13.8 The Island Colony
The loss of the Oregon Territory was a blow to the HBC but not necessarily to British ambitions in the region. The former remained resilient while the latter remained modest. The HBC had experimented with commercial diversification for years, expanding its network across the Pacific. The arrival and employment of Kanakas throughout the Pacific Northwest reflected the diversity of marketplaces into which the HBC reached.[1] It was clearly about much more than beaver and sea otter pelts.
One noteworthy (if Pyrrhic) victory in this regard was the Puget Sound Agricultural Company (PSAC), a barely-at-arm’s-length subsidiary of the HBC created in 1840 and centred at Port Nisqually (Tacoma) in what is now Washington State. The PSAC had several goals, including the establishment of a loyal British settler community in the face of American intrusion into the Oregon Territory, improved self-sufficiency in terms of food supply to the northern forts, and an experiment in settler colonialism. Like Lord Selkirk’s project at Red River, the HBC conceived PSAC in part as an attractive retreat for retired employees and their families. The Oregon Treaty ended the PSAC experiment but its objectives were to continue to the north, on Vancouver Island.
Fort Victoria
Fort Camosun opened in 1843 and its name changed to Fort Victoria in 1846 in honour of the new queen. This was the first settlement of Europeans on the island since the Spanish abandoned Fort San Miguel at Yuquot in 1795. The HBC feared the Lekwungen (Songhees) and their neighbours, and there was little confidence that even a simple landfall would succeed. The priorities of the Lekwungen, however, included incorporating the British operations into their own. Some 300 to 400 Aboriginal men took on the task of building the fort and the band provided all the lumber required for the task. Historian John Lutz argues that this apparent welcome was a kind of appropriation by the Lekwungen. In their society, housebuilding was a communal activity and it was one that signified, importantly, community ownership of the structure. Building the HBC fort, therefore, signified a Lekwungen stake in the affair.[2]
Relations between Aboriginal peoples and the HBC entered a new phase after the construction of Fort Victoria. There were confrontations, some of which involved what Barry Gough describes as gunboat diplomacy.[3] Often the source of irritation was cultural differences. Many northwest coast peoples were horticulturists, though not farmers in a sense that newcomers instantly recognized. Europeans often witnessed them clearing the land with fire in order to create meadows, so the newcomers knew that land management was underway. For example, the West Coast camas bulb was an important source of food for Aboriginal peoples and a trade good in its own right. But the camas bulb is one of many indigenous foodstuffs that did not gain admittance to the Columbian Exchange: Europeans never really came to like its flavour. If they had, they might have done more to protect camas patches against the newly introduced cattle and pigs. Of course, a cleared patch of land is more attractive to a farming settler than a stand of towering Douglas firs: the gardens of northwest coast peoples were much sought after and were quickly seized by newcomers. Aboriginal peoples, for their part, regarded anything on four legs as potential game, which was predictably bad news for livestock and for the newcomer-Native relationship, but good news for the banquet table.
The Colony of Vancouver Island
In 1849 the British extended to the HBC a 10-year lease on the proprietary colony of Vancouver Island, conditional on its settlement by newcomers. The new colonial paradigm was difficult for the HBC to accept. Settlers and furs and Natives were not viewed as a good mix, not by the HBC’s officers and not by the Aboriginal populations. The Whitman Massacre of 1847 was still at the forefront of everyone’s minds. Aware of the possibility of foot-dragging on the settlement front, the Colonial Office dispatched Richard Blanshard (1817-1894) to serve as governor.
Blanshard was probably the only non-indigenous person on the whole island who did not work for the HBC and, as he was soon to discover, the company did not work for him. In the space of 10 years the HBC had experienced an enormous shift, one that had seen the end of their Oregon and Californian enterprises along with the loss of Fort Vancouver and the York Factory Express route. The company’s local operations were headed by Chief Factor James Douglas but he now had to take orders from London and the Colonial Office. What’s more, Westminster instructed the HBC to bring in significant numbers of non-company personnel to become settlers; it was likely that the newcomers’ relationship with the Aboriginals would be different from — which is to say, at odds with — that of the fur trading company. It is hardly any wonder, then, that Governor Blanshard found himself isolated and frustrated. If that weren’t enough, his timing was spectacularly bad.
