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Chapter 22 Antihypertensive Drugs Hypertension Defined (JNC-8) Pharmacology Overview 7 main categories of drugs to treat HTN Adrenergic drugs (old friend) Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Diuretics Vasodilators Direct renin inhibitors A. Adrenergic Drugs: 5 Subcategories and where they act A1. Adrenergic neuron blockers (central and peripheral)- we won’t talk about this A2. Alpha1 receptor blockers (peripheral) A3. Alpha2 receptor agonists (central) A4. Beta receptor blockers (peripheral) A5. Combined α and β receptor blockers (peripheral) A2. Peripherally Acting Adrenergic DrugAlpha1 Blockers (we’ve met these) Doxazosin, prazosin, alfuzosin Block alpha1-receptors which causes BP to decrease Reduces peripheral vascular resistance and BP by dilating both arterial and venous blood vessels Main Use: benign prostatic hyperplasia (BPH) Alpha1 Blockers REMEMBER Tamsulosin (Flomax)* is an α1 blocker BUT *Tamsulosin is not used to control BP, just for BPH. A3. Centrally Acting Adrenergic DrugsAlpha 2 agonist Clonidine and methyldopa 1- Stimulate alpha2-adrenergic receptors. in the brain Decreases sympathetic outflow from the CNS which decreases NE production 2. Stimulate alpha2-adrenergic receptors in kidneys remember alpha 2 opposes alpha 1 Dilates peripheral blood vessels → lowers peripheral resistance → Results in decreased BP So ….Clonidine (Catapres) Used primarily for its ability to decrease blood pressure in an urgent setting Also use in opioid withdrawal as previously discussed Oral (multiple times a day), and topical patch formulations Do not stop abruptly as it may lead to rebound hypertension In reality, Clonidine and methyldopa Not prescribed as first-line home antiHTN drugs High incidence of unwanted adverse effects: orthostatic hypotension, fatigue, and dizziness MIGHT be uses as adjunct drugs after other drugs have failed, in conjunction with other antiHTN such as diuretics A4. Adrenergic Drugs Selective Beta 1 Blockers Metoprolol, Atenolol Reduction of HR through β1 receptor blockade (remember adrenergic blocking of this receptor???) HR results in BP Cause reduced secretion of renin = BP A4. Adrenergic Drugs Selective Beta1 Blockers Nebivolol (Bystolic) Uses: hypertension and HF Action: blocks β1 receptors and produces vasodilatation, which results in a decrease in SVR High doses loses selectivity and blocks both β1 and β2 Less sexual dysfunction All BB- Do not stop abruptly; must be tapered over 1 to 2 weeks A4. Adrenergic Drugs NONSelective Beta Blockers Propranolol Acts equally on β1 and β2 Other uses include situational anxiety associated with public speaking, test taking As mentioned on previous slide, nebivolol at high doses becomes beta nonselective A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Dual antihypertensive effects of reduction in heart rate (beta1 receptor blockade) and vasodilation (alpha1 receptor blockade) Examples are carvedilol (common) and labetalol (not as common) A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Carvedilol (Coreg) Widely used drug that is well tolerated Uses: HTN, mild to moderate HF in conjunction with digoxin, diuretics, and ACE inhibitors Contraindications: severe bradycardia or unstable HF, bronchospastic conditions such as asthma, and various cardiac conduction problems Adrenergic Drugs Indications - HTN But also for Glaucoma (topical) BPH: doxazosin, prazosin, and terazosin (2 for 1) Management of severe HF when used with cardiac glycosides and diuretics Contraindications Acute HF- have to stabilize first MOAIs- yeah doesn’t everything interact with MAOIs? Peptic ulcers Severe liver/kidney disease Asthma (with beta blockers) Adrenergic Drugs: Adverse Effects Orthostatic hypotension 1st-dose syncope Rebound hypertension with abrupt discontinuation Most common: Dry mouth, drowsiness, constipation, sedation Interactions- always check for specific drug interactions Can cause additive CNS depression with alcohol, benzodiazepines, opioids Question #1 When administering an alpha-adrenergic drug for hypertension, it is most important for the nurse to assess the patient for the development of what response? Hypotension Hyperkalemia Oliguria Respiratory distress Answer A Hypotension This is a key point in patient education These drugs have strong vasodilating properties and may cause severe hypotension, especially at the beginning of therapy. B. Angiotensin-Converting Enzyme Inhibitorsaka ACE Inhibitors or ACEi Large group of safe and effective drugs Currently are 10 ACEi Often used as first-line