7.8: Courtroom Players - Judges and Court Staff
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- Alison S. Burke, David Carter, Brian Fedorek, Tiffany Morey, Lore Rutz-Burri, & Shanell Sanchez
- Southern Oregon University via OpenOregon
In their 1977 book, Felony Justice: An organizational analysis of criminal courts, James Eisenstein and Herbert Jacob, coined the term “courtroom workgroup.” [1] They specifically referred to the cooperative working relationship between prosecutors, defense attorneys, and judges in working together (as opposed to an adversarial relationship that the public might expect) to efficiently resolve most of the cases in the criminal courts. This chapter more generally uses the term to include all the individuals working in the criminal courts—judges, attorneys, and the variety of court staff.
The accusatory phase (the pre-trial phase) and adjudicatory phase (the trial phase) of the criminal justice process include individuals who regularly work together in the trial courts. The prosecutor files the accusatory instrument called either an information or an indictment , and represents the state in plea bargaining, on pretrial motions, during the trial, and in the sentencing phase. The defense attorney represents the defendant after charges have been filed, through the pre-trial process, in a trial, and during sentencing, and maybe on the appeal as well. Judges, aided by several court personnel, conduct the pretrial, trial, and sentencing hearings. Prosecutors, defense counsel, and judges perform different roles, but all are concerned with the judicial process and the interpretation of the law. These law professionals are graduates of law schools and have passed the bar examination establishing their knowledge of the law and their ability to do legal analysis. As persons admitted by the state or federal bar associations to the practice of law, they are subject to the same legal codes of professional responsibility, disciplinary rules, and ethical rules and opinions for lawyers. Although the American criminal justice system is said to represent the adversarial model, the reality is that prosecutors, defense attorneys, judges and court staff work with cooperation and consensus rather than conflict. This is understandable when considering the common goal of efficient and expedition case processing and prescribed and agreed upon rules for achieving those goals.
Trial judges: Misperceptions and Realities
Trial court judges are responsible for presiding over pre-trial, trial and sentencing hearings, as well as probation and parole revocation hearings. They issue search and arrest warrants, set bail or authorize release, sentence offenders, engage in pre-sentence conferences with attorneys, work with court clerks, bailiffs, jail staff, etc. Trial judges have considerable, but not unlimited, discretion. In addition to the ethical and disciplinary rules governing all attorneys in the state, trial judges are subject to judicial codes of conduct. Judges are bound by the applicable rules of law when deciding cases and writing their legal opinions. Some rules governing judges are flexible guidelines while other rules are very precise requirements.
During the pretrial phase, judges make rulings on the parties’ motions, such as motions to exclude certain physical or testimonial evidence, motions to compel discovery, and motions to change venue. Because most cases are resolved prior to trial through plea-bargaining, one important judicial function is taking the defendant’s guilty plea.
At trial, if the defendant elects to waive a jury, there is a bench trial, and the judge sits as the “trier of fact.” Like jurors in a jury trial, the judge has considerable discretion when deciding what facts were proven (or not) by the parties and what witnesses he or she finds credible. When the defendant elects for a jury trial, the jury decides what the facts are. In either a bench or jury trial, the trial judge rules: on the admissibility of evidence (whether a jury is entitled to hear certain testimony or look at physical evidence), whether witnesses are competent, whether privileges exist, whether witnesses qualify as experts, whether jurors will be excused from jury service, etc. At the end of the jury trial, the judge gives a set of jury instructions to the jurors which informs them on the law that applies to the case they are deciding.
If the defendant is convicted, then the judge will impose the sentence. Except for death penalty cases, jurors are generally not involved with sentencing the defendant. Judges have perhaps the broadest discretion in their role imposing sentences. However, with more states enacting mandatory minimums and sentence guidelines, judicial discretion has been severely curtailed.
“In the eyes of most Americans, the judge is the key player in the courtroom workgroup. The symbolism and ceremony of a criminal trial reinforce this view. The judge is seated on a raised bench, robed in black, and wields a gavel to maintain order in the courtroom. Moreover, the participants and spectators—including the defense attorney and the prosecutor—are commanded to ‘all rise’ when the judge enters or leaves the courtroom. It is no wonder, then that the judge is seen as the most influential person in court.
This view of the judge, though accurate to some degree, is misleading for at least two reasons. First, although the judge clearly plays an important role—in many cases, the lead role—in state and federal criminal courts, other actors play significant supporting roles. This is particularly the case in the majority of criminal cases that are settled by plea, not trial. In these cases, the key player may be the prosecutor rather than the judge. A second reason why the traditional view of the judge is misleading is that it is based on an inaccurate assessment of the role of the judge. Judging involves more than presiding at trials. In fact, most of what judges do during a typical day or week is something other than presiding at trials—reading case files, conducting hearings, accepting guilty pleas, pronouncing sentences, and managing court dockets.” [2]
The role played by the judge, in other words, is both less influential and more varied than the traditional view would have people believe.
Trial Judge Selection and Qualifications
The sole qualification to be a judge in most jurisdictions is graduating from a law school and membership in the state’s bar association. Although the trend is for judges to be lawyers prior, a few jurisdictions do not require justices of the peace or municipal judges to be attorneys.
States procedures in selecting judges vary tremendously. “Almost no two states are alike and many states employ different methods of selection depending on the different levels of the judiciary creating ‘hybrid’ systems of selection” [3] . Nevertheless, the primary differences surround whether judges are elected or appointed, or selected based on merit. There are four primary methods used to select judges in the United States: appointment, with or without confirmation by another agency; partisan political election; non-partisan election; and a combination of nomination by a commission, appointment and periodic reelection (the Missouri Plan).
There are variations within these four primary methods. As noted above, states may use different methods to select judges based on the level in the judicial hierarchy. For example, municipal judges may be appointed, while supreme court judges are elected. Each selection method has its critics and advocates, and the relative merits of each are generally judged by the selection methods ability to achieve judicial independence and accountability. Notwithstanding the critiques of each of the methods, there has been little empirical evidence that the quality of judges, in terms of competency, effectiveness, or honesty, varies depending on the methods used to select the judge. [4] [5] [6]
The length of time a judge will “sit”, called a term in office or tenure, varies greatly, generally from four to sixteen years. Frequently, the term for a trial judge is less than a term for an appellate judge. At the appellate level, six years is the shortest term, and many states use terms of ten years or more for their appellate judges. Only a few states have lifetime tenure for their judges.
In the federal system, the President appoints Article III judges (U.S. District Court, U.S. Circuit Court, and U.S. Supreme Court judges) with the advice and consent of the Senate. In Article III, U.S. Constitution states that federal judges are appointed to “hold their Offices during Good Behavior.” On February 25, 2019, the Court in Rizo v. Yovino, ___ U.S. ___ (2019) refused to address the merits of the case (an important employment wage discrimination case) because the judge who wrote the Ninth Circuit opinion died eleven days before its release. What will likely become an oft-quoted sentiment, “Federal judges are appointed for life, not for eternity.”
The district courts appoint federal magistrate judges to either four or eight-year terms. Though it would seem that politics has played an increasing role in the selection of judges in the federal system, perceptions are influenced by what we currently hear and read. The reality is that complaints of political overreaching in selecting federal judges have been with us since the federal courts were first staffed.
Link to Washington Post showing political judicial appointments since President Reagan https://www.washingtonpost.com/graphics/2018/politics/trump-federal-judges/?utm_term=.479982ef3fd6)
Link to Washington Post article showing political party breakdown in the confirmation of Justice Gorsuch in 2017 and comparing the breakdown with other current U.S. Supreme Court justices https://www.washingtonpost.com/graphics/politics/scotus-confirmation-votes/?tid=graphics-story&utm_term=.35b33aa30d39
A 1952 article shows that the role of politics in judicial selection is not only a recent concern https://library.cqpress.com/cqresearcher/document.php?id=cqresrre1952012300
Judicial Clerk, Law Clerk, and Judicial Assistants
Generally, judges have one or two main assistants. These individuals are known as “judicial clerk”, “clerk of court”, “law clerk”, or “judicial assistant”. Of course, there may be several court clerks who interact each day with all the judges in the courthouse, but generally, judges have only one or two judicial assistants who work directly with them. The clerk of court works directly with the trial judge and is responsible for court records and paperwork both before and after the trial. Usually, each judge has his or her own clerk. The clerk prepares all case files that a judge will need for the day. During hearings and the trial, these clerks record and mark physical evidence introduced in the trial, swear in the witnesses, or administer the oath to the witness, take notes cataloging the recordings, etc. In some jurisdictions, the law clerks are lawyers who have just completed law school and may have already passed the bar exam. In other jurisdictions, the law clerks are not legally trained but may have specialized paralegal training or legal assistant training.
