lobes can be distinguished in the
cerebellum: the flocculonodular lobe, anterior lobe (above the primary
fissure), and the posterior lobe (below the primary fissure).
Key Terms
- granule cells : An extremely small type of neuron that is the the smallest cell found in the brain.
- neocortex : The largest part of the cerebral cortex of the human brain, covering the two cerebral hemispheres.
-
Purkinje cells
: A class of GABAergic neurons located in the cerebellar cortex that are some of the largest neurons in the human brain.
GABA is the chief inhibitory neurotransmitter
in the mammalian
central nervous system. - cerebellum : Part of the hindbrain. In humans, it lies between the brainstem and the cerebrum. It plays an important role in sensory perception, motor output, balance, and posture.
The cerebellum has the appearance of a separate structure attached to the bottom of the brain, tucked underneath the cerebral hemispheres. The surface of the cerebellum is covered with finely spaced parallel grooves, in striking contrast to the broad irregular convolutions of the cerebral cortex.
Cerebellum : Brain section showing cerebellum position and structure
These parallel grooves conceal the fact that the cerebellum is actually a continuous thin layer of tissue (the cerebellar cortex), tightly folded in the style of an accordion. This thin layer contains several types of neurons with a highly regular arrangement, most importantly Purkinje cells and granule cells. This complex neural network gives rise to a massive signal-processing capability, but almost all of its output is directed to a set of small deep cerebellar nuclei lying in the interior of the cerebellum.
Cells of the Cerebellum : Transverse section of a cerebellar folium, showing principal cell types and connections.
The cerebellum is separated from the overlying cerebrum by a layer of leathery dura mater. Anatomists classify the cerebellum as part of the metencephalon, which also includes the pons, and all its connections with other parts of the brain travel through the pons. The metencephalon is the upper part of the rhombencephalon, or hindbrain. Like the cerebral cortex, the cerebellum is divided into two hemispheres. It also contains a narrow midline zone called the vermis. A set of large folds is, by convention, used to divide the overall structure into 10 smaller lobules. Due to its large number of tiny granule cells, the cerebellum contains more neurons than the rest of the brain put together, but comprises only 10% of total brain volume.
Based on surface appearance, three lobes can be distinguished in the cerebellum: the flocculonodular lobe, anterior lobe (above the primary fissure), and the posterior lobe (below the primary fissure). Excluding the flocculonodular lobe, which has distinct connections and functions, the cerebellum can be parsed functionally into a medial sector called the spinocerebellum and a larger lateral sector called the cerebrocerebellum. A narrow strip of protruding tissue along the midline is called the vermis (Latin for “worm”).
Divisions of the cerebellum : Schematic representation of the major anatomical subdivisions of the cerebellum. Superior view of an “unrolled” cerebellum, placing the vermis in one plane.
The smallest region, the flocculonodular lobe, is often called the vestibulocerebellum. It is the oldest part of the brain in evolutionary terms (archicerebellum) and participates mainly in balance and spatial orientation. Its primary connections are with the vestibular nuclei, although it also receives visual and other sensory input.
The medial zone of the anterior and posterior lobes constitutes the spinocerebellum, also known as the paleocerebellum. It receives proprioception input from the dorsal columns of the spinal cord (including the spinocerebellar tract) and from the trigeminal nerve, as well as from visual and auditory systems. It sends fibers to deep cerebellar nuclei that in turn project to both the cerebral cortex and the brain stem, thus providing modulation of descending motor systems.
The lateral zone, which in humans is by far the largest part, constitutes the cerebrocerebellum, also known as the neocerebellum. It receives input exclusively from the cerebral cortex (especially the parietal lobe) via the pontine nuclei (forming corticopontocerebellar pathways), and sends output mainly to the ventrolateral thalamus (in turn connected to motor areas of the premotor cortex and primary motor area of the cerebral cortex) and to the red nucleus.


10.4: Applying the Nursing Process to Personality Disorders
This section will apply the nursing process to caring for a client diagnosed with borderline personality disorder who is hospitalized due to self-injurious behavior.