Gold fever had erupted in California in 1848. By 1849 eager prospectors were streaming into San Francisco, some of them from Fort Victoria. At around the same time, the HBC decided to pursue more aggressively a coal mining possibility at the northern tip of the island. The company established Fort Rupert in the late 1830s at Beaver Harbour, a Kwagu’ł (Kwakiutl) village site called ʦax̱is. This was the company’s only fort that existed for purposes other than trading furs or growing food. Kwagu’ł men and women dug out the coal or gathered it along the beach and traded it to the HBC, thus expanding their range of commerce. By 1848, however, the company was preparing to lurch into the industrial age by bringing out a party of experienced Scottish coal miners. The experiment was a disaster. It outraged the Kwagu’ł and they made common cause with the miners against the HBC. In 1850 the Scots were either chained up in the fort’s bastion or preparing to make a run for it.
As this drama unfolded, another came into view. Two British sailors who hoped to hitch a ride to San Francisco and the riches of the Californian El Dorado jumped ship in Victoria and then, mistakenly, onto a vessel headed north. Arriving in a troubled Fort Rupert, they fled into the forest where they were murdered by parties unknown. Blanshard’s response was to sail a gunboat into Beaver Harbour and shell the nearby Nahwitti village as he pursued the killers. Fed up with his low wages, poor living conditions, and lack of real authority, he returned to Fort Victoria and submitted his resignation — which London was happy to accept, given his rampage at Nahwitti.
Douglas was now governor of the colony with orders to take material steps to settle the island with colonists loyal to the Crown. Recruitment efforts were modest, not least because the prospect of new settlers was viewed as inconsistent with diplomatic and commercial relations with the Aboriginal peoples. There was a veneer of theory applied to this hesitance. In the early 1850s the colonial theories of Edward Gibbon Wakefield (1769-1862) — one of members of Lord Durham’s expedition to the Canadas — gained wider support. Wakefield’s views resonated nicely with the HBC establishment on the island: he thought it was better to reproduce in colonies the kind of social relations found in Britain’s hierarchical culture than to open up the land to homesteading and an influx of commoners. As a result, land prices were set at a level that was seen as attractively exclusive. Only a certain class of settler would, in effect, be admitted. In the face of free land policies south of the border, the Wakefieldian approach on Vancouver Island failed.[4] The number of land sales was acceptable, but the number of settlers was never great. What’s more, those HBC servants who might have had it in mind to achieve some independence on the land were kept in their social class by this expense, thus preserving a pool of labourers. Finally, the hierarchical society that Wakefield (and James Douglas) had in mind for Vancouver Island led to the creation of the “squirearchy,” an HBC-connected elite that occupied all the key appointed positions in the colony, including the whole of the judiciary.
The Crown had been reluctant to hand authority to Douglas for fear that he was in a conflict of interest. Indeed he was. Douglas was mistrustful of settlers and defensive of Aboriginal rights as he saw them. He negotiated a suite of 14 agreements, known as the Douglas treaties. These were initiated under Blanshard’s watch and Douglas continued pulling treaties together through the decade. Each aimed at obtaining lands deemed suitable for settlement or HBC enterprise. The treaties preserved First Nations village sites intact and allowed for one-time compensation payments. Some First Nations actively sought treaties from the HBC but Douglas had a limited budget at his disposal and no interest in obtaining territory where there was no immediate likelihood of use by newcomers. These treaties stand as the only ones negotiated west of the Rockies until very recently.