Local and State Trial Court Administrators
Local and state trial court administrators oversee the administration of the courts. These administrators’ responsibility includes: hiring and training court personnel (clerks, judicial assistants, bailiffs), ensuring that the court caseloads are efficiently processed, keeping records, sending case files to reviewing courts, ensuring that local court rules are being implemented, and working with the local and state bar associations to establish effective communications to promote the expedient resolutions of civil and criminal cases.
Indigency Verification Officers
The Indigency Verification Officer (IVO) is a court employee who investigates defendants’ financial status and determines whether they meet the criteria for court-appointed counsel. More than 75% of all individuals accused of a crime qualify as indigent. How poor a defendant must be to qualify for a court-appointed attorney varies from place to place, and each IVO uses a screening device that takes into consideration the cost of defense in the locality as well as defendant’s financial circumstances. One difficulty in qualifying for a court-appointed attorney is having equity in a home that cannot be easily sold quickly enough to provide resources for the defendant to hire an attorney. Another difficulty for indigency verification officers is getting the information needed from defendants who may be suffering from mental health issues.
Bailiffs
Bailiffs are the court staff responsible for courtroom security. Bailiffs are often local sheriff deputies or other law enforcement officers (or sometimes former officers), but they can also be civilians hired by the court. Sometimes, courts will use volunteer bailiffs. Bailiffs work under the supervision of the trial court administrator. During court proceedings, bailiffs or clerks call the session to order, announce the entry of the judge, make sure that public spectators remain orderly, keep out witnesses who might testify later (if the judge orders them excluded upon request of either party), and attend to the jurors. As courtroom security becomes a bigger concern, law enforcement officers are increasingly used as bailiffs, and they are responsible for the safety of the court personnel, spectators, witnesses, and any of the parties. In some communities, law enforcement bailiffs may transport in-custody defendants from the jail to the courthouse and back. In most jurisdictions today, bailiffs screen people for weapons and require them to silence cell phones before allowing them to enter the courtroom.
Jury Clerk
The jury clerk: sends out jury summons to potential jurors, works with jurors requests for postponements of jury service, coordinates with the scheduling clerk to make sure enough potential jurors show up at the courthouse each day there is a trial, schedules enough grand jurors to fill all the necessary grand jury panels, arranges payment to jurors for their jury service, and arranges lodging and meals for jurors in the rare event of jury sequestration.
Court Clerks and Staff
Court structure varies from the courthouse to courthouse, but frequently court staff is divided into units. For example, staff may be assigned to work in the criminal unit, the civil unit, the traffic unit, the small claims unit, the juvenile unit, the family unit, or the probate unit. In smaller communities, there may be just a few court clerks who “do it all”. With the trend towards specialized courts (drug courts, mental health courts, domestic violence courts, and veteran courts), staff may specialize in and/or rotate in and out of the various units. Court staff are expected to have a vast knowledge of myriad local court rules and protocols, statutes, and administrative rules that govern filing processes, filing fees, filing timelines, accounting, record maintenance, as well as a knowledge of general office practices such as ordering supplies, mastering office machinery, and ensuring that safety protocol is established and followed. Recently, many courts have transitioned to electronic filing of all documents, usually managed through a centralized state court system. This transition presents challenges to court staff as they learn the new filing software, keep up with new filings, and archive the past court documents.
Release Assistance Officers
Release assistance officers (RAO) are court employees who meet with defendants at the jail to gather information to pass on to the judge who makes release decisions. Release assistance officers make their recommendations based on the defendant’s likelihood of reappearance and other considerations specified by statute or local rules. In determining whether the defendant is likely to reappear, the RAO considers: the defendant’s ties to the community, the defendant’s prior record of failures to appear, the defendant’s employment history, whether the defendant lives in the community, the nature and seriousness of the charges, and any potential threat the defendant may present to the community.
The availability of space at the jail may also play a role in whether an individual is released. Court and jail staff may need to work together to establish release protocols when space is limited. The RAO should have a significant voice in drafting those protocols. Whether the RAO recommends security (bail) or conditional release, the RAO will generally suggest to the judge the conditions that the defendant should abide by if he or she makes bail or is conditionally released. Defendants released prior to trial will sign release agreements indicating the conditions of release recommended by the RAO and imposed by the judge. RAOs may also investigate the defendant’s proposed living conditions upon release to make sure that they promote lawful activity and the ability for reappearance for all scheduled court appearances.
Scheduling Clerk
The scheduling clerk, or docketing clerk, set all hearings and trials on the court docket. The scheduling clerk notes the anticipated duration of trials (most trials are concluded within one day), speedy trial constraints, statutory and local court rules time frames, etc. The role of the scheduling clerk is extremely important, and an experienced scheduling clerk contributes to the overall efficiency of the legal process. Ineffective or inefficient scheduling causes delay, frustration, and may impede the justice process. Part of scheduling, or docketing, is keeping track of law enforcement officers’ and defense attorneys’ scheduled vacations. In addition, the scheduling clerk must be mindful of the judges’ calendars which should track scheduled vacation time and training days, and also needed desk time, the time necessary for resolving cases they have taken under advisement. (Note that trial judges can either decide “from the bench”, meaning they will rule immediately on the issues before them during the hearing, or after taking the case under advisement, meaning they will rule through a written decision/opinion letter after spending time researching the law, reviewing the parties written pleadings, and considering the oral arguments).
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Eisentstein, J., & Jacob, H. (1977). Felony Justice: An organizational analysis of criminal courts. Boston, MA: Little Brown and Co.
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Spohn, C. & Hemmens, C. (2012)
Courts: A Text/Reader
(2nd ed.). Los Angeles, CA: SAGE Publications, Inc.
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Berkson, L.C. (2005). J
udicial selection in the United States: A special report.
In E.E. Slotnick (Ed.) Judicial Politics: Readings from Judicature (3d ed., pp. 50). Washington, DC: CQ Press
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Atkins B.M. & Glick, H.R. (1974). Formal judicial recruitment and state supreme court decisions.
American Politics Quarterly
, 2, 427-449
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Dubois, P.L. (1986), Accountability, independence, and the selection of state judges: The role of popular judicial elections.
Southwestern Law Journal
, 40, 31-52
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Nagel, S. (1975).
Improving the legal process
. Lexington, MA: Lexington Books.
↵


4.1: Simple Interest and Discount
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Learning Objectives
In this section, you will learn to:
- Find simple interest.
- Find present value.
- Find discounts and proceeds.
Simple Interest
It costs to borrow money. The rent one pays for the use of money is called the interest . The amount of money that is being borrowed or loaned is called the principal or present value . Simple interest is paid only on the original amount borrowed. When the money is loaned out, the person who borrows the money generally pays a fixed rate of interest on the principal for the time period he keeps the money. Although the interest rate is often specified for a year, it may be specified for a week, a month, or a quarter, etc. The credit card companies often list their charges as monthly rates, sometimes it is as high as 1.5% a month.
Definition: Simple Interest
If an amount \(P\) is borrowed for a time \(t\) at an interest rate of \(r\) per time period, then the simple interest is given by
\[ I = P \cdot r \cdot t \nonumber \]
Definition: Accumulated Value
The total amount \(A\), also called the accumulated value or the future value, is given by
\[ \begin{align*} A &= P + I \\[4pt] &= P + Prt \end{align*} \nonumber \]
or
\[ A = P(1+rt) \label{simple3} \]
where interest rate \(r\) is expressed in decimals.