Assessment
Assessment includes interviewing the client, observing verbal and nonverbal behaviors, completing a mental status examination, and performing a psychosocial assessment. Review information about performing a mental status examination and psychosocial assessment in the “ Application of the Nursing Process in Mental Health Care ” chapter.
Assessment findings for clients hospitalized with borderline personality disorder may include the following [1] :
- Feelings of emptiness
- Self-mutilation and self-harm
- Suicidal behaviors, gestures, or threats
- Extreme mood shifts that occur in a matter of hours or days
- Impulsive behavior such as reckless driving, unsafe sex, substance use, gambling, overspending, or binge eating
- Intense feelings of abandonment
- A tendency towards anger, sarcasm, and bitterness
- Intense and unstable relationships
Review how to assess for suicide risk in the “ Foundational Mental Health Concepts ” chapter.
Diagnostic and Lab Work
There is no specific laboratory test that diagnoses personality disorders. Laboratory or diagnostic tests may be used to rule out other possible causes for the behaviors the client is exhibiting. For example, a thyroid stimulating hormone (TSH) test may be ordered because thyroid disorders can affect mood.
Diagnoses
Mental health disorders are diagnosed by mental health providers using the diagnostic criteria in the DSM-5 . Personality disorder diagnoses are typically not made until late adolescence or over the age of 18 because it is important to determine if the symptoms are traits of a developmental stage or pervasive traits of a personality disorder in multiple contexts.
Nurses create individualized nursing care plans based on the client’s response to their mental health disorder(s). Common nursing diagnoses related to the clusters of personality disorders include the following:
- Cluster A: Social Isolation, Disturbed Thought Process, Risk for Loneliness
- Cluster B: Risk for Suicide, Risk for Self-Directed Violence, Social Isolation, Chronic Low Self-Esteem, Ineffective Coping
- Cluster C: Anxiety, Risk for Loneliness, Social Isolation
Common nursing diagnoses for clients diagnosed and hospitalized with borderline personality disorder are further described in Table 10.4.
Table 10.4 Common Nursing Diagnoses for Clients With Borderline Personality Disorder [2] , [3]
| Nursing Diagnosis | Definition | Selected Defining Characteristics and/or Risk Factors |
|---|---|---|
| Risk for Suicide | Susceptible to self-inflicted, life-threatening injury. |
|
| Risk for Self-Mutilation | Deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension. |
|
| Risk for Other-Directed Violence | Susceptible to behaviors in which an individual demonstrates they can be physically, emotionally, and/or sexually harmful to others. |
|
| Ineffective Coping | A pattern of invalid appraisal of stressors, with cognitive and/or behavioral efforts, that fails to manage demands related to well-being. |
|
| Defensive Coping | Repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard. |
|
| Social Isolation | Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state. |
|
| Ineffective Family Health Management r/t manipulative behavior | Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state. |
|
| Risk for Spiritual Distress as manifested by poor relationships | A state of suffering related to the impaired ability to experience meaning in life through connections with self, others, the world, or a superior being. |
|
Outcome Identification
In the acute care setting, the focus for setting goals and outcomes is the reason for admission, which may include conditions such as suicidal ideation, self-injurious behavior, severe depression, or severe anxiety. Outcomes should address the acute nursing diagnoses with prioritization on safety. For example, if the client has a nursing diagnosis of Risk for Self-Mutilation , a SMART outcome could be, “The client will refrain from intentional self-inflicted injury during hospitalization.” Read more information about setting SMART outcomes in the “ Application of the Nursing Process in Mental Health Care ” chapter.
Examples of other SMART outcomes for clients hospitalized with borderline personality disorder may include the following [4] :
- The client will remain safe and free of injury during their hospital stay.
- The client will seek help from staff when experiencing urges to self-mutilate during hospitalization.
- The client will identify three triggers to self-mutilation by the end of the shift.
- The client will describe two preferred healthy coping strategies by the end of the week.
