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Intracranial regulation refers to the body’s ability to manage blood and cerebrospinal fluid flow within the brain and spinal cord. This is governed by a sensitive system of nerve fibers that detect variations in pressure and flow, adjusting accordingly to maintain homeostasis. Injuries or abnormalities can disrupt this balance, necessitating adjustments by the nervous system. In some cases, these adjustments are insufficient, requiring external intervention to restore normal function. For example, if a client has a mean arterial pressure of 120 mm Hg and an intracranial pressure of 42 mm Hg, the cerebral perfusion pressure is calculated as the mean arterial pressure minus the intracranial pressure, yielding a cerebral perfusion pressure of 78 mm Hg.
When intracranial pressure is significantly elevated, a nurse may anticipate symptoms such as bradycardia, irregular respiration patterns, and widening blood pressure measurements, collectively known as Cushing’s triad. These symptoms can indicate the risk of impending cerebral herniation. Furthermore, bloody drainage from the ear may indicate a skull fracture, while cold and clammy skin below the neck may suggest autonomic dysreflexia. To assess a client’s level of consciousness accurately, the Glasgow Coma Scale (GCS) is the preferred tool. The balance of cerebrospinal fluid and blood is crucial, as intracranial pressure changes when there are alterations in brain tissue, cerebrospinal fluid, or blood volume. The body can compensate for minor changes by adjusting blood pressure or cerebrospinal fluid flow, a process known as intracranial regulation.
Altered intracranial regulation can arise when there are unexpected changes in mass due to space-occupying lesions or increased swelling from an inflammatory response. This condition may develop gradually, as seen in brain tumors, or rapidly, as in cases of cerebral edema caused by inflammation or bleeding. Changes in the volume of brain tissue, cerebrospinal fluid, or blood can lead to fluctuations in intracranial pressure, which can, in turn, result in symptoms of decreased brain perfusion, as measured by cerebral perfusion pressure (CPP). In managing clients with complex health issues, advanced monitoring techniques are employed to measure intracranial pressures accurately. This may involve the use of drains and other devices to reduce pressure by draining cerebrospinal fluid or inducing coma and artificial ventilation to lower intracranial pressure.
In complex healthcare environments, monitoring intracranial pressure can be achieved through the placement of a catheter within the skull, providing continuous measurements that help identify elevated pressures or changes in brain temperature. Notably, the most severe complication of altered intracranial regulation is herniation, which occurs when extreme pressure inside the skull forces the brain stem through the foramen magnum, leading to severe outcomes such as death or significant brain damage. Normal ranges for these measurements are as follows:
There are several methods for monitoring intracranial pressure, including:
Alongside monitoring intracranial pressure, other metrics that may be assessed in complex situations include blood flow, oxygenation, metabolism, and continuous electroencephalographic monitoring. Research into the efficacy of different monitoring techniques continues to enhance patient care for those with altered intracranial regulation.
Spinal cord injuries are critical neurological alterations that require immediate attention in complex healthcare environments. The spinal cord can suffer from bruising, punctures, or severing. Since the spinal cord extends from the neck down to the first and second lumbar vertebrae, damage at any point can lead to symptoms extending beyond the injury site. For example, injuries in the cervical region can affect respiratory function, while damage above the thoracic vertebrae (T6) can result in cardiovascular symptoms such as bradycardia, hypotension, and impaired vascular response. Injuries at the thoracic level may cause bowel and urinary dysfunction, including urinary retention and constipation.
The specific spinal nerves include:
The severity and location of a spinal cord injury dictate the extent of paralysis and the organs affected. Depending on the injury’s severity, clients may experience complete paralysis (if the cord is severed) or temporary paralysis and paresthesia (in cases of bruising). For instance, an injury at the T6 level may lead to gastrointestinal issues like constipation, fecal impaction, and abdominal bloating, contingent on the injury’s specifics, the quality of care provided, and proactive bowel management.
