Muscles

The nurse rests fingers on both masseters and both temporalis muscles while the patient clenches, comparing bulk and strength side to side. A weak or wasted side points to a problem in the mandibular branch (V3), which carries all of the nerve's motor fibers. Sensation is checked separately with light touch on the forehead, cheek, and chin, comparing sides.

With fingertips just in front of each tragus, the nurse has the patient open and close the mouth. The joint should move smoothly, and a painless click can be a normal finding. Pain, a grating feel (crepitus), locking, the jaw pulling to one side, or an opening narrower than about three fingers is documented and reported.

The nurse asks the patient to raise the eyebrows, close the eyes tightly while the nurse tries to open them, smile showing teeth, and puff out the cheeks. Any asymmetry is documented by side and by whether the forehead moved.

In Bell palsy the whole half of the face is limp, forehead included, because the facial nerve itself is inflamed and swollen. The eye on that side cannot blink or close, so the nurse gives artificial tears by day and lubricating ointment with an eye patch or tape at night, and teaches the patient to chew on the strong side and check the cheek for pocketed food.

The nurse tests the spinal accessory nerve by having the patient turn the head against the nurse's hand; the sternocleidomastoid opposite the direction of the turn should tighten. The nurse then has the patient shrug against resistance to test the trapezius, which the same nerve supplies. Weakness points to a problem with the nerve on the side of the weak muscle.

The nurse asks the patient to stick the tongue straight out and move it side to side. A tongue that drifts toward one side is weak on that side; the nurse documents the direction and watches for trouble swallowing and speaking.

A drowsy or post-seizure patient is turned onto the side so gravity pulls the tongue forward and secretions drain out of the mouth instead of down the throat. The nurse keeps suction at the bedside and does not leave the patient flat on the back.

The nurse teaches pursed-lip breathing: in through the nose, then out slowly through pursed lips with the exhale longer than the inhale, which keeps small airways open so trapped air can leave. Diaphragmatic breathing, one hand on the belly that rises on inhale, shifts the work back to the diaphragm and away from the neck and shoulder muscles.

Ascites and abdominal distension push the diaphragm up and shrink the room the lungs have to expand, so the nurse raises the patient to semi-Fowler's or high-Fowler's to let the dome drop. In a hiatal hernia, part of the stomach slides up through the diaphragm's opening for the esophagus; the nurse teaches small frequent meals, not lying down after eating, and sleeping with the head of the bed raised.

The nurse pinches a fold of fat at least 2 inches from the umbilicus and injects at 90 degrees if 2 inches of tissue can be grasped, or 45 degrees if only 1 inch can. Insulin absorbs fastest and most evenly from the abdomen, and the client rotates spots within it so the tissue does not harden. A client who always injects in the same spot needs more teaching.

The nurse does not aspirate and does not massage the site, because both increase bruising. For a prefilled enoxaparin syringe, the nurse leaves the air bubble in, inserts the whole needle at 90 degrees into a pinched fold held throughout the injection, and alternates the left and right sides of the abdomen.

The nurse has the patient hold a pillow or folded blanket firmly over the incision while coughing and deep breathing. Bracing the wall eases pain and takes strain off the sutures, so the patient breathes deeply instead of taking shallow, guarded breaths that raise the risk of atelectasis and pneumonia.

The nurse teaches the patient to empty the bladder, then squeeze as if holding back urine and gas, hold about 3 seconds, relax for the same time, and repeat about 10 times, three times a day, with the buttocks, thighs, and belly relaxed and breathing normal. The patient may stop the urine stream once to find the muscle but must not practice while voiding, because that can leave urine in the bladder and raise infection risk. Results take weeks to months of daily practice, so the nurse encourages the patient to keep going.

Leaking a small amount with a cough, sneeze, laugh, or lift is stress incontinence, and pelvic floor training is its first-line treatment. A sudden, strong urge followed by leaking is urge incontinence, managed mainly with bladder training, timed voiding, and cutting bladder irritants such as caffeine. The nurse asks when the leaking happens, because the teaching plan depends on the answer.

After a vaginal birth the nurse inspects the perineum for redness, swelling, bruising, and drainage, and checks how well the edges of any tear or episiotomy stay together. Once the patient is comfortable, the nurse teaches pelvic floor contractions to help restore muscle tone and lower the risk of later incontinence.

The nurse raises the bed to working height, stands with feet apart for a wide base, bends at the hips and knees, holds the load close, and lifts with the legs. The nurse pivots the feet instead of twisting the trunk, because twisting under a load strains the back muscles. A patient who cannot help is moved with a draw sheet, slide board, or mechanical lift and enough staff, not lifted by hand.