Planning Interventions
Individuals diagnosed with borderline personality disorder may be suicidal, self-mutilating, impulsive, angry, manipulative, or aggressive. Nurses plan interventions according to the symptoms the client is currently exhibiting with the goal of keeping the client and others safe and free of injury. Review interventions for clients diagnosed with Risk of Suicide in the “ Application of the Nursing Process in Mental Health Care ” chapter.
Clear boundaries and limits should be set and consistently reinforced by the health care team. When behavioral problems emerge, the nurse should calmly review therapeutic goals, limits, and boundaries with the client. [5]
Implementing Interventions
Promoting Safety
When implementing planned interventions, the nurse must always consider safety. Develop a crisis/safety plan with the client that includes components such as these:
- Identifying thoughts or behaviors that increase the risk of harming self or others
- Identifying people, events, or situations that trigger those thoughts or behaviors
- Implementing coping strategies
- Reaching out to other coping resources
For example, if a client performs superficial self-injurious behavior, the nurse should act based on agency policy while remaining neutral and dressing the client’s self-inflicted wounds in a matter-of-fact manner. The client may be asked to write down the sequence of events leading up to the injuries, as well as the consequences, before staff will discuss the event. This cognitive exercise encourages the client to think independently about their triggers and behaviors and facilitates discussion about alternative actions. [6]
Review information regarding developing a safety plan in the “ Establishing Safety ” section of the “Foundational Mental Health Concepts” chapter.
De-Escalating
The nurse should implement de-escalation strategies if the client exhibits early signs of increasing levels of anxiety or agitation. Strategies include the following:
- Speaking in a calm voice
- Avoiding overreacting
- Implementing active listening
- Expressing support and concern
- Avoiding continuous eye contact
- Asking how you can help
- Reducing stimuli
- Moving slowly
- Remaining patient and not rushing them
- Offering options instead of trying to take control
- Avoiding touching the client without permission
- Verbalizing actions before initiating them
- Providing space so the client doesn’t feel trapped
- Avoiding arguing and judgmental comments
- Setting limits early and enforcing them consistently across team members
- Addressing manipulative behaviors therapeutically
If the client continues to escalate, measures must be taken to keep the client and others safe. Review signs of crisis and crisis interventions in the “ Stress, Coping, and Crisis Intervention ” chapter. If interventions are not effective in de-escalating a client at risk to themselves or others, seclusion or restraints may be required. Review using seclusion and restraints in the “ Psychosis and Schizophrenia ” chapter.
Coping Strategies
Teaching self-care and coping strategies is helpful for people diagnosed with personality disorders and their loved ones. [7] Read about stress management and coping strategies in the “ Stress, Coping, and Crisis Intervention ” chapter.
For clients seeking immediate relief from intense symptoms such as panic or depersonalization, nurses can teach how to stimulate the parasympathetic nervous system. Stimulation of the vagal nerve can result in an immediate, direct relief of intense emotions. This can be accomplished by doing the following [8] :
- Applying ice or ice-cold water to the face
- Performing paced-breathing techniques in which the exhalation phase is at least two to four counts longer than the inhalation phase. For example, advise the client to inhale while counting to four and then exhale while counting to eight.
Collaborative Interventions
Psychotherapy
First-line treatment for personality disorders is psychotherapy. Examples of psychotherapy used with clients with personality disorders are cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, mentalization-based therapy, psychodynamic psychotherapy, and psychoeducation. Read more about these treatments in the “ Treatment for Personality Disorders ” section of this chapter.
Pharmacotherapy
There are no specific medications approved to treat personality disorders. However, clients may be treated for symptoms associated with personality disorders that cause them significant impairment and distress. Read more information about common medications used to treat symptoms of personality disorders in the “ Treatment for Personality Disorders ” section of this chapter.
Evaluation
Refer to the SMART outcomes established for each individual client to evaluate the effectiveness of the planned interventions. Modification of the established nursing care plan may be required based on the effectiveness of the interventions.