Example \(\PageIndex{1}\)
Ursula borrows $600 for 5 months at a simple interest rate of 15% per year. Find the interest, and the total amount she is obligated to pay?
Solution
The interest is computed by multiplying the principal with the interest rate and the time.
\[\begin{align*} \mathrm{I} &=\operatorname{Prt} \\[4pt] &=\$ 600(0.15) \frac{5}{12} \\[4pt] &=\$ 37.50 \end{align*} \nonumber \]
The total amount is
\[\begin{align*} \mathrm{A} &=\mathrm{P}+\mathrm{I} \\[4pt] &=\$ 600+\$ 37.50 \\[4pt] &=\$ 637.50 \end{align*} \nonumber \]
Incidentally, the total amount can be computed directly via Equation \ref{simple3} as
\[\begin{align*} A &=P(1+r t) \\[4pt] &=\$ 600[1+(0.15)(5 / 12)] \\[4pt] &=\$ 600(1+0.0625) \\[4pt] &=\$ 637.50 \end{align*} \nonumber \]
Example \(\PageIndex{2}\)
Jose deposited $2500 in an account that pays 6% simple interest. How much money will he have at the end of 3 years?
Solution
The total amount or the future value is given by Equation \ref{simple3}.
\[\begin{align*} A &= P(1 + rt) \\[4pt] &=\$ 2500[1+(.06)(3)] \\[4pt] \mathrm{A} &=\$ 2950 \end{align*} \nonumber \]
Example \(\PageIndex{3}\)
Darnel owes a total of $3060 which includes 12% interest for the three years he borrowed the money. How much did he originally borrow?
Solution
This time we are asked to compute the principal \(P\) via Equation \ref{simple3}.
\[\begin{align*} \$ 3060 &=\mathrm{P}[1+(0.12)(3)] \\[4pt] \$ 3060 &=\mathrm{P}(1.36) \\[4pt] \dfrac{\$ 3060}{1.36}&=\mathrm{P} \\[4pt] \$ 2250 &=\mathrm{P} \quad \text { Darnel originally borrowed \$2250. } \end{align*} \nonumber \]
Example \(\PageIndex{4}\)
A Visa credit card company charges a 1.5% finance charge each month on the unpaid balance. If Martha owed $2350 and has not paid her bill for three months, how much does she owe now?
Solution
Before we attempt the problem, the reader should note that in this problem the rate of finance charge is given per month and not per year.
The total amount Martha owes is the previous unpaid balance plus the finance charge.
\[ A=\$ 2350+\$ 2350(.015)(3)=\$ 2350+\$ 105.75=\$ 2455.75 \nonumber \]
Alternatively, again, we can compute the amount directly by using formula \(A = P(1 + rt)\)
\[A=\$ 2350[1+(.015)(3)]=\$ 2350(1.045)=\$ 2455.75 \nonumber \]
Discount and Proceeds
Banks often deduct the simple interest from the loan amount at the time that the loan is made. When this happens, we say the loan has been discounted. The interest that is deducted is called the discount , and the actual amount that is given to the borrower is called the proceeds . The amount the borrower is obligated to repay is called the maturity value.
Discount and Proceeds
If an amount \(M\) is borrowed for a time \(t\) at a discount rate of \(r\) per year, then the discount \(D\) is
\[ D = M \cdot r \cdot t \nonumber \]
The proceeds \(P\), the actual amount the borrower gets, is given by
\[\begin{align*} P &=M-D \\[4pt] &=M-M r t \end{align*} \nonumber \]
or
\[P = M(1-rt) \nonumber \]
where interest rate \(r\) is expressed in decimals.
Example \(\PageIndex{5}\)
Francisco borrows $1200 for 10 months at a simple interest rate of 15% per year. Determine the discount and the proceeds.
Solution
The discount \(D\) is the interest on the loan that the bank deducts from the loan amount.
\[\begin{array}{l}
\mathrm{D}=\mathrm{Mrt} \\
\mathrm{D}=\$ 1200(0.15)\left(\frac{10}{12}\right)=\$ 150
\end{array} \nonumber \]
Therefore, the bank deducts $150 from the maturity value of $1200, and gives Francisco $1050. Francisco is obligated to repay the bank $1200.
In this case, the discount \(D\) = $150, and the proceeds
\[P = \$1200 - \$150 = \$1050. \nonumber \]
Example \(\PageIndex{6}\)
If Francisco wants to receive $1200 for 10 months at a simple interest rate of 15% per year, what amount of loan should he apply for?
Solution
In this problem, we are given the proceeds \(P\) and are being asked to find the maturity value \(M\).
We have \(P\) = $1200, \(r = 0.15\), \(t\) = 10/12 . We need to find \(M\).
We know \(P = M - D\)
but also \(D = Mrt\)
therefore
\[\begin{align*} \mathrm{P} &=\mathrm{M}-\mathrm{Mrt} \\[4pt] &=\mathrm{M}(1-\mathrm{rt}) \\[4pt] \$ 1200 &=\mathrm{M}\left[1-(0.15)\left(\dfrac{10}{12}\right)\right] \end{align*} \nonumber \]
We need to solve for \(M\).
\[\begin{align*}
\$ 1200 &=\mathrm{M}(1-0.125) \\[4pt]
\$ 1200 &=\mathrm{M}(0.875) \\[4pt]
\dfrac{\$ 1200}{0.875} &=\mathrm{M} \\[4pt]
\$ 1371.43 &=\mathrm{M}
\end{align*} \nonumber \]
Therefore, Francisco should ask for a loan for $1371.43.
The bank will discount $171.43 and Francisco will receive $1200.
Summary
Below is a summary of the formulas we developed for calculations involving simple interest:
Simple interest
If an amount \(P\) is borrowed for a time \(t\) at an interest rate of \(r\) per time period, then the simple interest is given by
\[ I = P \cdot r \cdot t \nonumber \]
The total amount \(A\), also called the accumulated value or the future value, is given by
\[ A = P + I = P + Prt \nonumber \]
or
\[ A = P(1+rt) \nonumber \]
where interest rate \(r\) is expressed in decimals.
Discount and Proceeds
If an amount \(M\) is borrowed for a time \(t\) at a discount rate of \(r\) per year, then the discount \(D\) is
\[ D = M \cdot r \cdot t \nonumber \]
The proceeds \(P\), the actual amount the borrower gets, is given by
\[\begin{array}{l}
P=M-D \\
P=M-M r t
\end{array} \nonumber \]
or \[P = M(1-rt) \nonumber \]
where interest rate \(r\) is expressed in decimals.
At the end of the loan's term, the borrower repays the entire maturity amount \(M\).


7.4: Intramuscular Injections
Intramuscular (IM) injections deposit medications into the muscle fascia, which has a rich blood supply, allowing medications to be absorbed faster through muscle fibres than they are through the subcutaneous route (Malkin, 2008; Ogston-Tuck, 2014a; Perry et al., 2014). The IM site is used for medications that require a quick absorption rate but also a reasonably prolonged action (Rodgers & King, 2000). Due to their rich blood supply, IM injection sites can absorb larger volumes of solution, which means a range of medications, such as sedatives, anti-emetics, hormonal therapies, analgesics, and immunizations, can be administered intramuscularly in the community and acute care setting (Hunter, 2008; Ogston-Tuck, 2014a). In addition, muscle tissue is less sensitive than subcutaneous tissue to irritating solutions and concentrated and viscous medications (Greenway, 2014; Perry et al., 2014; Rodgers & King, 2000).
The technique of IM injections has changed over the past years due to evidence-based research and changes in equipment available for the procedure. An IM site is chosen based on the age and condition of the patient and the volume and type of medication injected. When choosing a needle size, the weight of the patient, age, amount of adipose tissue, medication viscosity, and injection site all influence the needle selection (Hunter, 2008; Perry et al., 2014; Workman, 1999).