drugs for HF and hypertension May be combined with a thiazide diuretic, loop diuretic, or Calcium Channel Blocker (CCB) You need to understand the basics ACE Inhibitors: Review RAAS ACE converts angiotensin I, formed through the action of renin, to angiotensin II Angiotensin 2 is a potent vasoconstrictor and also induces aldosterone secretion by the adrenal glands Aldosterone stimulates sodium resorption (H20 follows Na Both act to raise BP which causes kidneys to reduce renin production ACEi= Great drug to treat HTN BUT contraindicated in pregnancy (2nd,3rd trimester due to fetal renal damage) and breastfeeding first few weeks after birth B. ACE Inhibitors - PRIL Lisinopril (Prinivil) super common, often the 1st drug Enalapril (Vasotec) also common Captopril (Capoten) great if liver disease present Benazepril (Lotensin) Fosinopril (Monopril) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik) Primary Effects of the ACE Inhibitors Prevent Na (and H2O) resorption by inhibiting aldosterone secretion (volume reduction) (GO BACK TO RAAS DIAGRAM) blood volume decreases work of the heart preload, or the left ventricular end-diastolic volume which is important in HF ACE SUMMARY OF ACTIVITY 1) Prevent vasoconstriction caused by angiotensin 2 (2) Prevent aldosterone secretion  less sodium and water resorption Cardioprotective Effects of ACEi They slow progression of left ventricular hypertrophy (ventricular remodeling) after MI so considered cardioprotective ACE inhibitors have been shown to decrease morbidity and mortality in patients with HF Renal Protective Effects of ACEi ACE inhibitors: reduce glomerular filtration pressure by volume reduction Cardiovascular drug of choice for patients with diabetes since it helps protect kidneys by reducing pressure. Sometimes used low dose for kidney protection with DM without HTN B. ACEi Enalapril (Vasotec) Only ACEi available in both oral and IV Enalapril IV does not require cardiac monitoring Oral enalapril: prodrug (metabolized in liver) Improves patient’s chances of survival after an MI Reduces the incidence of HF B. ACEi Captopril (Capoten) Uses: prevention of ventricular remodeling after MI; reduce the risk of HF after MI Shortest half-life Must be administered multiple times throughout the day so this limits its use Not a prodrug so good for patient with liver disease Question #2 A patient with diabetes has a new prescription for the ACE inhibitor lisinopril. She questions this order because her provider has never told her that she has hypertension. What is the best explanation for this order? The doctor knows best The patient is confused This medication has cardioprotective properties This medication has a protective effect on the kidneys for patients with diabetes Answer D ACE inhibitors have been shown to have a protective effect on the kidneys because they reduce glomerular filtration pressure. This property makes them the cardiovascular drug of choice for patients with diabetes. Question #3 A patient with a history of pancreatitis and cirrhosis is also being treated for hypertension. Which drug will most likely be ordered for this patient? Clonidine Prazosin Diltiazem Captopril Answer D Captopril Captopril is not a prodrug; therefore, it does not need to be metabolized by the liver to be effective. This is an advantage in patients with liver disease. ACE Inhibitors: Adverse Effects *Dry, nonproductive cough, which reverses when therapy is stopped. This is a class effect Dizziness- Note: First-dose hypotensive effect may occur Headache & Fatigue Possible hyperkalemia ** Angioedema: rare but potentially fatal Not safe in pregnancy-are contraindicated during the second and third trimesters of pregnancy because of increased risk of fetal renal damage C. Angiotensin II Receptor Blockers(ARB) Considered an alternative to ACEi Less likely to cause a dry cough and hyper K+ that is common with ACE inhibitors Angiotensin II Receptor Blockers: Mechanism of Action Go back to RAAS diagram! ARBs affect primarily 2 places 1. Vascular smooth muscle - blocks vasoconstriction 2. Adrenal gland -Selectively blocks the binding of Ang 2 to certain Ang 2 receptors inhibiting secretion of aldosterone Lowers volume retention and BP Angiotensin II Receptor Blockers -ARTAN Losartan (Cozaar)- very common Eprosartan (Teveten) Valsartan (Diovan) Irbesartan (Avapro) Candesartan (Atacand) Olmesartan (Benicar) Telmisartan (Micardis) Azilsartan (Edarbi) C. ARB Losartan (Cozaar) Beneficial in patients with HTN and HF Used with caution in patients with kidney or liver dysfunction and in patients with renal artery