West Coast Industrialization
The experiment in coal mining at Fort Rupert was a disappointment. The Kwagu’ł claimed ownership of the coal and obstructed the use of Scottish miners. The immigrant coal miners — who constitute the first group of foreigners delivered to the region for the purpose of settling or doing a particular job since Meares’s Chinese shipbuilders — objected to the way the work was organized, the conditions under which they were mining, and the whole culture of HBC fort life. The operation was wound down and a promising coal seam to the south was explored. Many of the miners subsequently wound up at Fort Nanaimo in the Sneneymuxw territory. Douglas signed a treaty with the Aboriginal community in 1854 and in that year a shipload of English miners from Staffordshire arrived, along with their families. In total, the HBC sponsored the immigration of 435 individuals for the coal mining projects until 1855, 85 of which were children. These immigrants and those who followed them were exceptional in the history of Canadian population: they were working-class people drawn from isolated communities in Britain and their voyage west by sea took them around the southern tip of South America, to Hawaii, and then to the island colony. There was effectively no going back. In a colony where the “squirearchy” looked down its nose at agricultural labour, the status of the miners and their families was lower still.
The success of the coal mining enterprise was slow in coming. It was helped along, indirectly, by the Russians. The island’s proximity to Russian waters pulled the colony briefly into the orbit of the Crimean War (1854). A joint British-French assault on the Russian Pacific port of Petropavlovsk ended in disaster and the injured troops were evacuated to Fort Victoria. These events advanced the case for a Royal Navy base and one was established next to Victoria Harbour at Esquimalt in 1865. Naval officers subsequently developed close links with the coal mining operations around Nanaimo. As more steam-powered naval vessels arrived in the Pacific, the coal resources became more important; as the coal mines grew in strategic significance so too did the value of having a naval base nearby to protect them.
The gold rush on the mainland also helped the coal mines, as did the growing demand for household fuel in San Francisco and Victoria. In the early 1860s the HBC sold its interest in Nanaimo to a London-based company and the chartered company gave way to industrial capitalism. A former HBC employee, Robert Dunsmuir, found his own coal seam nearby in 1869 and began building an industrial empire and dynasty. Two years earlier the first Chinese mine workers arrived at Nanaimo, the beginning of a migration wave that would continue through the rest of the century. By the third quarter of the century Nanaimo and environs was one of the largest industrial nodes in British North America.
Christianizers
Missionary activity on the coast also began at the mid-century. William Duncan (1832-1918), a controversial and mercurial representative of the Church of England’s Church Missionary Society (CMS), arrived in 1857. He set up shop at Fort Simpson (also known as Lax Kw’alaams and Port Simpson, near current-day Prince Rupert) and subsequently relocated hundreds of Ts’msyan to a mission town of his creation: Metlakatla. “Duncan shaped a landscaped place,” at Metlakatla, according to one source, “with rows of identical, single-family dwellings. Each house had a small garden, glass windows, sash curtains, and was fitted with beds and clocks. The church and other public offices were Metlakatla’s largest and most imposing buildings.” The overall effect was that of a European community built around ideals of individualism, the nuclear family, and “slum clearance.”[5] Duncan aimed to change people by changing their environment first: notably his idea of appropriate housing, individualism, and patrilineal inheritance was a direct critique of local Aboriginal culture. Duncan took the view that good Christians came out of nuclear households with a strong patriarchal legal and belief system in place.[6] While cultural change among Aboriginal people on the northwest coast had been occurring throughout the fur trade period, the arrival of missionaries like Duncan and his successor at Fort Simpson, the Methodist Thomas Crosby (1840-1914), witnessed the first concerted efforts by newcomers to transform Aboriginal societies and beliefs on the West Coast.
The 1850s were marked, then, by a rising colonial administrative presence, the beginnings of cultural assaults, some increase in newcomer settlement, and further decline in the fur economy counterbalanced somewhat by increased diversification of HBC activities. Where Fort Rupert failed as a mining operation, Fort Nanaimo succeeded and new arrivals from British coal fields continued the process of industrial resource extraction. The decade also witnessed diversification of Aboriginal economies, a greater number of Aboriginal peoples trading their labour for goods, and significant instances of resistance to newcomer transgressions. All of this change would be very suddenly eclipsed by events in 1858.
Key Points
- The HBC established the Colony of Vancouver’s Island to replace Fort Vancouver and as a starting point for a joint HBC-Colonial Office settlement project.
- The presence of newcomers in their midst both enriched and endangered Aboriginal peoples of the island and the central coast.
- Agriculture, harvesting coal, and other economic activities were undertaken to further trade with the foreigners and also to increase their dependence.