Intramuscular injections must be done carefully to avoid complications. Complications with IM include muscle atrophy, injury to bone, cellulitis, sterile abscesses, pain, and nerve injury (Hunter, 2008; Ogston-Tuck, 2014a). With IMs, there is an increased risk of injecting the medication directly into the patient’s bloodstream. In addition, any factors that impair blood flow to the local tissue will affect the rate and extent of drug absorption. Because of the adverse and documented effects of pain associated with IM injections, always use this route of administration as a last alternative; consider other methods first (Perry et al., 2014).
Sites for intramuscular injections include the ventrogluteal, vastus lateralis, and the deltoid site. Literature shows inconsistency in the selection of sites for deep muscular injections: selection may be based on familiarity and confidence rather than on “best practice” (Ogston-Tuck, 2014a). However, there is sufficient evidence that the ventrogluteal IM site is the preferred site whenever possible, and is an acceptable site for oily and irritating medications. The ventrogluteal site is free from blood vessels and nerves, and has the greatest thickness of muscle when compared to other sites (Cocoman & Murray, 2008; Malkin, 2008; Ogston-Tuck, 2014a). A longer needle with a larger gauge is required to penetrate deep muscle tissue. The needle is inserted at a 90-degree angle perpendicular to the patient’s body, or at as close to a 90-degree angle as possible. Use a quick, darting motion when inserting the needle.
Aspiration refers to the action of pulling back on the plunger for 5 seconds prior to injecting medication (Ipp, Sam, & Parkin, 2006). Current practice in the acute care setting is to aspirate IM injections to check for blood return in the syringe. Lack of blood in the syringe confirms that the needle is in the muscle and not in a blood vessel. If blood is aspirated, remove the needle, discard it appropriately, and re-prepare and administer the medications (Perry et al., 2014). Recent research has found that there is no evidence to support the practice of aspiration, but despite policy changes, the procedure of aspiration continues to be taught and practised (Canadian Agency for Drugs and Technologies in Health, 2014; Greenway, 2014; Sepah, Samad, & Altaf, 2014; Sisson, 2015). Vaccinations and immunizations given by IM injections are never aspirated (Centers for Disease Control, 2015).
The Z-track method is a method of administrating an IM injection that prevents the medication being tracked through the subcutaneous tissue, sealing the medication in the muscle, and minimizing irritation from the medication. Using the Z-track technique, the skin is pulled laterally, away from the injection site, before the injection; then the medication is injected, the needle is withdrawn, and the skin is released. This method can be used if the overlying tissue can be displaced (Lynn, 2011).
IM Injection Sites
Table 7.7 describes the three injection sites for IM injections.
| Table 7.7 Intramuscular Injection Sites | |||
|
Site |
Additional Information |
||
| Ventrogluteal |
The site involves the gluteus medius and minimus muscle and is the safest injection site for adults and children. The site provides the greatest thickness of gluteal muscles, is free from penetrating nerves and blood vessels, and has a thin layer of fat.
To locate the ventrogluteal site, place the patient in a supine or lateral position (on their side). The right hand is used for the left hip, and the left hand is used for the right hip. Place the heel or palm of your hand on the greater trochanter, with the thumb pointed toward the belly button. Extend your index finger to the anterior superior iliac spine and spread your middle finger pointing towards the iliac crest. Insert the needle into the V formed between your index and middle fingers. This is the preferred site for all oily and irritating solutions for patients of any age. Needle gauge is determined by the solution. An aqueous solution can be given with a 20 to 25 gauge needle. Viscous or oil-based solutions can be given with 18 to 21 gauge needles. The needle length is based on patient weight and body mass index. A thin adult may require a 16 mm to 25 mm (5/8 to 1 inch) needle, while an average adult may require a 25 mm (1 inch) needle, and a larger adult (over 70 kg) may require a 25 mm to 38 mm (1 to 1 1/2 inch) needle. Children and infants will require shorter needles. Refer to the agency policies regarding needle length for infants, children, and adolescents. For the ventrogluteal muscle of an average adult, give up to 3 ml of medication. |
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| Vastus lateralis |
The vastus lateralis is commonly used for immunizations in children from infants through to toddlers. The muscle is thick and well developed. This muscle is located on the anterior lateral aspect of the thigh and extends from one hand’s breadth above the knee to one hand’s breadth below the greater trochanter. The middle third of the muscle is used for injections. The width of the muscle used extends from the mid-line of the thigh to the mid-line of the outer thigh. To help relax the patient, ask the patient to lie flat with knees slightly bent, or have the patient in a sitting position.
The length of the needle is based on the patient’s age, weight and body mass index. In general, the recommended needle length for an adult is 25 mm to 38 mm (1 to 1 1/2 inch). The gauge of the needle is determined by the type of medication administered. Aqueous solutions can be given with a 20 to 25 gauge needle; oily or viscous medication should be administered with 18 to 21 gauge needles. A smaller gauge needle (22 to 25 gauge) should be used with children. The length will be shorter for infants and children; see agency guidelines. The maximum amount of medication for a single injection is 3 ml. |
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| Deltoid muscle |
The deltoid muscle has a triangular shape and is easy to locate and access, but is commonly underdeveloped in adults. Begin by having the patient relax the arm. The patient can be standing, sitting, or lying down. To locate the landmark for the deltoid muscle, expose the upper arm and find the acromion process by palpating the bony prominence. The injection site is in the middle of the deltoid muscle, about 2.5 to 5 cm (1 to 2 inches) below the acromion process. To locate this area, lay three fingers across the deltoid muscle and below the acromion process. The injection site is generally three finger widths below, in the middle of the muscle.
Select needle length based on age, weight, and body mass. In general, for an adult male weighing 60 to 118 kg (130 to 260 lbs), a 25 mm (1 inch) needle is sufficient. For women under 60 kg (130 lbs), a 16 mm (5/8 inch) needle is sufficient, while for women between 60 and 90 kg (130 to 200 lbs), a 25 mm (1 inch) needle is required. A 38mm (1 1/2 inch) length needle may be required for women over 90 kg (200 lbs) for a deltoid IM injection. Refer to agency policy regarding specifications for infants, children, adolescents, and immunizations. The maximum amount of medication for a single injection is generally 1 ml. For immunizations, a smaller 22 to 25 gauge needle should be used. |
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| Data source: Berman & Snyder, 2016; Davidson & Rourke, 2014; Ogston-Tuck, 2014a; Perry et al., 2014 |
Special Considerations:
- Avoid muscles that are emaciated or atrophied; they will absorb medications poorly.
- IM injection sites should be rotated to decrease the risk of hypertrophy.
- Older adults and thin patients may only tolerate up to 2 ml in a single injection.
- Choose a site that is free from pain, infection, abrasions, or necrosis.
- The dorsogluteal site should be avoided for intramuscular injections. If a needle hits the sciatic nerve, the patient may experience partial or permanent paralysis of the leg.
IM Injections
Consider the type of medication and the age, condition, and size of the patient when selecting an IM site. Rotate IM sites to avoid complications. Potential complications include lingering pain, tissue necrosis, abscesses, and injury to blood vessels, bones, or nerves. If administering a vaccination, always refer to the vaccination guidelines for site selection. Checklist 58 outlines the steps to perform an IM injection.