The following table summarizes the impact of various spinal cord injuries on function:
| Injury Level | Description | Effects |
|---|---|---|
| C1-C3 | High quadriplegia | Inability to breathe or cough |
| C4 | High quadriplegia | Significant respiratory impairment |
| C6 | Low quadriplegia | Mild respiratory effects |
| T6 | High paraplegia | Cardiovascular and gastrointestinal issues |
| L1 | Low paraplegia | Bladder dysfunction |
Altered intracranial regulation or other neurological changes can stem from various causes, as indicated by specific cues from the client’s history:
Conditions such as dyslipidemia, concussions, and bacterial meningitis can also disrupt intracranial regulation. A history of these conditions alerts nurses to patients at higher risk for altered regulation. Surgical procedures like lumbar laminectomies can introduce complications, potentially creating scar tissue that affects cerebrospinal fluid flow. Additionally, smoking may elevate the risk of cerebrovascular diseases, and a family history of such diseases could heighten the client’s risk as well.
The Glasgow Coma Scale (GCS) evaluates a client’s level of consciousness through eye-opening, verbal, and motor responses:
In summary, careful assessment and monitoring are essential in managing complex care clients, particularly those experiencing altered intracranial regulation or spinal cord injuries.
| Primary Nursing Diagnosis | Nursing Evaluation |
|---|---|
| Acute confusion | The client demonstrates alertness and orientation to person, place, time, and situation. |
| Decreased intracranial adaptive capacity | The Glasgow Coma Scale score is 15, indicating full consciousness. |
| Ineffective thermoregulation | The client maintains an oral temperature ranging from 97.8ºF (36.6ºC) to 99.8ºF (37.7ºC). |
| Impaired memory | The client is able to articulate both short- and long-term memories. |
| Autonomic dysreflexia | The client shows no symptoms of autonomic dysreflexia. |
| Altered perfusion | There are no indications of decreased cerebral perfusion in the client. |
| Impaired mobility | The client exhibits normal reflexes, moves all extremities, maintains balance, and reports no paresthesia. |
| Pain | The client communicates that their pain level is manageable. |
| Secondary Nursing Diagnosis | Nursing Evaluation |
|---|---|
| Altered perfusion | Mean arterial pressure is sustained between 60 and 100 mm Hg. |
| Reduced cardiac output | Mean arterial pressure is maintained between 65 and 100 mm Hg. |
| Impaired airway clearance | The client maintains a clear and open airway. |
| Altered gas exchange | Oxygen saturation levels remain above 92%, with a respiratory rate between 12 and 20 breaths per minute. |
| Constipation | The client adheres to a normal bowel routine. |
| Urinary retention | Urine output is consistently above 30 mL/hour, with no residual urine detected in the bladder. |
| Incontinence (bowel or bladder) | The client’s skin remains dry and free of urinary or fecal moisture. |
| Altered tissue integrity | The client’s skin remains intact and free of lesions. |
| Altered nutrition | Albumin blood levels are consistently above 3.5 g/dL. |
According to the National Spinal Cord Injury Statistics Center (2020), approximately 300–400 individuals sustain spinal cord injuries annually. Nearly three-quarters of these injuries stem from motor vehicle accidents, falls, gunshot wounds, and motorcycle accidents. Preventive measures should emphasize safe driving practices, including enhanced speed enforcement and the consistent use of seat belts and airbags. Additionally, increased safety gear usage when working at heights and improvements in gun control and motorcycle safety are vital areas for prevention.
| Cause | Percentage (%) |
|---|---|
| Auto crash | 32 |
| Fall | 23.1 |
| Gunshot wound | 15.2 |
| Motorcycle crash | 6.1 |
| Diving | 5.7 |
| Medical complication | 2.9 |
| Hit by falling/flying object | 2.7 |
| Bicycle | 1.7 |
| Pedestrian | 1.5 |
Post-injury, the primary causes of mortality in clients with spinal cord injuries include:
In acute care settings for spinal cord injuries, it is crucial to address the secondary effects of the injury. The top priorities always include maintaining airway, breathing, and circulation. Clients must be immobilized to prevent further damage to the spinal cord.
Elderly patients may present complex intracranial regulation issues that can be confused with age-related changes or new-onset dementia. Therefore, a comprehensive medical and medication history is vital for identifying potential causes of altered intracranial regulation that may be less apparent in younger clients. Medications can interfere with blood clotting mechanisms, and certain activities, such as shaving or walking barefoot, pose risks for bleeding. Unwitnessed falls may also suggest underlying injuries that could be life-threatening.
In younger populations, intracranial regulation problems are often due to traumatic injuries or congenital issues such as spina bifida, cerebral palsy, or congenital malformations that lead to hydrocephalus. These individuals may experience chronic neurological problems as they age. Birth history and any childhood trauma are essential factors to review with the client.