For an acute strain, the nurse applies cold for about the first 48 to 72 hours and heat after that, and positions the patient supine with a pillow under the knees or side-lying with knees bent to take tension off the back. The nurse gives analgesics or muscle relaxants as ordered. Before treating the pain as muscle, the nurse checks leg strength, sensation, and bladder and bowel function.

The nurse rests both hands on the patient's shoulders and asks for a shrug against them, then asks the patient to turn the head against the nurse's hand, which tests the sternocleidomastoid. A weak shrug on one side points to the accessory nerve on that same side, but stroke, neck injury, pain, or poor effort can look the same. The nurse documents the finding with the rest of the cranial nerve exam and reports it without naming a cause.

The nurse injects at 90 degrees into the center of the muscle, 2 to 3 fingerbreadths below the acromion and above the armpit level, with no more than about 1 mL. Larger volumes and irritating drugs go to the ventrogluteal site, because the small deltoid cannot hold them without pain and tissue damage.

The nurse uses a 22 to 25 gauge needle, about 1 inch for most adults and 1.5 inches for larger adults, following CDC weight-based guidance. A needle too short leaves the dose in fat, which can weaken the vaccine response and cause more soreness and swelling at the site.

The nurse keeps the arm in the sling as ordered and teaches the patient to do only the exercises the surgeon allows. No lifting, pushing, or pulling with that arm until the surgeon clears it, because the reattached tendon can pull loose before it heals to the bone.

The nurse asks whether the patient can raise the arm overhead and reach behind the back, and about pain when lying on that shoulder at night. Weakness or pain with these moves points to a cuff problem, so the nurse reports it instead of having the patient push through it.

The nurse steadies the upper arm and asks the patient to straighten the elbow against resistance; a working triceps shows C7 function. A patient with a C6 injury can bend the elbow and bend the wrist back but cannot straighten the elbow against resistance. Judge function by voluntary movement, not by reflexes, which are absent during spinal shock.

The nurse teaches the patient to point and flex the feet ten times every hour while awake, applies sequential compression devices as ordered, and gets the patient walking as early as possible. Each contraction squeezes the deep veins and keeps blood from pooling.

A calf that lies pointed for days shortens at the Achilles tendon until the foot cannot come back to neutral. The nurse keeps the ankles at 90 degrees with a footboard or padded boots and ranges the ankle each shift.

Inject at 90 degrees with a needle of about 1 to 1.5 inches, chosen by the patient's size. A well-muscled adult can take a volume of about 3 mL here, less in a thin or older adult; follow facility policy. Rotate sites when injections repeat.

For an irritating or staining drug such as iron dextran, pull the skin and tissue about 1 to 1.5 inches to one side, inject, wait about 10 seconds, withdraw, then let the skin go. Do not massage the site afterward. The shifted tissue seals the needle track, so the drug stays in the muscle instead of leaking into the skin.

The nurse gives infant and toddler IM vaccines in the vastus lateralis, middle third of the outer front of the thigh, at a 90-degree angle, keeping infant volumes small (about 0.5 mL, or per facility policy). It is chosen because the muscle is well developed even in a newborn and no major nerve or blood vessel lies beneath it. Adults who inject their own IM drugs are taught this same site because they can see it and reach it sitting down.

For a thigh IM injection, the nurse finds the middle third of the thigh and moves to its outer front surface, the vastus lateralis, rather than the midline over the rectus femoris. CDC lists the deltoid and vastus lateralis as IM sites, and the ventrogluteal site is also taught. A patient learning to self-inject is shown the outer thigh and told never to use the inner thigh or groin.

Muscle that is not used loses strength within days of bed rest. The nurse does active or passive range of motion as ordered, teaches exercises the patient can do in bed, gets the patient up as early as allowed, and checks protein intake, because muscle needs both load and building material to hold its mass.

At each neurovascular check the nurse has the patient pull the foot and toes up and tests light touch between the great and second toes, the skin supplied by the deep peroneal nerve. The nurse compares each result with the baseline, because a change here is an early warning from both the anterior compartment and the peroneal nerve.

For an infant's vaccine, the nurse uses this site at a 90-degree angle. The CDC needle length is 5/8 inch for a newborn in the first 28 days and 1 inch for infants 1 to 12 months. A parent or helper holds the child and steadies the leg so a kick does not move the needle. The dorsogluteal site is avoided in young children because the muscle is thin and the sciatic nerve lies close by.

The thigh is easy for a seated patient to see and reach, so the nurse teaches patients and parents to use an epinephrine auto-injector here. The nurse teaches them to call 911 after using it, because symptoms can come back after the drug wears off.