Checklist 58: Administering an Intramuscular InjectionDisclaimer: Always review and follow your hospital policy regarding this specific skill. |
|||
Safety Considerations:
|
|||
Steps |
Additional Information |
||
| Assessment | |||
| 1. Perform hand hygiene. | Hand hygiene prevents the spread of microorganisms. | ||
| 2. Compare MAR to patient wristband and use two patient identifiers to confirm patient. | Using two identifiers improves medication safety by ensuring you have selected the correct patient. | ||
| 3. Assess the patient’s symptoms, knowledge of the medication to be received, history of allergies, drug allergies, and types of allergic reactions. | Assess patient data such as vital signs, laboratory values, and allergies before preparing and administering medications by injection. | ||
| 4. Assess for any factors that may contraindicate an IM injection. | Factors to look for include circulatory shock, surgery, or muscle atrophy. | ||
| Preparation | |||
| 5. Verify practitioner’s order and MAR. | |||
| 6. Review medication information, such as purpose, action, side effects, normal dose, rate of administration, time of onset, peak and duration, and nursing implications. | Knowledge of the medication ensures the correct patient receives the correct dose of the correct medication at the correct time via the correct route for the correct reason using the correct documentation. | ||
| 7. Assemble supplies. | Assemble medication, non-sterile gloves, alcohol swabs, syringes, needles, and sharps container. | ||
| 8. Prepare medication from an ampule or a vial as per hospital policy. Always compare MAR to the practitioner’s original orders to ensure accuracy and completeness. | This prevents medication errors by providing an additional check. | ||
| 9. NEVER leave the medication unsupervised once prepared. | Medications left unattended may lead to medication errors. | ||
| Procedure | |||
| 10. Perform hand hygiene. | Hand hygiene prevents the transmission of microorganisms. | ||
| 11. Close curtains or door. | This creates privacy for the patient. | ||
| 12. Verify patient using two unique identifiers and compare to MAR. | This step confirms the correct identity of the patient. | ||
| 13. Explain the procedure and the medication, and give the patient time to ask questions. | Knowing what is happening helps minimize patient anxiety. Let the patient know there may be mild burning at the injection site. | ||
| 14. Don non-sterile gloves and prepare the patient in the correct position. Ensure a sharps disposal container is close by for disposal of needle after administration. |
This prepares the patient for injection.
Ensuring the sharps container is close by allows for safe disposal of the needle. |
||
| 15. Locate correct site using landmarks, and clean area with alcohol or antiseptic swab. Allow site to dry completely. | Allowing the site to dry prevents stinging during injection. | ||
| 16. Place a clean swab or dry gauze between your third and fourth fingers. | This allows for easy access to dry gauze after injection. | ||
| 17. Remove needle cap by pulling it straight off the needle. Hold syringe between thumb and forefinger on dominant hand as if holding a dart. | This prevents needle from touching side of the cap and prevents contamination. | ||
| 18. With non-dominant hand, hold the skin around the injection site. | This secures the area for injection. | ||
| 19. With the dominant hand, inject the needle quickly into the muscle at a 90-degree angle, using a steady and smooth motion. | Insert the needle with a dart-like motion. | ||
| 20. After the needle pierces the skin, use the thumb and forefinger of the non-dominant hand to hold the syringe. | Movement of the needle once injected can cause additional discomfort for the patient. | ||
|
21. If required by agency policy, aspirate for blood. If no blood appears, inject the medication slowly and steadily.
If blood appears, discard syringe and needle, and prepare the medication again. |
Because the injection sites recommended for immunizations do not contain large blood vessels, aspiration is not necessary when immunizing. | ||
| 22. Once medication is completely injected, remove the needle using a smooth, steady motion. Remove the needle at the same angle at which it was inserted. | Using a smooth motion prevents any unnecessary pain to the patient. | ||
| 23. Cover injection site with sterile gauze, using gentle pressure, and apply Band-Aid as required. | Covering prevents infection at the injection site. | ||
| 24. Place safety shield on needle and discard syringe in appropriate sharps container. | Placing sharps in appropriate puncture-proof and leak-proof receptacles prevents accidental needle-stick injuries. | ||
| 25. Discard supplies, remove gloves, and perform hand hygiene. | This step prevents the spread of microorganisms. | ||
| 26. Document procedure as per agency policy. | Document the medication, time, route, site, date of administration, and effect of the medication; any adverse effects; unexpected outcomes; and any interventions applied. | ||
| 27. Assess patient’s response to the medication after the appropriate time frame. | Assess for effectiveness of the medication (onset, peak, and duration). Assess injection site for pain, bruising, burning, or tingling. | ||
| Data source: CDC, 2013, 2015; Perry et al., 2014 |
Checklist 59 outlines the steps to perform a Z-track IM injection.
Checklist 59: Administering a Z -Track Intramuscular InjectionDisclaimer: Always review and follow your hospital policy regarding this specific skill. |
|||
Safety Considerations:
|
|||
Steps |
Additional Information |
||
| Assessment | |||
| 1. Perform hand hygiene. | Hand hygiene prevents the spread of microorganisms. | ||
| 2. Compare Mar to the patient’s wristband and use two patient identifiers to confirm patient. | Using two identifiers improves medication safety by ensuring you have selected the correct patient. | ||
| 3. Assess the patient’s symptoms, knowledge of the medication to be received, history of allergies, drug allergies, and types of allergic reactions. | Assess patient data such as vital signs, laboratory values, and allergies before preparing and administering medications by injection. | ||
| 4. Assess for any factors that may contraindicate an injection. | Factors to look for include circulatory shock, surgery, or muscle atrophy. | ||
| Preparation | |||
| 5. Verify practitioner’s order and MAR. | |||
| 6. Review medication information such as purpose, action, side effects, normal dose, rate of administration, time of onset, peak and duration, and nursing implications. | Knowledge of the medication ensures the correct patient receives the correct dose of the correct medication at the correct time via the correct route for the correct reason using the correct documentation. | ||
| 7. Verify expiry date and check for particulates, discoloration, or loss of integrity (sterility). | Discoloured or outdated medication may be harmful. If a medication is discoloured or cloudy, always check manufacturer’s specification for the medication. | ||
| 8. Assemble supplies. | Assemble medication, non-sterile gloves, syringes, needles, and sharps container. | ||
| 9. Prepare medication from an ampule or a vial as per hospital policy. Always compare MAR to the practitioner’s original orders to ensure accuracy and completeness. | This prevents medication errors by providing an additional check. | ||
| 10. NEVER leave the medication unsupervised once prepared. | Unsupervised medication may lead to medication errors | ||
| Procedure | |||
| 11. Perform hand hygiene. | Hand hygiene prevents transmission of microorganisms | ||
| 12. Close curtains or door. | This creates privacy for the patient. | ||
| 13. Verify patient using two unique identifiers and compare to MAR. |
This confirms the correct identity of the patient.
Follow policy for safe medication administration. |
||
| 14. Explain the procedure and the medication, and give the patient time to ask questions. | Knowing what is happening helps minimize patient anxiety. Let the patient know there may be mild burning at the injection site. | ||
| 15. Don non-sterile gloves, select the correct site, and prepare the patient in the correct position. Ensure a sharp disposal container is close by for disposal of needle after administration. |
This prepares the patient for injection.
Ensuring the sharps container is close by allows for safe disposal of the needle. |
||
| 16. Locate correct site using landmarks, and clean area with alcohol or antiseptic swab. Allow site to dry completely. | Allowing the site to dry prevents stinging during injection. | ||
| 17. Place a clean swab or dry gauze between your third and fourth fingers. |
This allows for easy access to dry gauze after injection. |
||
| 18. Remove needle cap by pulling it straight off the needle. Hold syringe between thumb and forefinger on dominant hand as if holding a dart. | This prevents needle from touching side of the cap and prevents contamination. | ||
| 19. Displace skin in a Z-track manner by pulling the skin down or to one side about 2 cm (1 in.) with your non-dominant hand. |
The Z-track method creates a zigzag path to prevent medication from leaking into the subcutaneous tissue. This method may be used for all injections, or may be specified by the medication.
|
||
|
20. With skin held to one side, quickly insert needle at a 90-degree angle.
After needle pierces skin, continue pulling on skin with non-dominant hand, and at the same time grasp lower end of syringe barrel with fingers of non-dominant hand to stabilize it. Move dominant hand to end of plunger. If required by agency policy, aspirate for blood. If no blood appears, inject the medication slowly. |
Insert the needle with a dart-like motion. A quick injection is less painful. Inject medication at 10 seconds/ml.
Because the injection sites recommended for immunizations do not contain large blood vessels, aspiration is not necessary when immunizing.
|
||
| 21. Once medication is given, leave the needle in place for 10 seconds. Avoid moving the syringe. |
Leaving the needle in place allows the medication to be displaced.