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
- Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- Halter, M. (2022). Varcarolis’ foundations of psychiatric-mental health nursing (9th ed.). Saunders. ↵
- American Psychiatric Association. (n.d.). What are personality disorders? https://www.psychiatry.org/patients-families/personality-disorders/what-are-personality-disorders ↵
- Nelson, K. J. (2021). Pharmacotherapy for personality disorders. UpToDate. https://www.uptodate.com ↵


4.9: Lists
The next kind of data I want to mention are
lists
. Lists are an extremely fundamental data structure in R, and as you start making the transition from a novice to a savvy R user you will use lists all the time. I don’t use lists very often in this book – not directly – but most of the advanced data structures in R are built from lists (e.g., data frames are actually a specific type of list). Because lists are so important to how R stores things, it’s useful to have a basic understanding of them. Okay, so what is a list, exactly? Like data frames, lists are just “collections of variables.” However, unlike data frames – which are basically supposed to look like a nice “rectangular” table of data – there are no constraints on what kinds of variables we include, and no requirement that the variables have any particular relationship to one another. In order to understand what this actually
means
, the best thing to do is create a list, which we can do using the
list()
function. If I type this as my command:
Dan <- list( age = 34,
nerd = TRUE,
parents = c("Joe","Liz")
)
R creates a new list variable called
Dan
, which is a bundle of three different variables:
age
,
nerd
and
parents
. Notice, that the
parents
variable is longer than the others. This is perfectly acceptable for a list, but it wouldn’t be for a data frame. If we now print out the variable, you can see the way that R stores the list:
print( Dan )
## $age
## [1] 34
##
## $nerd
## [1] TRUE
##
## $parents
## [1] "Joe" "Liz"
As you might have guessed from those
$
symbols everywhere, the variables are stored in exactly the same way that they are for a data frame (again, this is not surprising: data frames
are
a type of list). So you will (I hope) be entirely unsurprised and probably quite bored when I tell you that you can extract the variables from the list using the
$
operator, like so:
Dan$nerd
## [1] TRUE
If you need to add new entries to the list, the easiest way to do so is to again use
$
, as the following example illustrates. If I type a command like this
Dan$children <- "Alex"
then R creates a new entry to the end of the list called
children
, and assigns it a value of
"Alex"
. If I were now to
print()
this list out, you’d see a new entry at the bottom of the printout. Finally, it’s actually possible for lists to contain other lists, so it’s quite possible that I would end up using a command like
Dan$children$age
to find out how old my son is. Or I could try to remember it myself I suppose.


5.9: Induced Abortion
By the end of this section, you will be able to:
- Discuss medically induced abortion
- Discuss surgically induced abortion
- Discuss the role of the nurse when providing education and referral for an induced abortion
A person deciding to end a pregnancy may do so for many reasons. The person may be choosing to end this pregnancy because it was unplanned or unwanted, was the result of a sexual assault, or is likely to impact their health negatively. In some cases, the fetus has a condition incompatible with life. Other reasons can be financial, relationship problems, and other family responsibilities (Hatcher, 2018). Regardless of the reason, each person should be respected and supported throughout the process. The nurse will assess the person’s need for emotional and mental health support, counseling, and social support resources. Many hospitals and clinics have resources available such as postpartum depression assistance from social work, follow-up appointments for postpartum contraception, and mental health and support services. Each state in the United States now has specific laws on the legality of abortion , and nurses are responsible for knowing the laws in the state or states they practice in.
The nurse will assess the person by reviewing a health history and obtaining a last menstrual period (LMP). If the LMP is unknown, an ultrasound might be performed. The nurse will also draw blood for lab work to determine the person’s blood type, hemoglobin or hematocrit, and possibly STI status. The health-care provider and nurse will provide education and obtain informed consent. Two types of abortions are available and will be discussed in this module: medically induced abortion and surgically induced abortion.