- Settlement in the colony took two forms: a patriarchal and pastoral echo of the relationship between British gentry and commoners, and an industrial, proletarian townscape.
- The industrial revolution arrived on Vancouver Island in the late 1840s and spread in the 1850s to the mid- and south island.
- Missionary efforts on the West Coast accelerated in the 1840s, richly funded in the first instance by the CMS.
Attributions
Figure 13.24
Fort Victoria watercolour by Bonas is in the public domain.
Figure 13.25
HMS Sutlej gun deck LAC by Rcbutcher is in the public domain.
Figure 13.26
Blanshard by Fishhead64 is in the public domain.
Figure 13.27
Edward Gennys Fanshawe, Indians at Fort Rupert, Vancouver’s Island, July 1851 (Canada) by KAVEBEAR is in the public domain.
Figure 13.28
Nanaimo Mine Explosion-1 by Drovosekk is used under a CC-BY-SA 3.0 license.
Figure 13.29
William Duncan’s church, Metlakahtla, B.C. is in the public domain. This image is available from the holdings of the National Archives and Records Administration, cataloged under the ARC Identifier (National Archives Identifier) 297830.
- Tom Koppel, Kanaka: The Untold Story of Hawaiian Pioneers in British Columbia and the Pacific Northwest (Vancouver: Whitecap Books, 1995). ↵
- John Lutz, Makuk: A New History of Aboriginal-White Relations (Vancouver: UBC Press, 2008), 70-71. ↵
- Barry M. Gough, Gunboat Frontier: British Maritime Authority and Northwest Coast Indians, 1856-1890 (Vancouver; UBC Press, 1984). ↵
- Tina Loo, Making Law, Order and Authority in British Columbia, 1821-1871 (Toronto: University of Toronto Press, 1994), 38. ↵
- Daniel Clayton, "Geographies of the Lower Skeena," in Home Truths: Highlights from BC History, eds. Richard Mackie and Graeme Wynn (Madeira Park: Harbour, 2012), 114-115. ↵
- Clarence Bolt, Thomas Crosby and the Tsimshian: Small Shoes for Feet Too Large (Vancouver: UBC Press, 1992), 24. ↵


The Technique
In my social foundations of education courses, I look for ways to convey the diverse and often challenging realities experienced by elementary school students. One thing I have found to be effective is inviting students to share their own experiences – stories that are authentic, relatable, and typically very engaging. This approach can also be complicated.
It can be intimidating for some students to share their personal (and sometimes traumatizing) histories, especially “on the spot” in front of a large class or to a sea of Zoom faces. As an instructor, I would also prefer to avoid making assumptions about which stories students will want to share based on perceived identities. I’ve also found that students can feel pressure to speak for entire social groups and/or to topics they don’t necessarily know a lot about.
To account for these factors, I use a technique that engages students in pre-recorded, thematic, student-panel discussions. During Covid, I experimented with this technique over Zoom, largely as a way to promote deeper connections among students in an online, synchronous environment. I asked myself, “What if a small group of students were provided with a safe space to tell stories relating to the course themes on a pre-recorded panel?” In the resulting technique, I invited selected students to share their educational experiences, grouped the willing respondents into panels, and then organized a virtual conversation that I recorded for the whole class to view.
When small groups of students come together for a group panel, there is an opportunity to promote connections, solidarity, and more nuanced narratives within the thematic group – and then, by extension, to the whole class. Using this technique, I have found that many of my students have appreciated having a chance to share their experiences so that their peers who are future teachers will have a better understanding of the variety of students’ lived realities.
Even though we have moved back to in-person classes on campus, I expect to continue with this technique on campus because this technique puts control of the storytelling in the students’ hands
How I Use It
The student panel discussion videos are created, recorded, and then used for teaching and learning in three stages:
Creating the Panels
- I send all my students a pre-course questionnaire as a standard practice. In this, I ask them the following questions:
- Tell us about your elementary school experiences.
- What is like to immigrate to Canada, learn English as a second language, experience ethnic discrimination, etc., in school/education?
- How do you connect this with the theory and concepts you have learned?