Movement of the needle can cause additional discomfort for the patient. |
||
| 22. Once medication is completely injected, remove the needle using a smooth, steady motion. Then release the skin. |
Using a smooth motion prevents any unnecessary pain to the patient.
|
||
| 23. Cover injection site with sterile gauze, using gentle pressure, and apply Band-Aid as required. Do not massage site. | Covering prevents infection at the injection site. | ||
| 24. Place safety shield or needle guard on needle and discard syringe in appropriate sharps container. | Placing sharps in appropriate puncture-proof and leak-proof receptacles prevents accidental needle-stick injuries. | ||
| 25. Discard supplies, remove gloves, and perform hand hygiene. | This step prevents the spread of microorganisms. | ||
| 26. Document procedure as per agency policy. | Document the medication, time, route, site, date of administration, and effect of the medication; any adverse effects; unexpected outcomes; and any interventions applied. | ||
| 27. Assess patient’s response to the medication after the appropriate time frame. | Assess for effectiveness of the medication (onset, peak, and duration). Assess injection site for pain, bruising, burning, or tingling. | ||
| Data source: Centers for Disease Control, 2013, 2015; Perry et al., 2014 |
Critical Thinking Exercises
- How can you make an injection less painful for a patient? Name four techniques.
- When giving an IM injection, how can you avoid injury to a patient who is very thin?


34.4: Digestive System Regulation
Skills to Develop
- Discuss the role of neural regulation in digestive processes
- Explain how hormones regulate digestion
The brain is the control center for the sensation of hunger and satiety. The functions of the digestive system are regulated through neural and hormonal responses.
Neural Responses to Food
In reaction to the smell, sight, or thought of food, like that shown in Figure \(\PageIndex{1}\), the first hormonal response is that of salivation. The salivary glands secrete more saliva in response to the stimulus presented by food in preparation for digestion. Simultaneously, the stomach begins to produce hydrochloric acid to digest the food. Recall that the peristaltic movements of the esophagus and other organs of the digestive tract are under the control of the brain. The brain prepares these muscles for movement as well. When the stomach is full, the part of the brain that detects satiety signals fullness. There are three overlapping phases of gastric control—the cephalic phase, the gastric phase, and the intestinal phase—each requires many enzymes and is under neural control as well.
Digestive Phases
The response to food begins even before food enters the mouth. The first phase of ingestion, called the cephalic phase , is controlled by the neural response to the stimulus provided by food. All aspects—such as sight, sense, and smell—trigger the neural responses resulting in salivation and secretion of gastric juices. The gastric and salivary secretion in the cephalic phase can also take place due to the thought of food. Right now, if you think about a piece of chocolate or a crispy potato chip, the increase in salivation is a cephalic phase response to the thought. The central nervous system prepares the stomach to receive food.
The gastric phase begins once the food arrives in the stomach. It builds on the stimulation provided during the cephalic phase. Gastric acids and enzymes process the ingested materials. The gastric phase is stimulated by (1) distension of the stomach, (2) a decrease in the pH of the gastric contents, and (3) the presence of undigested material. This phase consists of local, hormonal, and neural responses. These responses stimulate secretions and powerful contractions.
The intestinal phase begins when chyme enters the small intestine triggering digestive secretions. This phase controls the rate of gastric emptying. In addition to gastrin emptying, when chyme enters the small intestine, it triggers other hormonal and neural events that coordinate the activities of the intestinal tract, pancreas, liver, and gallbladder.
Hormonal Responses to Food
The endocrine system controls the response of the various glands in the body and the release of hormones at the appropriate times.
One of the important factors under hormonal control is the stomach acid environment. During the gastric phase, the hormone gastrin is secreted by G cells in the stomach in response to the presence of proteins. Gastrin stimulates the release of stomach acid, or hydrochloric acid (HCl) which aids in the digestion of the proteins. However, when the stomach is emptied, the acidic environment need not be maintained and a hormone called somatostatin stops the release of hydrochloric acid. This is controlled by a negative feedback mechanism.
In the duodenum, digestive secretions from the liver, pancreas, and gallbladder play an important role in digesting chyme during the intestinal phase. In order to neutralize the acidic chyme, a hormone called secretin stimulates the pancreas to produce alkaline bicarbonate solution and deliver it to the duodenum. Secretin acts in tandem with another hormone called cholecystokinin (CCK). Not only does CCK stimulate the pancreas to produce the requisite pancreatic juices, it also stimulates the gallbladder to release bile into the duodenum.
Another level of hormonal control occurs in response to the composition of food. Foods high in lipids take a long time to digest. A hormone called gastric inhibitory peptide is secreted by the small intestine to slow down the peristaltic movements of the intestine to allow fatty foods more time to be digested and absorbed.
Understanding the hormonal control of the digestive system is an important area of ongoing research. Scientists are exploring the role of each hormone in the digestive process and developing ways to target these hormones. Advances could lead to knowledge that may help to battle the obesity epidemic.
Summary
The brain and the endocrine system control digestive processes. The brain controls the responses of hunger and satiety. The endocrine system controls the release of hormones and enzymes required for digestion of food in the digestive tract.
Glossary
- cephalic phase
- first phase of digestion, controlled by the neural response to the stimulus provided by food
- cholecystokinin
- hormone that stimulates the contraction of the gallbladder to release bile
- endocrine system
- system that controls the response of the various glands in the body and the release of hormones at the appropriate times
- gastric inhibitory peptide
- hormone secreted by the small intestine in the presence of fatty acids and sugars; it also inhibits acid production and peristalsis in order to slow down the rate at which food enters the small intestine
- gastric phase
- digestive phase beginning once food enters the stomach; gastric acids and enzymes process the ingested materials
- gastrin
- hormone which stimulates hydrochloric acid secretion in the stomach
- intestinal phase
- third digestive phase; begins when chyme enters the small intestine triggering digestive secretions and controlling the rate of gastric emptying
- secretin
- hormone which stimulates sodium bicarbonate secretion in the small intestine
- somatostatin
- hormone released to stop acid secretion when the stomach is empty


10.4: The Doctrine of Affections
Introduction
The doctrine of the affections—also known as the doctrine of affects , doctrine of the passions , theory of the affects , or by the German term Affektenlehre— was a theory in the aesthetics of painting, music, and theater, widely used in the baroque era (1600–1750). Literary theorists of that age, by contrast, rarely discussed the details of what was called “pathetic composition,” taking it for granted that a poet should be required to “wake the soul by tender strokes of art.” The doctrine was derived from ancient theories of rhetoric and oratory. Some pieces or movements of music express one Affekt throughout; however, a skillful composer like Johann Sebastian Bach could express different affects within a movement.
History and Definition
The doctrine of the affections was an elaborate theory based on the idea that the passions could be represented by their outward visible or audible signs. It drew largely on elements with a long previous history, but first came to general prominence in the mid-seventeenth century amongst the French scholar-critics associated with the Court of Versailles, helping to place it at the center of artistic activity for all of Europe. The term itself, however, was only first devised in the twentieth century by German musicologists Hermann Kretzschmar, Harry Goldschmidt, and Arnold Schering, to describe this aesthetic theory.
René Descartes held that there were six basic affects, which can be combined together into numerous intermediate forms:
- Admiration (admiration)
- Amour (love)
- Haine (hatred)
- Désir (desire)
- Joie (joy)
- Tristesse (sorrow)
Another authority also mentions sadness, anger, and jealousy.
Lorenzo Giacomini (1552–1598) in his Orationi e discorsi defined an affection as “a spiritual movement or operation of the mind in which it is attracted or repelled by an object it has come to know as a result of an imbalance in the animal spirits and vapours that flow continually throughout the body.”
Affections are not the same as emotions; however, they are a spiritual movement of the mind.
A prominent baroque proponent of the doctrine of the affections was Johann Mattheson.
Key Signature
Key signature was used to convey the different affections.
C Major: rejoicing, impudent
C Minor: sweet, but sad
D Major: stubborn, noisy, warlike and rousing
D Minor: devout, serious, grand, calming
E Flat Major: pathetic, plaintive
E Major: the fatal separation of body and soul
E Minor: pensive and grieving, but not without hope
G Flat Minor: distress, abandonment
G Major: persuasive and brilliant
G Minor: grace, kindness, loveliness
A Major: gripping and clear
A Minor: honorable and calm
B Flat Major: magnificent, yet modest
B Minor: hard, unpleasant and desperate
In the following video, Sean Avram Carpenter performs the Adagio from Sonata No. 1 in G Minor by J. S. Bach. What affect (or “affection”) do you think Bach was trying to convey with this piece?