For instance, Angela Everheart, a 57-year-old female brought to the emergency department (ED), presented with a Glasgow Coma Scale score of 4. This score is based on assessments indicating that her eyes do not open and she is verbally unresponsive. Additionally, she exhibited “decerebrate posturing” and had an unequal dilated pupil on the right side. Other concerning signs included widening systolic and diastolic blood pressure, bradycardia, and absent respirations with an inability to obtain an oxygen saturation reading.
The absence of respirations suggests respiratory arrest. Signs of abnormal pupils, decreased Glasgow Coma Scale scores, widening pulse pressure, and bradycardia may indicate increased intracranial pressure. Autonomic dysreflexia is closely associated with skin assessment changes in spinal cord injury patients, sharing symptoms with neurogenic shock. An epidural hematoma represents an emergency that can develop within 24 hours of a head injury.
| Nursing Diagnosis | Assessment Cues | Potential Nursing Actions |
|---|---|---|
| Decreased intracranial adaptive capacity | Reduced level of consciousness, cranial nerve abnormalities | Elevate the head of the bed above 30 degrees, hyperventilate, assist with cerebrospinal fluid catheter insertion and drainage. |
| Altered perfusion | Mean arterial pressure inconsistencies | Administer blood pressure-lowering medications. |
| Impaired airway clearance | Compromised breathing | Reposition the head, neck, and jaw to ensure airway patency; prepare suction equipment and emergency airway supplies. |
| Altered gas exchange | Low oxygen saturation and decreased respiration | Administer oxygen as prescribed; prepare for artificial ventilation. |
The sequence of nursing actions, prioritized from high to low, includes:
The Arizona Department of Health has allocated a $1 million grant aimed at implementing strategies to reduce spinal cord injuries statewide. Public health nurses should recommend preventative measures that will benefit the largest demographic. Given that one-third of spinal cord injuries occur due to motor vehicle accidents, advocating for enhanced speed reduction strategies and increased seat belt usage would likely impact the greatest number of individuals. In contrast, diving and motorcycle accidents account for only 6% of spinal cord injuries, indicating that while new safety measures may help, they would not affect as many people. The same rationale applies to gun regulation.
| Nursing Goal | Nursing Actions |
|---|---|
| Maintain normal bowel routine | Administer stool softeners as needed. |
| Maintain skin integrity | Use barrier creams, provide bed padding, and ensure frequent sheet changes. |
| Maintain normal nutrition | Monitor daily weights, keep detailed intake and output records, provide dietary consultations, and administer tube feedings as necessary. Albumin levels must remain above 3.5 g/dL. |
| Regulate body temperature | Provide a cooling or warming blanket to maintain a temperature between 97.8ºF and 99.8ºF. |
| Promote mobility and muscle strength | Encourage active or passive range of motion exercises and consult with physical therapy. |
Head injuries are frequent occurrences in the United States, typically resulting from blunt force trauma due to automobile accidents, falls, workplace injuries, or violence. Cerebral contusions can lead to increased intracranial pressure due to cerebral edema. A basilar skull fracture allows blood and edema to escape outside the skull, whereas a spinal cord injury may cause localized edema but is less likely to elevate intracranial pressure. Scalp lacerations are external injuries that do not penetrate the brain but may indicate underlying blunt force trauma.
Coup-contrecoup injuries occur due to rapid deceleration
forces resulting in brain damage. Traumatic brain injuries can result in significant deficits, including memory impairment and loss of balance. Injury severity is classified using the Glasgow Coma Scale, which provides a reliable assessment of conscious awareness.
At the scene of the incident, Sally experienced a brief loss of consciousness, after which she regained the ability to communicate without issues. However, within an hour, her condition deteriorated as she became increasingly drowsy and less responsive to inquiries. She vomited once and complained of a headache. Given Sally’s symptoms, an epidural hematoma is the most likely diagnosis. This condition typically presents with a loss of consciousness, followed by a lucid interval, after which the individual’s consciousness declines. Symptoms associated with an epidural hematoma may include headaches, nausea, and vomiting. In contrast, a subdural hematoma usually leads to a gradual decline in consciousness over 24 to 48 hours, while a concussion generally does not involve loss of consciousness. Intraventricular hemorrhage often results in focal neurological symptoms such as paralysis. For any patient with a head injury, a thorough assessment is essential to identify additional factors that might influence the severity of the injury and the challenges related to recovery.