stenosis ***Not safe for breastfeeding women and should not be used in pregnancy (Cat C 1st trimester, Cat D 2nd-3rd trimester), potential fetal toxicity Appear to be equally effective for the treatment of hypertension and well tolerated ARBs less likely to cause cough and hyperK+ but can still happen Evidence that ARBs are associated with lower mortality after MI than ACE inhibitors Never take ACEi and ARBs at the same time* 5. Calcium Channel Blockers (CCB) Primary use: HTN, angina, some dysrhythmias Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction Results in: Relaxed blood vessels to the heart Decreased peripheral smooth muscle tone Decreased SVResistance Decreased BP E. Diuretics First-line antiHTN in JNC 8 guidelines Decreases fluid volume The results from diuresis: preload, Peripheral resistance Overall effect  Decreased workload of the heart and decreased BP Thiazide diuretics are the most commonly used diuretics for HTN Ie hydrochlorothiazide (HCTZ), chlorthalidone We will discuss diuretics further in the chapter on diuretics F. Vasodilators Directly relax arterial or venous smooth muscle (or both) Results in: Decreased SVR Decreased afterload Peripheral vasodilation Indicated for treatment of HTN May be used in combination with other drugs F. Vasodilators Hydralazine (Apresoline) Orally: routine cases of essential hypertension Injectable: hypertensive emergencies BiDil: specifically indicated as an adjunct for treatment of HF in African-American patients F. Vasodilators Sodium Nitroprusside (Nitropress) *Sodium nitroprusside and IV diazoxide are reserved for the management of hypertensive emergencies. Contraindications: severe HF, known inadequate cerebral perfusion (especially during neurosurgical procedures) F. Vasodilators Adverse Effects Hydralazine: dizziness, headache, tachycardia, edema, dyspnea, N/V/D, vitamin B6 deficiency, rash Sodium nitroprusside: hypotension, bradycardia, decreased platelet aggregation, rash G. Direct Renin Inhibitors Aliskirin (Tekturna) Blocks the RAS pathway at the point of activation. Inhibiting renin production prevents the downstream production of Ang II (potent vasoconstrictor) Adverse effects: N/V, severe hypotension, hyponatremia, hyperkalemia… Contraindicated in patients with DM taking ACEi or ARB Miscellaneous Antihypertensives Eplerenone (Inspra) Newer class of drugs called selective aldosterone blockers (remember RAAS?) Reduces BP by blocking the actions of aldosterone at its corresponding receptors in the kidney, heart, blood vessels, and brain Indications: routine treatment of hypertension and for post-MI HF Contraindicated if serum potassium levels are high (above 5.6 mEq/L) A Special Form of HTNTreatment of Pulmonary Hypertension Sildenafil and Tadalafil Commonly used for erectile dysfunction Used for pulmonary hypertension but with different trade names Sildenafil: Revatio* (Viagra for ED) Tadalafil: Adcirca* (Cialis for ED)

Create a test of 20 questions on place value and decimals ordering, comparing, rounding

Growing up in Sioux Falls, South Dakota, a small city surrounded by endless plains, I've found unexpected echoes of home in China's smaller towns — from the warmth of locals in Huaihua, Central China's Hunan province, to the quiet charm of Yangshuo, South China's Guangxi Zhuang autonomous region. With an itch to see more of China's lesser-visited regions, I began planning a trip to the northwest with seven friends — five Americans, one Pakistani, one Zimbabwean, and one Colombian. We bought round-trip tickets from Shanghai to Yinchuan, Ningxia Hui autonomous region, for less than $120 each. From there, we planned to rent a car and drive to Xining in Qinghai, then on to Qinghai Lake, and finally to Lanzhou, Gansu. To make that possible, several of us applied for Chinese driver's licenses, a process that involved translating our US licenses into Mandarin and passing a short test on traffic laws. Within a day, we were licensed. As we piled into two rental cars in late March to begin our eight-day journey, it became clear that this wasn't just a road trip — it was the culmination of our four years in China, the Mandarin we had so diligently studied, and our ongoing effort to contribute to US-China people-to-people relations. Right away, we drew curious reactions. At the Yinchuan airport, taxi drivers offered us rides into the city, only to stare in astonishment when we told them we had rented cars. "You're driving? In China?" one driver asked, visibly surprised. It was a reaction we'd encountered multiple times during our trip, as foreign drivers are