Medically Induced Abortions
A medically induced abortion is a termination of pregnancy induced by medications. According to the American College of Obstetricians and Gynecologists (2022b), 25 percent of women in the United States will have an abortion by the age of 45 years. In 2000, the FDA approved a combination of mifepristone (Mifeprex) and misoprostol (Cytotec) for people seeking medically induced abortions but has since restricted access to mifepristone (Hatcher, 2018). Mifepristone, a selective progesterone receptor modulator, acts as an antiprogestin, which causes uterine lining necrosis, softening of the cervix, and contractility of the uterus (ACOG, 2020). Misoprostol, a prostaglandin E1, softens the cervix and induces uterine contractions (ACOG, 2020). The two-medication regimen of mifepristone followed by misoprostol has a 95 percent to 98 percent effectiveness rate when used by people whose gestation is 63 days or less from their LMP (Osuga et al., 2023). If the medications do not induce abortion or the abortion is not complete, an aspiration abortion should be advised (Hatcher, 2018). Side effects reported during medically induced abortions include intense nausea, vomiting, abdominal pain and cramping especially after the misoprostol is taken, and bleeding through fewer than two pads in an hour, with small clots after the products of conception have passed (Osuga et al., 2023).
Time Frames
If the gestational age is less than 70 days, oral mifepristone will be given as a 200-mg dose in the office; 24 to 48 hours later, 800 mcg of misoprostol will be taken at home (ACOG, 2020). Cramping and bleeding will occur and evacuate the uterus of the products of conception. At 7 to 14 days, the person will return to the office for a follow-up to ensure that the uterus is empty and that bleeding is not excessive, and to discuss contraceptive choices for future planning.
Who to See and Who Is Eligible
A person desiring a medically induced abortion will need to see a medical doctor, certified nurse-midwife, or nurse practitioner. The pregnancy is confirmed and gestational age is estimated. Patients who are eligible for medically induced abortions are those who are no more than 63 days post LMP, or 9 weeks; contraindications are suspected ectopic pregnancy, long-term use of corticosteroids, and severe anemia (Hatcher, 2018).
Surgically Induced Abortions
If the patient is more than 9 weeks past the first day of their LMP, they are no longer eligible for a medically induced abortion and will require a surgically induced abortion. A surgically induced abortion is a procedure in which manual dilation of the cervix occurs, followed by emptying of the uterine cavity. Aspiration abortion, done with the patient under local anesthesia, consists of dilating the cervix with a dilator and evacuating the uterine contents using a vacuum aspirator (Brown & Shvartsman, 2023). This procedure can be done up to 13 weeks’ gestation (ACOG, 2022b). Side effects of an aspiration abortion include retained products of conception, undiagnosed ectopic pregnancy, and uterine perforation; emergent symptoms are fever, severe abdominal pain, and bleeding that soaks a pad in an hour (Brown & Shvartsman, 2023). Second trimester abortions (14 weeks’ gestation and greater) can occur due to delayed pregnancy testing, inability to obtain funding, inability to find a provider or clinic that performs abortion services, or diagnosis of major fetal anomalies detected in the second trimester (ACOG, 2013). Other reasons for second trimester abortions consist of preeclampsia, preterm premature rupture of membranes, and fetal demise (ACOG, 2013). From 14 weeks to 20 weeks’ gestation, a dilation and evacuation (D&E) is conducted. The D&E procedure requires a preprocedure cervical prep of osmotic dilator s or misoprostol to soften and dilate the cervix (ACOG, 2013). During the D&E procedure, the provider aspirates the amniotic fluid and removes the fetus through the cervix, using forceps (ACOG, 2013). Dismemberment usually occurs as the fetus is being pulled through the cervix; therefore, a suction curettage should be performed to ensure all products of conception are removed (ACOG, 2013). According to ACOG (2013) after 20 weeks’ gestation, induction of labor is usually preferred, using misoprostol, mifepristone, manual cervical dilator s (balloon, osmotic dilators), and/or oxytocin (Pitocin). Complications of surgically induced abortions consist of hemorrhage; incomplete abortion, where tissue remains in the uterus; intrauterine blood clots; cervical, uterine, or abdominal trauma; uterine perforation; and infection (ACOG, 2013; Hatcher, 2018).