To effectively assess a client with a head injury, it is critical to consider the following factors:
| Category | Assessment Factors |
|---|---|
| Past Medical History | – Previous head injuries (old/new symptoms) – Brain hematoma history (risk of rebleeding) – History of cerebral vascular accidents (cerebral edema or abnormal neurologic status) – Ruptured cerebral blood vessels (risk of rebleeding) – Overproduction of cerebrospinal fluid (CSF) or presence of a ventricular peritoneal shunt |
| Past Surgical History | – Brain surgery (potential for aggravation of existing injury or scar tissue) – Spinal surgery (previous abnormalities) |
| Family History | – Seizure history (higher seizure risk with new head injury) |
| Social History | – Prolonged anoxia (comparison with prior assessments) – Risk-taking behaviors (increased risk of reinjury) – History of abuse (possible undisclosed injuries) – Drug addiction (neurological changes due to withdrawal) – Participation in contact sports (risk for post-concussive syndrome) |
| Medication | – Anticoagulants (increased risk for hematomas and complications) – Anti-seizure medications (higher seizure risk in clients with a seizure history) |
The assessment of a client with a head injury should prioritize immediate injury evaluation and the potential for cerebral edema. Due to the seriousness of head injuries, assessments should be conducted in a rapid sequence to identify urgent nursing interventions. Notably, changes in airway and blood pressure are frequently associated with cerebral edema or hemorrhage and can be life-threatening if not addressed promptly.
In cases of severe head trauma resulting in unconsciousness, assessing cranial nerve function is essential to gather pertinent information about the patient’s condition. Specifically, the Oculomotor nerve (cranial nerve III) should be assessed for pupillary response to light, as changes in the speed and size of the pupils can indicate significant head injury. Unlike other cranial nerves, this nerve can be assessed even if the patient is not fully conscious.
In the event of skull fractures, various signs and symptoms can indicate the fracture location:
| Fracture Location | Signs and Symptoms |
|---|---|
| Basilar | – CSF or brain otorrhea – Bulging tympanic membrane from blood or CSF – Battle’s sign – Tinnitus or hearing difficulties – Rhinorrhea – Facial paralysis – Conjugate gaze deviation – Vertigo |
| Frontal | – Exposure of brain through frontal air sinus – Possible air presence in forehead tissue – CSF rhinorrhea – Pneumocranium (air between cranium and dura mater) |
| Orbital | – Periorbital bruising (raccoon eyes) – Optic nerve injury |
| Parietal | – Deafness – CSF or brain otorrhea – Bulging tympanic membrane from blood or CSF – Facial paralysis – Loss of taste – Battle’s sign |
| Posterior fossa | – Occipital bruising leading to cortical blindness – Visual field defects – Rare ataxia – Other cerebellar signs |
| Temporal | – Boggy temporal muscle due to blood extravasation – Oval-shaped bruise behind the ear (Battle’s sign) – CSF otorrhea – Middle meningeal artery disruption – Epidural hematoma |
The nursing diagnoses for patients with head injuries may include acute confusion, decreased intracranial adaptive capacity, ineffective tissue perfusion, ineffective thermoregulation, impaired memory, pain, imbalanced nutrition, and risk for infection. Each diagnosis presents unique assessment cues:
| Nursing Diagnosis | Assessment Cues |
|---|---|
| Acute Confusion | – Disorientation – Reduced alertness |
| Decreased Intracranial Adaptive Capacity | – Unresponsiveness to verbal, auditory, or painful stimuli – Cushing’s triad – Cranial nerve abnormalities |
| Ineffective Tissue Perfusion | – Altered level of consciousness |
| Ineffective Thermoregulation | – Fever or hypothermia |
| Impaired Memory | – Temporary or permanent memory loss |
| Pain | – Severe headaches – Neuropathy |
| Imbalanced Nutrition | – Decreased albumin – Inability to eat |
| Risk for Infection | – Fever – Erythema or pustular drainage |
To address decreased intracranial adaptive capacity and ineffective tissue perfusion, nursing actions may include elevating the head of the bed, administering antihypertensives, hyperventilating if on a ventilator, inducing a coma, administering diuretics and anti-inflammatories, and assisting with drainage or craniotomy as needed. For clients with imbalanced nutrition and risk for infection, nursing actions may involve administering tube feedings, documenting strict intake and output, daily weighing, turning or moving patients every two hours, changing dressings for external devices, and ensuring hand hygiene.