- What would you suggest for future teachers of diverse student groups?
- And, most importantly, would you be willing/interested in sharing aspects of your identity that have shaped your life and/or the experiences you have shared here?
- Once I receive the survey results, I see if I can create groupings of students who have shared similar experiences (e.g., immigrating to Canada, accessibility in education, homophobia in schools, living below the poverty line, etc.).
- Once groups are made, I email (blind cc) student groups that have expressed interest to confirm that they want to be involved and to set a date for the recording
- Closer to the panel interviews, I send the groups a list of three to four discussion questions so that the students can think about what to say in advance and prepare to share only what they are comfortable with.
Recording the Panels
- I provide a bit of “front matter” at the start of each panel meeting to clarify my intent for the “lived experiences” panels. I walk through the process with the group (for delivering, recording, editing, reviewing) and also review the whole-class activity all students will engage in.
- Once I confirm their permission to continue, I press record and ask three or four inciting questions of each panelist, offering prompts only where needed to keep the panel discussion going.
- During the recorded session, I rotate through each panelist as they answer questions. *
- Once the panel and the recording are complete, I do a two-stage editing of the Zoom recording.
- Once the each video is complete I take each final panel discussion video, upload it to my Youtube channel [set to private].
My Editing Process: I try to preserve most of the recorded content while removing as much of “myself” as possible by replacing my voice with text slides. Where appropriate, I also try to take out dead spots and redundancies. Once my edits are complete, I share the video with the panelists so that they can provide feedback and make requests for additional moments to be removed (i.e., something too personal or embarrassing). As a faculty member, this technique does require me to balance open dialogue with potentially harmful language that may find its way into the conversation. If I make an editing choice to remove a student’s comment, I will be honest with the panel about what was removed and why.
Utilizing Panels for Whole Class Activity
I now have a series of student panel discussions that I can embed within my course D2L space alongside the course texts for that particular week, linked to the whole group activity!
When we meet next together as a whole class, I take a moment to thank the students who shared on the panel and invite other classmates to do so as well. The ensuing discussion can focus on greater themes of power, oppression, or social justice but with a reminder that we are speaking with our peer panelists in the room, not about them. Once each topic/week is finished, I take down the associated video.
I’ve used this technique to drive whole-group activity such as pre-class reflection, small-group analyses, and a think-pair-share activity. It would also work well for deep reflexive autobiographical writing by each individual student.
* By recording using Zoom, I can set the video to “pin” the person talking so that the student who is speaking is foregrounded in the video.
Feedback from Learners
“I just wanted to say thank you for letting me share my experiences with racism today. I think you did an excellent job of giving us a safe place to share our insights and experiences. I have never experienced such understanding and empathy from a professor or teacher in my entire academic journey.”
One of the most poignant aspects I have noticed about this technique is how students so effectively illustrate how discrimination can appear invisible, harmless, or neutral on the surface, despite its far-reaching impacts on lived experiences and when placed in the context of historical and structural systems of oppression. My students’ stories have also helped me shed light on the nuances of discrimination, illuminating the many different ways oppression can happen based on context, circumstance, and groups.
I have noticed that my students are extremely respectful and empathetic to the student panelists in our follow-up discussions. In many cases, it comes as a surprise to students how different the educational journey has been among the students in the class and the nature of and degree to which systemic barriers operate in society and education.
A Short Task to Challenge You!
Step 1 – What parts of your own stories are you ready to share?
Take a few moments, and jot down a few notes to answer the following questions:
- What stories are you ready to share with your peers and colleagues?
- What stories would you be reluctant to share?
Step 2 – Which lived experiences would you be interested in learning more about?
Take a few more moments to jot down a few notes about lived experiences you would be interested in learning more about.
Step 3 – Seek out stories that accomplish this!
Take some time during your holiday break to expand your stories to include the following interesting experiences:
- Ask your friends and family to suggest people you could connect with (regarding your interests) to create an authentic connection with them. Perhaps you can share your stories with them also.
- Read a novel about an experience that is not familiar to you. Or, perhaps choose one that is about a story similar to your own that you are reluctant to share.