Contributors and Attributions
- Doctrine of the Affections. Located at : https://en.Wikipedia.org/wiki/Doctrine_of_the_affections . License : CC BY-SA: Attribution-ShareAlike
- Johann Mattheson. Provided by : Wikimedia. Located at : https://commons.wikimedia.org/wiki/File:Johann_Mattheson.jpg . License : CC BY-SA: Attribution-ShareAlike
- Adagio from Sonata No. 1 in G minor by J. S. Bach. Located at : https://www.youtube.com/watch?v=_pnhewS40ns . License : All Rights Reserved . License Terms : Standard YouTube License


8.1.2E: Occupation
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In the United States, occupation and occupational prestige are primary indicators of social class, along with income, wealth, and education.
Learning Objectives
- Explain how occupation may affect a person’s social class
Key Points
- High status professional occupations, such as those of a doctor, lawyer, or CEO, require high educational attainment and are associated with the upper-middle and upper classes.
- Occupation often corresponds with income and educational attainment, which combined determine a person’s social class. However, occupations with high occupational prestige can increase one’s social class without a corresponding increase in indicators, such as income.
- To enter the professions, a person usually must hold a professional degree. Examples of professional degrees include JDs for law, MDs for medicine, and MBAs for business.
Key Terms
- profession : An occupation, trade, craft, or activity in which one has a professed expertise in a particular area, especially one requiring a high level of skill or training.
- educational attainment : Educational attainment is a term commonly used by statisticians to refer to the highest degree of education an individual has completed.
- occupational prestige : The rating of a job based on the social esteem or respect granted to an occupation.
In the United States, occupation is a primary indicator of social class, along with income, wealth, and education. Occupation is closely linked to Americans’ identities, and is a salient marker of status. The importance of occupation in part results from the substantial amount of time that American’s devote to their careers. The average work week in the United States for those employed full time is 42.9 hours long, and 30% of the population works more than 40 hours per week.
High educational attainment is generally a pre-requisite for entering high status professional occupations. Professional occupations, sometimes called “the professions” or “white collar jobs,” include highly skilled positions, such as that of a lawyer, physician, and CEO. Having a professional occupation is associated with being a member of the upper-middle or upper class. To enter the professions, a person usually must hold a professional degree. Examples of professional degrees include JDs for law, MDs for medicine, and MBAs for business. Because the professions are considered highly skilled, require high educational attainment, and provide high incomes, they are associated with high social status.
Sociologists often talk about the status associated with various occupations in terms of occupational prestige. Occupational prestige refers to the esteem in which society holds a particular occupation. Occupational prestige is one way in which occupation may affect a person’s social class independent of income and educational attainment. While high status occupations often reap high incomes and require significant education, in some cases these three variables are not linked. For example, being a university professor has high status and requires high educational attainment, but does not always result in high income. Its status depends upon the high esteem in which professors are held. In large part because of high occupational prestige, university professors are generally considered members of the upper-middle class. Conversely, funeral directors generally have high incomes and often high educational attainment. Being a funeral director is not a high status job, however, because Americans do not tend to hold the occupation in high esteem it has low occupational prestige. Funeral directors are, therefore, often considered members of the middle class. As illustrated by this example, occupations with high prestige can raise one’s social class even without improving one’s economic status.
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7.3: Applying the Nursing Process
This section outlines the steps of the nursing process when providing care for individuals with altered sensory function in any setting.
Assessment
When assessing a patient for sensory impairments, it is important to first establish a therapeutic relationship. Individuals may be hesitant to discuss sensory problems. By establishing a good rapport, patients are more likely to share their sensory concerns and effects on functioning. The health history should include questions regarding current status of sensory function, as well as risk for development of sensory impairment. For example, medications that can be ototoxic should be considered a risk factor for hearing impairment. Additionally, opioids and sedatives depress the central nervous system and can impair stimuli perception and reaction. Techniques to identify deficits in vision, hearing, smell, taste, and sensation are used during the physical exam. Read additional information about assessment techniques using the following hyperlinks.
Read about common disorders of the eyes and ears in the “ Eye and Ear Assessment ” chapter of the Open RN Nursing Skills textbook.
Read more about assessing sensory functioning in the “Neurological Assessment” chapter of the Open RN Nursing Skills textbook.
There are several factors to consider when assessing a patient’s sensory functioning, such as age, their perception of the impairment, and the impact of the sensory impairment on their daily functioning. Age is an important consideration because many sensory functions can be affected by the aging process. However, it should not be assumed that all sensory problems are a normal part of the aging process. It is important to assess the patient’s perception of sensory impairment and its impact on their functioning, as well for any changes in recent behavior, mental status, emotional status, or cognitive function changes. For example, individuals experiencing hearing loss may be more irritable or anxious and avoid social gatherings due to their hearing impairment. If a patient is experiencing confusion, it is important to evaluate underlying factors that can cause confusion.
The environment is also an important consideration when assessing an individual’s sensory functioning. It is important to understand the patient’s daily activities and their ability to perform them; their work and living environment; their use of protective equipment, such as ear protection when working with loud equipment; and their adherence with routine screenings, such as vision and hearing exams. Individuals with sensory impairments are at increased risk for falls and injury, so it is important to encourage basic safety features in the environment, including adequate lighting, availability of handrails and grab bars, hazard-free walkways, and appropriate settings on water heater controls.
When sensory impairments are identified, they should be documented in the patient’s chart and communicated to collaborative team members working with the individual. For example, when an individual has a hearing impairment, it is important to consider their alternative communication needs. They may use lipreading and require face-to-face views when communicating. The use of assistive devices for sensory functioning, such as glasses and hearing aids, should also be documented and communicated. It is important to ensure proper functioning of the devices for optimal patient outcomes. In fact, a hospitalized older adult is at greater risk for developing delirium when their typical glasses and hearing aids (i.e., their “eyes and ears”) are not available, causing sensory deprivation.
See Table 7.3a for a comparison of expected versus unexpected findings on assessment, including those that require notification of the health care provider.
| Assessment | Expected Findings | Unexpected Findings |
|---|---|---|
|
Hearing and Ears:
Assess ability to appropriately answer questions individually and in a group setting. Assess the ear canal for excess cerumen. Perform a whisper test while standing behind the seated patient. Observe the patient’s balance and gait. |
The patient can converse and answer questions. Presbycusis can occur with aging. | Inability to communicate; complaints of ringing in ears (tinnitus), decreased attention, and withdrawal from conversations. Poor coordination, loss of proprioception, increased falls. Report to the health care provider recent changes in hearing, new tinnitus, imbalance, or dizziness. |
|
Vision:
Assess near vision by the ability to read printed material. Use the Snellen chart to assess distant vision. In a long-term care or home setting, observe the patient’s ability to perform ADLs. |
Around age 40, reading glasses may become necessary for close work. | Report to the health care provider new changes in vision. |
|
Touch:
Assess ability to feel stimuli by lightly touching the extremities, bottom of the feet, and fingers. Ask if the patient has unusual sensations in their extremities (e.g., tingling, burning, pain). |
The patient can feel light touch and discriminate between warm and cold. | Inability to feel light touch; reported new numbness, tingling, or pain in the extremities. Report to the health care provider sudden changes in sensation or peripheral neuropathy or new onset of facial numbness (such as in the case of a cerebrovascular accident, commonly referred to as a stroke). |
|
Smell:
Assess ability to identify odors with eyes closed. |
The patient can identify smells such as vanilla, lemon, or coffee. The sense of smell often diminishes with advancing age. | Inability to differentiate odors or decreased sensitivity to strong odors. |
|
Taste:
Ask about food intake and taste. |
The patient can determine if food is salty, sweet, or spicy. | Inability to discriminate taste, leading to changes in appetite, weight loss, excess use of salt or sugar, and depression. |
|
Sensory Input:
Assess for cognitive, perceptual, and affective changes. |
Sensory stimulation is adequate to maintain awareness. | Irritability, restlessness, covering ears or eyes to shield themselves from sensory input, increased sensitivity to tactile input. Reduced learning capacity or inability to think. Confusion, boredom, changes in visual/motor coordination. Report to health care provider sudden changes in cognitive, perceptual, or affective abilities. |
Diagnoses
Commonly used NANDA-I nursing diagnoses for patients experiencing alterations in sensory function include the following: [1]
- Risk for Injury
- Risk for Falls
- Impaired Verbal Communication
- Social Isolation
A common NANDA diagnosis related to sensory alterations is Risk for Injury , which is defined as, “Susceptible to physical damage due to environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.” “Alteration in sensation” is an associated condition for this nursing diagnosis. For risk diagnoses, there are no related factors (etiological factors) because you are identifying a vulnerability in a patient for a potential problem that is not yet present. Additionally, the nurse cannot resolve sensory alteration, so it should not be listed as a related factor to which interventions are directed. Instead, the phrase “as evidenced by” is used to refer to the evidence of risk that exists.