rare in China, especially in remote regions. In Yinchuan, we stocked up on snacks and adjusted to the chilly desert air. From there, we headed west, navigating wide highways framed by dramatic landscapes: arid plains, jagged mountains, and occasionally, a herd of sheep crossing the road. The vastness of the Northwest was humbling — and as someone who grew up on the wide-open prairies of South Dakota, it felt oddly familiar. One of the highlights of our trip was camping by Qinghai Lake, the largest saltwater lake in China. A few summers ago, Santiago Solano, one of my classmates from the US, cycled from Xi'an in Shaanxi to Urumqi in the Xinjiang Uygur autonomous region over the course of a month and met many kind strangers along the way. One of them was Geng San, a Tibetan lamb herder who managed a piece of land right next to Qinghai Lake and graciously invited us to camp there. "That's what China is — it's the people. The quiet generosity of an old Tibetan nomad who, years after we first met, still offered us a place to rest on his land," said Solano, who is also part of the group on this trip. But apparently, we underestimated just how cold it would be to camp next to Qinghai Lake in late March. It was deathly freezing. In preparation for the trip, we had ordered two tent kits and eight sleeping bags. However, when the temperature eventually dropped to — 10 C, all of us piled into the cars and turned the heaters on. So much for camping. From Qinghai Lake, we drove to Lanzhou, where we visited many food markets and tried every type of noodle on offer. Since we are college students, we rented a gaming hotel room — something I've only ever seen in China. At night, instead of attending local parties as we had before, we stayed in the hotel and gamed late into the morning. For me, the trip was as much about the journey as it was about the destinations. Driving through Northwest China gave us a unique perspective on the region's natural beauty and its people. At gas stations, shopkeepers greeted us with curiosity and kindness, often offering recommendations for nearby attractions. At roadside carts, we sampled local specialties, grabbing a quick skewer and a mango for the road. And at every stop, we were touched by the warmth and hospitality that make traveling in China so rewarding. As an American who has lived in China for several years, I'm often asked about my experiences here. Trips like this one remind me of the similarities between the two countries, despite their differences. Just as road trips are a quintessential part of American culture, they've become my favorite way to explore China. Whether it's driving through the rolling hills of South Dakota or the deserts of Ningxia, there's something universal about the freedom and camaraderie that come with having complete control over where you end up. Written by Charlie Howes, a 22-year-old American who has lived in China since 2019. He completed his final year of high school at Beijing No 80 High School and is currently studying at New York University Shanghai. He has founded a company in China focused on facilitating US-China trade and plans to continue living in Shanghai long term. He enjoys road trips, cycling around the world, learning languages, and meeting new people.

We found you were making a quiz on the subject of "What is a rubric? A tool comprising a set of criteria (with possible levels of performance quality on the criteria) developed to assess learners’ work, from written to oral to visual. It is used tomeasureperformance,suchastheprocess of doing something (e.g.,playing a musical instrument, making a speech) or products of the learners’ work (e.g., concept map, laboratory report, bookshelf) (Brookhart, 2013). BENEFITS OF USING RUBRICS Support authentic assessment Reflects how well learners are able to apply knowledge inthe real-world context. Communicate expectations Gives learners an idea of what is expected of them. It is especially useful when the rubrics are communicated to the learners before they are assessed. Improve performance Explicit criteria and performance level descriptions allow learners to understand the desired performance. Learners are able to assess themselves by referring to the specific criteria and performance-level descriptions. Provide informative feedback Instructors are able to provide constructive feedback to learners on their weaknesses and strengths. Promote thinking andlearning 4 Provide informative feedback Instructors are able to provide constructive feedback to learners on their weaknesses and strengths. Learners are able to