IM injections

Introduction Introduce yourself Get consent and mention confidentiality Confirm patient identity (ask patients name, DOB and ask patient if they know what injection are they going to get) Explanation Explain what is the injection for Explain what is IM injection and where to inject (deltoid) Ask if patient had any injections before and do they know how it feels like Ask if patient has any known allergies!!!! Identification of 5 rights Patient Drug (check vial and drug chart to make sure it's the correct drug) Dose (measure dose correctly) - (Desired dose x volume in vial) / concentration of vial = volume to be given Route (IM injection, using 23 needle) Time (ask patient if he had any injections 24 hours prior to this one Procedure 1. Fill syringe will correct volume 2. Insert needle but do not remove cap till the very end 3. Give patient alcohol swab 4. IM injections 90 degrees entry, pencil grip with fingers resting on arm, DRAW BACK, inject 5. Withdraw needle and discard immediately 6. Put on the cotton ball and get patient to hold on to it on top of puncture site 7. Record the time, site and type of injection on the drug chart Closure Ask if patient is feeling alright. If they feel anything weird, get them to come back immediately. Complications of injections Patient will have different response if given in different route Can cause allergic reaction Contamination can cause infections

Musculoskeletal Shoulder examination Introduction Introduce yourself and mention why you are here Explain that this examination involves looking, feeling and moving the arms and shoulder along with some special test Get patients consent and mention confidentiality Tell patient that it would make the examination easier if patient is willing to remove the shirt Ask patient which side is hurting Examination procedure 1. Watch patient when patient is walking or taking off shirt 2. Look (Inspection) Determine redness, scaring, swelling, unevenness on both sides Remember compare both sides (must mention) 3. Feel (Palpation) always start with the good side Feel the temperature of the skin and make sure there is no difference (use the back of the hand for show) Feel for tenderness or pain as well (ask patient if it is painful if you apply some pressure to certain areas) Palpate bony landmarks trapezius, scapula spine, acromium, glenohumeral joint, clavicle, acromioclavicular joint, sternoclavicular joint, greater & lesser tubercle and find the tendon of long head biceps & supraspinatus tendon 4. Move (Active and Passive movements) Flexion & extension, get patient to extend the arms all the way to the back until they cant extend anymore. Look at the range of movement External rotation (flex elbow at 90 degrees externally rotate) Internal rotation (get patient to touch their back) Abduction & adduction, get patient to move arms up wards and come downwards again. When moving down, mention that it is called the painful-arc test so ask patient to do it really slowly After active movements, now do passive movements with hands on the joints as well check for crepitus 5. Special test Apley scratch test get patient to touch the shoulder, back of the neck and their back Empty can test get patient to lift arm in abducted and slightly internally rotated position, push the hands down and ask patient to resist. Tell patient it is for supraspinatus tendon and muscle Infraspinatus/ teres minor test essentially resist external and internal rotation of patient Biceps test resist flexion Check biceps tendon during flexion and extension Check supraspinatus tendon (move arm up and down when pressing on tendon, ask patient if it is painful) MUST MENTION Apprehension test explain that it is to check for any potential for dislocation of the shoulder and you are not allowed to performed this test. 6. Thank patient and ask patient to put on their cloths. WASH HANDS

Musculoskeletal Hip examination Introduction same Examination procedure 1. Watch as patient is walking in the room 2. Look (inspection) Observe one leg at a time Same as above Get patient to walk to and fro and determine gait Get patient to squat down as well 3. Feel (palpation) Same as above Determine bony landmarks iliac crest, iliac tubercle, ASIS, greater trochanter, PSIS, ischial tuberosity and sacroiliac joint Feel ASIS with thumb and greater trochanter with fingers and note posture make sure that both your thumbs are parallel to each other which means that there isnt any wrong Do the Trendelenburg test with hands on the same position. Get patient to flex knee. 4. Move (Active and Passive movement) Abduction and adduction (place hand on ASIS as patient move) Flexion get patient to lift their leg up as high as they can, one leg at a time Internal & external rotation hold on to patients ankle, and get patient to move the knee outwards and inwards Extension get patient to roll over on their stomach and raise their legs up. Repeat all these steps with passive movements while holding onto the joint 5. Measure Measure the true leg length first from ASIS to inferior medial malleolus, compare both sides (must mention every step) Then measure apparent leg length from belly button till the inferior medial malleolus, compare both sides also (must mention every step) 6. Special test Thomas test place one hand under the lumber spine and detect lumbar lordosis, get patient to flex both knees towards the chest and hold with hand, then release one knee and lay it flat on the bed. Check if the back is bent

Musculoskeletal Knee examination Introduction same Examination procedure 1. Watch as patient is walking in 2. Look (inspection) Watch patient in a number of positions include walking and squatting Look for varus (bow-leg) and valgus (knock knee) When patient is walking, study the gain and movement of knee Determine flexion deformity when patient is squatting down Look for scaring, redness, deformity, lumps (compare both sides)

3. Feel (palpation) Examine scaring, swelling, inflammation, temperature differences, muscle wasting Palpate quadriceps for muscle wasting Find bony landmarks femoral condyles, tibial tuberosity, borders of patella, insertions of hamstrings, popliteal fossa Patella tap compress the suprapatellar bursa of the joint space and tap the patella Determine bulge sign run the hand along the groove beside patella and one side and another, ensure that there isnt any bulge 4. Move (active and passive movements) Flexion & extension watch the movement of the patella when patient is moving, patella subluxation will cause it to slip laterally during flexion Passive movements - hold the patients knee when moving, check for crepitus and range of motion 5. Special test Patellar apprehension test side patella sideways over femoral condyle laterally for displacement in petello femoral joint while slowing flexing the knee, normal sign would be a reflex flexion of quadriceps (NOT PERFORMED BUT MUST BE EXPLAINED) Collateral ligaments test flex the knee slightly while holding the underside of the knee (popliteal region), forearm resting along the length of the tibia. Push the knee inwards or pull outwards. >10 degrees is abnormal Drawers test bend the knee to 90 degrees, sit on patients foot, hold the tibia with both thumbs below the patella, push and pull the tibia Lachmans test knee is flexed at 30 degrees, pull a towel under the knee, make sure the patients foot in not resting on the bed (rest only the heel), put hand firmly on femur and pull the tibia upwards Apleys grinding test patient lying on the stomach, knee flexed at 90 degrees, push the foot down and rotate the leg, hold on to the knee (check for crepitus, listen for grinding) McMurrays test patient lying on back, fully flexed knee, grip the heel and palpate the menisci, externally rotate heel and move leg in clockwise then anticlockwise. Listen for grinding and feel crepitus