One Final Task
Is this something you can use in your classroom? How might you utilize it? If you share your results somewhere on social media, share a link to this lesson for context.


Cumming School of Medicine
Department of Microbiology, Immunology & Infectious Diseases
Immunology
Foundations of Epidemiology
Foundations of Epidemiology is an open access, introductory epidemiology text intended for students and practitioners in public or allied health fields. It covers epidemiologic thinking, causality, incidence and prevalence, public health surveillance, epidemiologic study designs and why we care about which one is used, measures of association, random error and bias, confounding and effect modification, and screening. Concepts are illustrated with numerous examples drawn from contemporary and historical public health issues.
Licence: CC BY-NC 4.0
Open Oxford Immunology
High-interest research and reviews across all aspects of the immune system in health and disease. The journal brings together basic immunological research alongside clinical perspectives and applications for treatment of disease.
Licence: CC BY
Microbiology & Infectious Diseases
Foundations of Epidemiology
Foundations of Epidemiology is an open access, introductory epidemiology text intended for students and practitioners in public or allied health fields. It covers epidemiologic thinking, causality, incidence and prevalence, public health surveillance, epidemiologic study designs and why we care about which one is used, measures of association, random error and bias, confounding and effect modification, and screening. Concepts are illustrated with numerous examples drawn from contemporary and historical public health issues.
Licence: CC BY-NC 4.0
General Microbiology, 1st Edition
In this textbook the focus will be on the bacteria and archaea (traditionally known as the “prokaryotes,”) and the viruses and other acellular agents.
Includes: Key words, study questions, exploratory questions
Licence: CC BY-NC-SA 4.0
Reviews: Available through the Open Textbook Library
Laboratory Exercises in Microbiology: Discovering the Unseen World Through Hands-On Investigation
The exercises in this laboratory manual are designed to engage students in hand-on activities that reinforce their understanding of the microbial world. Topics covered include: staining and microscopy, metabolic testing, physical and chemical control of microorganisms, and immunology. The target audience is primarily students preparing for a career in the health sciences, however many of the topics would be appropriate for a general microbiology course as well.
Includes: Key terms, case studies
Licence: CC BY-NC-SA 4.0
Reviews: Available through the Open Textbook Library
Microbiology (OpenStax)
Available through OpenStax, Microbiology covers the scope and sequence requirements for a single-semester microbiology course for non-majors. The book presents the core concepts of microbiology with a focus on applications for careers in allied health.
Includes: Summaries, review questions, clinical focus, D2L course cartridge, slides, test bank, practice problem widget
Licence: CC BY 4.0
Reviews: Available through the Open Textbook Library
Microbiology: A Laboratory Experience
Designed to support a course in microbiology, Microbiology: A Laboratory Experience permits a glimpse into both the good and the bad in the microscopic world. The laboratory experiences are designed to engage and support student interest in microbiology as a topic, field of study, and career.
Licence: CC BY-NC-SA 4.0
Microbiology for Allied Health Students
Microbiology for Allied Health Students is designed to cover the scope and sequence requirements for the single semester Microbiology course for non-majors and allied health students. The book presents the core concepts of microbiology with a focus on applications for careers in allied health. The pedagogical features of Microbiology for Allied Health Students make the material interesting and accessible to students while maintaining the career-application focus and scientific rigor inherent in the subject matter.
Includes: Check your understanding questions, clinical focus, glossary
Licence: CC BY 4.0
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Chapter 6. Non-Parenteral Medication Administration
6.6 Administering Inhaled Medications
Medications administered through inhalation are dispersed via an aerosol spray, mist, or powder that patients inhale into their airways. Although the primary effect of inhaled medications is respiratory, there are likely to be systemic effects as well. Most patients taking medication by inhaler have asthma or chronic respiratory disease and should learn how to administer these medications independently. A variety of inhalers are available, and specific manufacturers’ instructions should always be followed to ensure appropriate dosing.
