Muscles

The nurse rests a thumb on the tendon in the elbow crease with the arm relaxed and strikes the thumb with the hammer. The elbow should flex slightly. An absent or exaggerated response is documented against the other arm and reported with the rest of the neuro check.

The nurse centers the cuff bladder over the brachial artery with the cuff's lower edge about an inch above the crease, and places the stethoscope on the artery just inside the biceps tendon. This is also the pulse checked during infant CPR.

In a hemiplegic arm the bending muscles overpower the straightening ones and the elbow, wrist, and fingers curl inward. The nurse does range of motion on every shift, positions the arm extended with the palm up, and uses a hand roll or splint as ordered.

The axillary nerve wraps around the upper humerus deep to the middle of the deltoid, not far below the injection site, so a needle placed low can reach it. Lower still, the radial nerve runs in a groove along the back of the humerus, so a site that drifts low and toward the back adds that risk. A needle placed too high can enter the bursa and joint under the acromion and leave a painful, stiff shoulder, so the nurse stays in the center of the triangle on the outer arm.

Do not use the deltoid in infants under 12 months; the nurse uses the vastus lateralis. For toddlers 1 to 2 years the vastus lateralis is still preferred, and the deltoid is used only if the muscle is big enough; from age 3 the deltoid is preferred. Avoid the arm on the side of a mastectomy or lymph node removal, or an arm with a dialysis fistula or graft, to protect against lymphedema and damage to the access; check the chart for a limb restriction and use the other arm or another site.

The nurse rests the weak arm on a pillow, shoulder slightly away from the body, elbow bent, hand higher than the elbow to limit swelling. To move or turn the patient, the nurse uses a draw sheet and supports the arm at the elbow and wrist, never pulling on the arm, because pulling drags the ball out of the socket. A sling or arm trough supports the arm when the patient sits up or walks.

The C7 patient is taught wheelchair push-ups, while the C6 patient, who cannot lift with a push-up, is taught to lean forward or side to side instead; either shift is done about every 15 to 30 minutes. Many C7 patients learn to transfer alone, while a C6 patient may need help or a sliding board. In bed, the nurse turns the patient at least every 2 hours, or as facility policy directs, to prevent pressure injury.

The nurse has the patient do chair push-ups before starting crutches to build the triceps, and teaches pushing up on the chair arms or mattress rather than pulling on the nurse. On crutches the weight rests on the hand grips with the elbows slightly bent, and the pads sit two to three finger widths below the armpit. Leaning on the pads can compress the radial nerve and cause numbness or wrist drop, so the nurse teaches the patient not to lean on them, reports these signs, and has the crutches refitted.