Nurse’s Role in Induced Abortion
Trained counselors meet with pregnant persons to provide all the options (abortion, parenting, and adoption) prior to deciding on abortion. The counselors also provide education, support, and referral for counseling for the person and their partner because of emotional and mental health needs after the procedure. Once the person has made an informed decision, they meet with the nurse. The nurse provides education prior to the abortion. For a medical abortion, the nurse explains the action of the medications, how to take them, what to expect, and how to follow up. For surgical abortion, the nurse explains the sedation to be used, dilation of the cervix, removal of the products of conception, and the need to return for a follow-up appointment. The nurse recommends taking ibuprofen (Motrin) or acetaminophen ( Tylenol ) for cramping pain. Consent forms are also reviewed.
Postprocedure education is provided by the nurse, including emergency contact information and instructions to call if bleeding has soaked two or more large pads per hour for 2 hours, if the temperature is greater than 100.4° F (38° C), and if abdominal pain with nausea or vomiting is present more than 24 hours after misoprostol (Hatcher, 2018). A discussion of hormonal withdrawal and the effect on the emotions of the patient should take place to prevent any psychologic issues after abortion (Coleman, 2018) The administration of Rho(D) immune globulin (RhoGAM) to the patient, if they have an Rh-negative blood type, is required, along with education regarding the use of RhoGAM. Any time RhoGAM is given, a copy of the administration card with date and dose given is provided to the patient for their medical record keeping at home. The nurse also reviews that the patient should refrain from vaginal coitus , inserting a tampon, or using a douche for 2 weeks. Last, the nurse instructs when the patient should return for contraception counseling .
Nurses working in abortion care can experience many emotions. According to research by Qian et al. (2021), many nurses and providers of abortion care experience burnout and emotional trauma. This research noted that providing abortion care caused many negative and positive emotions for nurses, and many nurses felt they lacked support from family, friends, and nurse colleagues due to the mixed emotions surrounding abortion. This research noted that nurses created coping strategies to support their patients but had to learn to conceal their own emotions. This study suggested the development of employee assistance programs to include psychologic care, cognitive behavior therapy, and professional support for nurses working to provide abortion care.
Some nurses feel a moral responsibility to refuse to provide abortion care. According to the American Nurses Association’s Code of Ethics (2015), in times of moral distress, nurses must express their moral concerns to the appropriate authority. This conscientious objection to being a part of the situation must be communicated in a timely and appropriate manner. Nurses are to maintain patient safety, avoid abandonment of the patient, and leave the patient only when nursing care is continued by others. Nurses must use self-evaluation to determine their moral limits and must follow this code to protect themselves and their patients.
Contraception as a Basic Human Right
Recently, two judges in the United States issued contradictory decisions that have the potential to impact access to medically induced abortions for people who are requesting them. In Texas, Judge Matthew Kacsmaryk ruled that the Food and Drug Administration improperly approved the use of mifepristone (Mifeprex) more than 20 years ago. This ruling made it illegal for clinicians to prescribe the drug for patients requesting early term abortions (prior to 10 weeks pregnant) (Savage & Belluck, 2023). Within hours of that decision, U.S. District Judge Thomas O. Rice issued a ruling in Washington State seeking to block the FDA from removing the drug from the market. Abortions became illegal in 14 states in 2022 after the Supreme Court ruling on Dobbs v. Jackson Women’s Health Organization , nearly 50 years after Roe v. Wade . Other states in the United States allow abortion but have limits of 12 weeks’ gestation or less.
The United Nations Population Fund (UNPFA) believes that the consequences of these decisions are serious, and that contraception is in fact a basic human right. According to the 2023 UNPFA Annual Report, the world population recently reached 8 billion lives. They write, “It is the basic right of every individual to decide freely the number, spacing and timing of their children” (Garbett, 2023). The report states that it is the job of our society to advocate to guarantee the ability of persons to make reproductive and sexual decisions free of discrimination, coercion and violence and to provide access to contraception methods that are affordable, accessible, and meet international standards of quality (Garbett, 2023).