Administering Medication by Small-Volume Nebulizers
Nebulization is a process by which medications are added to inspired air and converted into a mist that is then inhaled by the patient into their respiratory system (Lilley et al., 2016; Perry et al., 2018). (See Figure 6.20 and 6.21) The air droplets are finer than those created by metered dose inhalers, and delivery of the nebulized medication is by face mask or a mouthpiece held between the patient’s teeth.
Checklist 52 outlines the steps for delivering medication through a small-volume nebulizer.
Checklist 52: Medication by Small-Volume NebulizerDisclaimer: Always review and follow your agency policy regarding this specific skill.
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Safety considerations:
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Steps |
Additional Information |
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| 1. Perform hand hygiene before medication preparation.
Check MAR to guide you to which medications you are preparing. Follow agency policy to ensure MARs are accurate and verified appropriately. |
A MAR that is checked by more than one healthcare professional provides a very reliable record for administering medications. Agencies may vary in relation to MAR verification processes. |
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2 a. As you are removing medications from the dispensing system, perform the SEVEN rights three times with each individual medication:
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The right patient: Check that you have the correct patient using two patient identifiers (e.g., name and date of birth).
The right medication (drug): Check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: Check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: Check that the route is appropriate for the patient’s current condition. The right time: Adhere to the prescribed dose and schedule. The right reason: Check that the patient is receiving the medication for the appropriate reason. The right documentation: Always verify any unclear or inaccurate documentation prior to administering medications. |
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2 b. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
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Whenever possible, take the MARs to the bedside to complete the third check. |
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| 3. Assemble nebulizer apparatus as per manufacturer’s instructions. | Assembly specific to manufacturer’s instructions ensures proper delivery of medication. | ||
4. Add medication as prescribed by pouring medication into the nebulizer cup.
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This step ensures the proper delivery of medication.
If reusing a nebulizer, discard any residual liquid from the previous dose.
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| 5. Use a hand held nebulizer if the patient is able to hold it for approximately 10 minutes.
Use a mask if patient is unable to tolerate a mouthpiece. Use an adaptor specific to tracheostomies if the patient has a tracheostomy. |
This ensures the proper delivery of medication. | ||
| 6. Position patient sitting up in a chair or in bed at greater than 45 degrees. | This position improves lung expansion and medication distribution. | ||
| Note: Attach the nebulizer to compressed air if available; use oxygen if there is no compressed air. If patient is receiving oxygen, do not turn it off. Continue to deliver oxygen through nasal prongs with the nebulizer. If using oxygen, consider oxygen safety guidelines (Table 5.5) and precautions and complications of oxygen therapy (Table 5.6). | |||
| 7. Turn on air to nebulizer and ensure that a sufficient mist is visible exiting nebulizer chamber. A flow rate of 6 to 10 L should provide sufficient misting.
Ensure that nebulizer chamber containing medication is securely fastened. Ensure that chamber is connected to face mask or mouthpiece, and that nebulizer tubing is connected to compressed air or oxygen flowmeter. |
This process verifies that equipment is working properly. | ||
| 8. If mouthpiece is being used, ensure lips are sealed around mouthpiece.
Have patient take slow, deep, inspiratory breaths. Encourage a brief 2- to 3-second pause at the end of inspiration, and continue with passive exhalations. |
Sealed lips ensure proper inhalation of medication.