review and revise their work,thus reflecting on their learning experiences. Ensure fairness Learner performance assessed fairly given its objectivity. It helps avoid disputes between learners and instructors about the scores/grades achieved. TYPES OF RUBRIC ANALYTIC It consists of individual criterion with corresponding descriptor of performance. HOLISTIC It consists of performance descriptors that are placed together to refeclet to overalll performance. ANATOMY OF ANANALYTIC RUBRIC Rating scales with corresponding scores or weights The row represents the criteria for the desired performance, while the column represents the evaluation score. Under the rating scale (corresponding weights orscorescanbeassigned),theperformance descriptors are explicitly stated ANATOMYOF AHOLISTICRUBRIC Descriptions: It comprises the rating scale (corresponding weights or scores can be assigned) in the row while the combined desired performance descriptors are placed in the column. Description of the task The purpose of the assignment is to assess learner’s cognitive and analytic skills in applying knowledge gained and constructed throughout the course Diffusion of Innovation,bywatching the Surrogates movieand writing ananalytical review of the movie in the context of innovation diffusion.Iwant to provide learners with informative feedback on their cognitive and analytic skills such as the following: applying the concepts of innovation diffusion,making judgmentson the scenes related to innovation diffusion identified from the movie,selecting and critiquing theories of innovation diffusion and making connections between the theories,aswell asarguingand proposing necessary solutions to the problemss hown in the movie. ESTABLISHING ALTERNATIVEASSESSMENTINHIGHEREDUCATION VALIDITYAND RELIABILITYOF RUBRICS. Validity Measuring what is supossedto be measured. Reability Yielding consists results. Instruments that are used in the alternative assessment must be aligned to the learning outcomes and measure well what it intends to measure (valid) and produce consistent scores (reliable). The valid instrument will manifest the true ability (latent trait) of learners and permit appropriate inferences to be made about a specific group of people for specific purposes. TYPES OF VALIDITY FACE VALIDITY Simple form of validity thatapplies a superficial and subjective assessment whether the instrument measures what it is supposed to measure. CONTENT VALIDITY Refers to the extent to which the items on a measure assess the same content or how wellthe content material was sampled inthe measure. CONSTRUCT VALIDITY Refers to the extent to which the test may be said to measure a theoretical construct or trait. CONCURRENT VALIDITY Refers to the extent to which scores onanewmeasure are related to scores from a criterion measure administered at the same time. PREDICTIVE VALIDITY Refers to the uses of the scores from the new measure to predict performance on a criterion measure administered ata later time. STEPS TO CONSIDER WHEN ESTABLISHING CONTENT VALIDITY Calculate the level of expert agreeement for the content validity, get expert to verfy. Interview the expert ,make meta contentdata análisis from literatura. STEPS TO CONSIDER WHEN ESTABLISHING CONSTRUCCT VALIDITY Administer the instrument for alll learners, revise any item necccesay, run an apropriates statistical analiysis, administerthe instrument to learners as a pilot test . CONSTRUCTMAP Morepreciseconceptthan construct. Ranges from one extreme to another(fromhightolow,small tolarge,positivetonegative,or strongtoweak). Identifiesthepositionofthe respondentsinthisrange. Representativenessofsampling (questions and ability of respondents). EXAMPLEO FACONSTRUCTMAP:AFFECTIVE LEVELOF AFFECTIVE VARIABLES EXAMPLESOFITEMSIN MEASURINGTEAM WORKING SKILLS 5. Characterisation Learnersvolunteerstodothe groupworks. 4. Organisation Learners are willing to help others,althoughitisnottheir scopeoftask. 3. Valuing Learners respect other team members’opinionwhendoing thediscussion. 2. Responding Learnergivescooperationwhen neededingroupworks. 1. Receiving Learneracceptsthediversityof races and nationalities among groupmembers. EXAMPLEOFACONSTRUCTMAP:PSYCHOMOTOR LEVELOF PSYCHOMOTOR VARIABLES EXAMPLESOFITEMSIN MEASURING DIGITAL SKILLS 7.Origination Learnerscanmodifytheirowndevicesto performbetter. 6.Adaptation Learnerscansolveandtroubleshootthe problemwhileusingthecomputer. 5.ComplexOvertResponse Learnerscanusethecomputercompetently. 4.Mechanism Learners can use the computer independently,butstillmakeminorerrors. 