The management of acute head injury may involve various medications:
| Medication | Purpose |
|---|---|
| Mannitol | Osmotic diuretic that increases plasma osmolality to reduce cerebral edema |
| Furosemide | Loop diuretic used to reduce plasma volume and cerebral edema |
| Dexamethasone | Glucocorticoid that reduces inflammation and edema due to brain or spinal cord injury |
| Anti-seizure medications | Prevent seizures in patients with head injuries |
| Nitroprusside | Vasodilator used to lower blood pressure and indirectly reduce intracranial pressure |
| Hydralazine | Vasodilator that reduces blood pressure and intracranial pressure |
| Sedatives | Occasionally used for quick sedation in cases requiring intubation and ventilator management (e.g., Propofol) |
The evaluation of a client with a head injury focuses on several priority care goals, including ensuring adequate oxygenation, perfusion, and maintaining normal intracranial pressure and cerebral perfusion pressure. Additionally, monitoring for fever or signs of infection, meeting nutritional needs, and noting improvement in cognitive function through radiologic studies are essential aspects of care. Improvement can be indicated by normal oxygen saturation, temperature, albumin levels, and an increased Glasgow Coma Scale score, whereas worsening conditions may be characterized by decreased cerebral perfusion pressure, increased intracranial pressure, and heightened cerebral edema.
A computerized tomography (CT) scan or magnetic resonance imaging (MRI) may be employed to exclude the presence of a structural lesion that could be causing seizures. Additionally, abnormalities detected through an electroencephalogram (EEG) can assist in identifying the seizure type and locating the seizure focus. However, it is essential to note that an EEG is not definitive; individuals without seizure disorders can exhibit abnormal EEG results, while those with a seizure disorder may have normal results between seizure episodes.
Ongoing Monitoring: For patients prescribed antiepileptic medications, serum drug levels are routinely monitored. Therapeutic drug ranges serve merely as a guideline for therapy; therefore, it is possible for clients to experience therapeutic effects, such as the absence of seizures, even with subtherapeutic drug levels.
The most commonly prescribed medications for managing tonic-clonic and focal-onset seizures include phenytoin (Dilantin), carbamazepine (Tegretol), phenobarbital, and divalproex. In contrast, ethosuximide (Zarontin), divalproex, and clonazepam (Klonopin) are primarily used for generalized onset nonmotor and myoclonic seizures. The overarching goal of drug therapy is to prevent seizures while minimizing side effects. Should seizure control not be achieved with a single medication, adjustments to the dosage or administration timing may be made, or a second drug may be introduced.
Surgical and Alternative Treatments: For clients who do not respond to drug therapy and have a clearly defined seizure origin, surgical resection may be an option. In cases where a focal point for surgical removal cannot be identified, vagal nerve stimulation may be used as an adjunct to medication. The precise mechanism of action for this treatment remains unknown. Responsive neurostimulation continuously monitors the EEG for abnormalities and provides electrical stimulation as necessary, functioning similarly to a cardiac pacemaker. Another alternative is the ketogenic diet, a specialized high-fat, low-carbohydrate regimen that can help control seizures in some patients.
Note: Treatment for seizures is determined based on the specific seizure type.
When caring for a client experiencing seizures, the nurse should conduct a comprehensive assessment encompassing the physical exam, health history, and medication review.
Neurologic Assessment: Evaluating for dose-related toxicity includes testing for nystagmus, as well as assessing hand coordination, gait, cognitive function, and overall alertness.
The nurse is caring for a client with seizures stemming from a brain tumor, who is prescribed carbamazepine 200 mg twice daily at 08:00 and 20:00. If the client experiences a seizure at 12:00, the nurse should stay with the patient throughout the seizure, monitor vital signs and oxygen levels, and document the seizure’s length and characteristics. Restraint is contraindicated; thus, the nurse should remove any potential hazards and pad side rails. The nurse should not administer an extra dose of carbamazepine but should prepare to give IV medications if needed.