Therefore, a sample NANDA-I diagnosis in current PES format would be as follows: “Risk for Injury as evidenced by alteration in vision.”
Outcomes
An overall goal for a patient at risk for injury related to alteration in sensation is as follows:
- The patient will remain free from injury.
An example of a “SMART” expected outcome for a patient with impaired vision is as follows:
- The patient will be able to verbalize the layout of the room within four hours of admission.
Planning Interventions
There are many nursing interventions that can be implemented for individuals with impaired sensory function. To assist patients to communicate effectively and to promote their quality of life, it is important for the nurse to customize appropriate interventions based on their individual needs. As always, refer to an evidence-based nursing care planning resource when customizing interventions for specific patients. See Table 7.3b for basic nursing interventions to implement for a variety of sensory alterations. [2]
| Sensory Alteration | Nursing Interventions |
|---|---|
| Impaired Vision |
Ensure that patients have access to their glasses or contacts that are cleaned properly and have a current prescription. Provide magnifying glasses if needed.
Identify yourself whenever entering the room. Monitor functional implications of diminished vision. Provide adequate room lighting. Minimize glare (i.e., offer sunglasses or draw the window covering). Describe the environment to the patient as needed. Avoid rearranging the environment. Maintain an uncluttered environment and remove hazards such as scatter rugs and oxygen tubing when possible. Provide verbal explanations of the location of items or food. Provide reading materials in large print, as needed. Apply labels to frequently used items (e.g., mark medication bottles using high-contrasting colors). Encourage and assist in arranging annual eye exams, including screening for glaucoma. |
| Hearing Impairment |
Perform or arrange for routine hearing assessments. Assist the patient in acquiring a hearing aid or assistive hearing device when needed.
Ensure appropriate use of assistive hearing aids as needed; maintain batteries and cleanliness of the equipment. Gain patient’s attention before speaking. Avoid noisy background environments when speaking. Avoid communicating more than 2-3 feet away from the patient. Use gestures, when necessary. Simplify language (i.e., do not use slang but do use short, simple sentences) as appropriate. Facilitate lipreading by facing the patient directly in good lighting, allowing them to see your mouth while speaking. Avoid speaking with anything in your mouth (such as gum or a mint) and do not turn from them while speaking. Use a low, deep voice when speaking. For patients with severe hearing impairment, document their preferred method of communication (e.g., verbal, written, lipreading, or American Sign Language) in their plan of care. |
| Impaired Sensitivity to Odor |
Advise the patient to check pilot lights in home appliances visually.
Encourage the patient to check expiration dates on food items and marking dates on leftovers in the refrigerator. |
| Impaired Tactile Sensation |
Maintain water heater temperature at a safe range to avoid burns.
Check the temperature of bath water with a thermometer. |
| Impaired Oral Communication |
Listen to the patient and provide sufficient time for their answer. Avoid childlike phrases and words.
Ask questions that only require short or “yes” or “no” answers for patients with expressive aphasia. Keep explanations simple. Provide a communication board or other alternative methods of communication as appropriate. Collaborate with a speech therapist to develop a plan for effective communication. Provide education to family/caregivers to facilitate communication. |
| Sensory Overload |
Plan and combine nursing activities to avoid interrupting rest time.
Decrease noise level in the room and the hallway outside as much as possible, including both noises from medical devices and conversations. Close the room door if possible. |
| Sensory Deprivation |
Provide meaningful stimuli such as the patient’s choice of television, radio, reading material, calendars, photos of family members, and pets.
Provide social interaction as appropriate; encourage family members/caregivers to engage in meaningful conversations with individuals. |
Standards of Care
National Patient Safety Goals established by The Joint Commission include prevention of falls. Appropriately assessing the risk of falls for patients with sensory impairments and implementing effective nursing interventions to prevent falls help to meet this standard of care. [4]
Evaluation
Evaluate a patient’s progress toward the expected outcomes established. Include safety, functioning, ability to communicate, and satisfaction with quality of life when evaluating the effectiveness of interventions. Determine if changes in the plan of care are needed to better meet the needs of the individual.
- Herdman, T., & Kamitsuru, S. (2017). NANDA international nursing diagnoses: Definitions & classification 2018-2020 (11th ed.). Thieme Publishers. pp. 114, 393. ↵
- Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC) . Elsevier. pp. 115-117. ↵
- Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC) . Elsevier. pp. 115-117. ↵
- The Joint Commission. (n.d.). 2021 National patient safety goals . https://www.jointcommission.org/standards/national-patient-safety-goals/ ↵


6.1: The Simplest Type of Differential Equation
The simplest ordinary differential equations can be integrated directly by finding antiderivatives. These simplest odes have the form
\[\frac{d^{n} x}{d t^{n}}=G(t), \nonumber \]
where the derivative of \(x=x(t)\) can be of any order, and the right-hand-side may depend only on the independent variable \(t\) . As an example, consider a mass falling under the influence of constant gravity, such as approximately found on the Earth’s surface. Newton’s law, \(F=m a\) , results in the equation
\[m \frac{d^{2} x}{d t^{2}}=-m g, \nonumber \]
where \(x\) is the height of the object above the ground, \(m\) is the mass of the object, and \(g=9.8\) meter \(/ \sec ^{2}\) is the constant gravitational acceleration. As Galileo suggested, the mass cancels from the equation, and
\[\frac{d^{2} x}{d t^{2}}=-g \nonumber \]
Here, the right-hand-side of the ode is a constant. The first integration, obtained by antidifferentiation, yields
\[\frac{d x}{d t}=A-g t \nonumber \]
with \(A\) the first constant of integration; and the second integration yields
\[x=B+A t-\frac{1}{2} g t^{2} \nonumber \]
with \(B\) the second constant of integration. The two constants of integration \(A\) and \(B\) can then be determined from the initial conditions. If we know that the initial height of the mass is \(x_{0}\) , and the initial velocity is \(v_{0}\) , then the initial conditions are
\[x(0)=x_{0}, \quad \frac{d x}{d t}(0)=v_{0} . \nonumber \]
Substitution of these initial conditions into the equations for \(d x / d t\) and \(x\) allows us to solve for \(A\) and \(B\) . The unique solution that satisfies both the ode and the initial conditions is given by
\[x(t)=x_{0}+v_{0} t-\frac{1}{2} g t^{2} . \nonumber \]
For example, suppose we drop a ball off the top of a 50 meter building. How long will it take the ball to hit the ground? This question requires solution of Equation \ref{6.1} for the time \(T\) it takes for \(x(T)=0\) , given \(x_{0}=50\) meter and \(v_{0}=0\) . Solving for \(T\) ,
\[\begin{aligned} T &=\sqrt{\frac{2 x_{0}}{g}} \\ &=\sqrt{\frac{2 \cdot 50}{9.8}} \mathrm{sec} \\ & \approx 3.2 \mathrm{sec} . \end{aligned} \nonumber \]