3.GuidedResponses Learnerscanusethecomputer,butstill needguidance. 2.Set Learnersarereadytousethecomputer. 1.Perception Learnerscanobservehowtousecomputer. EXAMPLEOFACONSTRUCTMAP:COGNITIVE LEVELOF COGNITIV E VARIABLES EXAMPLESOFITEMS IN MEASURING THINKINGSKILLS 6. Creating Learners are able to suggest anewmodelorframeworkof learningdigitalcommunity. 5. Evaluating Learners are able to judge the impactofthescenariotowards educationperspective. 4. Analysing Learnerscandifferentiate the factsusingafew theories. 3. Applying Learnerscansolveproblems usingthefactsgiven. 2. Understanding Learnersareabletoexplainthe factsusingtheirownwords. 1. Remembering Learnersonlymemorisethe. Direction of Increasing “X” Learners Learners with high “X” Learners with mid range “X” Learners with low “X” Responses to Item Item response indicate highest level of X Item response indicate higher level of X Item response indicate lower level of X The construct map shows the lower ability students are in line with the lower level of items. This shows that when educators plan to develop an instrument, it Item response indicate lowest level of X Direction of Decreasing “X” is crucial to create an item difficulty thatrepresents learners’ ability. Learners’ ability Learners who engage in level characterisation Learners who engage in level organisation Learners who engage in level valuing Learners who engage in level responding Learners who engage in level receiving Direction of Decreasing“X” MEASURINGCONSTRUCTVALIDITY Unlike content validity, this construct validity can be analysed using statistical analysis. Use Exploratory FactorAnalysis [EFA], Confirmatory FactorAnalysis [CFA] or Unidimensionality to confirm all items are measuring the right construct and the raw variance explained for the latent variables is sufficient. Gap initem map also can show accuracy in construct validity. RELIABILITY The degree to which test scores are consistent over repeated administrations of the same/ equivalent test and therefore considered dependable and repeatable for an individual learner.A test thatproduces highly consistent and stable results (i.e. relative free from random error) is said to be highly reliable. TYPESOFRELIABILITY Test-retest demonstrates the stability of a measure over time 01 Internal consistency most of the items within a rating scale of a concept show consistency of scoring. Inter-rater the extent to which two or more independent raters are consistent in observing, recording and scoring data (should be 70% or higher agreement) 04 Intra-rater relies on one rater to rate an object or event twice (70% or higher of agreement) FACTORSAFFECTING VALIDITYANDHOWTO INCREASEVALIDITY? FACTORS AFFECTING VALIDITY HOWTO INCREASE VALIDITY? 1. Inaccuracy of items in measuringtheoutcomes 1. Vetting session to get reviewsfromtheexpert. 2. Pooritemsdevelopment 2. Followtheformatandtips indevelopinggooditems. 3. Unclearinstructions 3. Do pilot testing to measuretheusabilityof thetest. 4. Interveningevents 4. Controltheinternalthreats validityfactors. 5. Itemsdifficultyisnot suitableforthelearners 5. Create a construct map toensurethereisanitem thatrepresentslearners ability. FACTORS AFFECTING RELIABILIT Y HOWTOINCREASERELIABILITY? 1. TestLength 1. Thetestlengthshouldbeappropriate withtestdifficulty. 2. Test retest interval 2. Suggesteddurationisbetween3 weeksto2months. 3. Variability of scores 3. Doconstructmaptoensuretheitems aresuitablewithlearners’ability. 4. Guessing 4. Penalisetheguessinganswers.You alsocandetecteitherthelearnersare guessing or not using the statistical analysis named guessing analysis andpersonfitanalysis. 5. Inconsistency score from different raters 5. Appointtheratertomarkcertain questionsforalllearners(Thisalways happen when you have more than onesectionandhavemorethanone lecturer). CONCLUSION Coming back to the issue of validity and reliability in assessment, there is a need for educators to put an effort to ensurethattheitemsintheformofquestionsorinstructions arenotonlyclearbutalsoabletomeasurewhatitisintended tomeasurebasedontherelatedlearningoutcomes. Establishingvalidityandreliabilityofinstrumentscan provide educators with some indications of the quality of the measuring tools being used. Valid and reliable instruments enabletheeducatorstocontinuouslyusethemeasuringtools withoutreservation. Reliablenot valid Precisenot Accurate Reliableand valid Preciseand Accurate NotReliable butvalid NotPrecisebut Accurate NotReliable butNotvalid NotPrecisebut NotAccurate 94 ". Would you like to continue making it or start afresh?

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