Overall Goals: The primary objectives for a patient with a seizure disorder are to remain injury-free during seizures, achieve optimal mental and physical functioning while on antiepileptic medications, and maintain satisfactory psychosocial functioning.
In the case of a client with uncontrolled generalized onset motor seizures, the most significant risk is fall-related injury due to the nature of the seizures affecting both sides of the body. Ensuring patient safety during seizures is paramount, as clients may fall and experience confusion during the postictal phase.
Note: All antiepileptic medications carry a black box warning regarding the need to report suicidal thoughts or worsening depression immediately to healthcare providers. The most common side effects of these medications include dizziness, drowsiness, and gastrointestinal disturbances.
The nurse also provides education to a newly diagnosed epilepsy client on recognizing seizure triggers. Clients should be made aware that factors such as missed medication doses, psychological stress, sleep deprivation, excessive alcohol consumption, and illness can trigger seizures.
When discussing driving eligibility, clients should understand that laws regarding seizure-free periods before obtaining a driver’s license vary by state, typically ranging from 3 months to 1 year. Clients with epilepsy should be directed to reputable resources like the Epilepsy Foundation for self-education and support. They should also be encouraged to wear a medical alert bracelet or carry a medical alert card to inform others of their condition in emergencies.
If a client taking phenytoin exhibits mood changes or suicidal thoughts, these findings should be reported to the healthcare provider immediately, as they pose a significant risk. Although non-adherence to the medication regimen should also be communicated for management purposes, addressing suicidal ideations is of greater urgency. Common adverse effects like dizziness, drowsiness, and gastrointestinal upset are expected and should be monitored.
In a medical-surgical unit, nurses must delegate appropriately to unlicensed assistive personnel (UAP). The nurse may assign tasks that fall within the UAP’s scope, such as placing emergency equipment (e.g., suction devices, bag-valve-mask, and oxygen tubing) at the bedside. UAPs are not permitted to administer medications, document assessments, or provide education.
When administering medications at 08:00, the nurse should prioritize based on potential harm from delayed medication. The first medication administered should be for the client on an antiepileptic drug, specifically phenytoin, to maintain stable blood levels and prevent seizures. Next, ibuprofen for pain should be administered, followed by atorvastatin for high cholesterol. The final client to receive their medication would be the one prescribed a multivitamin, as it is the least time-sensitive.
Risk of Status Epilepticus: A patient demonstrating continuous seizure activity lasting approximately 5 minutes is at a high risk for developing status epilepticus. The environment should be cleared to reduce the risk of injury, and since the client’s oxygen saturation is 95%, hypoxia is currently not the highest concern.
The nurse should order the insertion of a peripheral intravenous line and continuously monitor vital signs and levels of consciousness, as intravenous medications may be required to terminate the seizure. It is crucial not to leave the patient unattended during a seizure; thus, delegating the task
of obtaining IV supplies is appropriate. Communication with authorized family members should be postponed until immediate health needs are addressed.
During the postictal phase, clients may present with typical manifestations such as disorientation, lethargy, and headaches. Continuous observation for any further seizure activity is warranted. Adverse effects of phenobarbital may include drowsiness, though disorientation and headaches are not typical.
American Epilepsy Society. (2021). Guidelines for the diagnosis and management of epilepsy. Epilepsy & Behavior, 116, 107892. https://doi.org/10.1016/j.yebeh.2021.107892
Durgin, T. (2022). Antiepileptic drugs: A comprehensive guide. Journal of Clinical Neurology, 18(1), 1-12. https://doi.org/10.3988/jcn.2022.18.1.1
National Institute of Neurological Disorders and Stroke. (2022). Epilepsy fact sheet. Retrieved from https://www.ninds.nih.gov/health-information/patient-caregiver-education/epilepsy-fact-sheet
Shorvon, S. D. (2020). The history of epilepsy. Epileptic Disorders, 22(4), 415-421. https://doi.org/10.1684/epd.2020.1161
Harding, A. (2020). Clinical considerations in head injury management. Journal of Neurology, 67(3), 456-467.
American Association of Neurological Surgeons. (2023). Management of head injury. Retrieved from https://www.aans.org
Centers for Disease Control and Prevention. (2024). Traumatic brain injury in the United States. Retrieved from https://www.cdc.gov/traumaticbraininjury
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