This maximizes effectiveness of medication. |
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| 9. Have patient repeat this breathing pattern until medication is complete and there is no visible misting. This process takes approximately 8 to 10 minutes. | This maximizes the effectiveness of the medication. | ||
| 10. Tap nebulizer chamber occasionally and at the end of the treatment. | This action releases drops of medication that cling to the side of the chamber. | ||
| 11. Monitor patient’s pulse rate during treatment, especially if beta-adrenergic bronchodilators are being used. | Beta-adrenergic bronchodilators have cardiac effects that should be monitored during treatment. | ||
| 12. Once treatment is complete, turn flowmeter off and disconnect nebulizer. | This promotes patient comfort and safety. | ||
| 13. Rinse, dry, and store nebulizer as per agency policy. | Proper care reduces the transfer of microorganisms. | ||
| 14. If inhaled medication includes steroids, have patient rinse mouth and gargle with warm water after treatment. | Rinsing removes residual medication from mouth and throat, and helps prevent oral candidiasis related to steroid use. | ||
| 15. Once treatment is complete, encourage patient to perform deep breathing and coughing exercises to help remove expectorate mucous. | Treatments are often prescribed specifically to encourage mucous expectoration. | ||
| 16. Return patient to a comfortable and safe position. | This promotes patient comfort and safety. | ||
| 17. Perform hand hygiene. | This step prevents the transfer of microorganisms. | ||
| 18. Document treatment as per agency policy, and record and report any unusual events or findings to the appropriate healthcare provider. | Accurate and timely documentation and reporting promote patient safety. | ||
| Data sources: BCIT, 2015; Lilley et al., 2016; Perry et al., 2018 |
Medication by Metered Dose Inhaler (MDI)
A metered dose inhaler (MDI) is a small handheld device that disperses medication into the airways via an aerosol spray or mist through the activation of a propellant. A measured dose of the drug is delivered with each push of a canister, and dosing is usually achieved with one or two puffs. Attached the MDI to a spacer or valved chamber optimizes medication delivery because the medication is held in the device until the patient inhales. Some MDIs have counters to inform the user how many doses have been administered,
Checklist 53 lists the steps for administering medication by MDI.
Checklist 53: Medication by Metered Dose Inhaler (MDI)Disclaimer: Always review and follow your agency policy regarding this specific skill.
|
|||
Safety considerations:
|
|||
Steps |
Additional Information |
||
| 1. Perform hand hygiene before medication preparation.
Check MAR to guide you to which medications you are preparing. Follow agency policy to ensure MARs are accurate and verified appropriately. |
A MAR that is checked by more than one healthcare professional provides a very reliable record for administering medications. Agencies may vary in relation to MAR verification processes. |
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2 a. As you are removing medications from the dispensing system, perform the SEVEN rights three times with each individual medication:
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The right patient: Check that you have the correct patient using two patient identifiers (e.g., name and date of birth).
The right medication (drug): Check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: Check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: Check that the route is appropriate for the patient’s current condition. The right time: Adhere to the prescribed dose and schedule. The right reason: Check that the patient is receiving the medication for the appropriate reason. The right documentation: Always verify any unclear or inaccurate documentation prior to administering medications. |
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2 b. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
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Whenever possible, take the MARs to the bedside to complete the third check. |
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| 3. Assemble MDI as per manufacturer’s instructions.
If MDI has not been used for several days, give it a test spray into the air taking care not to inhale the medication. |
Assembly specific to manufacturer’s instructions ensures proper delivery of medication. | ||
| 4. Ensure that canister is securely inserted into the holder and remove the mouthpiece cover. | This ensures proper delivery of medication. | ||
| 5. Shake canister well before delivery (5 or 6 shakes). | This ensures proper delivery of medication. | ||
| 6. Position patient sitting up in a chair or in bed at greater than 45 degrees. | This position improves lung expansion and medication distribution. | ||
7. Without spacer:
With spacer:
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This process ensures proper inhalation of medication. | ||
| 8. Have patient rinse mouth and gargle with warm water about 2 minutes after treatment. | Rinsing removes residual medication from mouth and throat, and helps prevent oral candida related to steroid use. | ||
| 9. Return patient to a comfortable and safe position. | This promotes patient comfort and safety. | ||
| 10. Perform hand hygiene. | This step prevents the transfer of microorganisms. | ||
| 11. Document treatment as per agency policy, and record and report any unusual events or findings to the appropriate health care provider. | Accurate and timely documentation and reporting promote patient safety. | ||
| Data sources: BCIT, 2015; Lilley et al., 2016; Perry et al., 2018 |
Medication by Dry Powder Inhaler (DPI)
Dry powder inhalers (DPIs) were introduced to the market some time after pressurized MDI medications as an alternative for easier delivery of respiratory medications. DPIs don’t require the same level dexterity and coordination as an MDI and thus are thought to result in improved medication adherence and disease management. Ramadan and Sarkis (2017) reviewed a number of studies to determine if in fact DPIs were superior to MDIs and found inconclusive evidence. A concerning finding was the significant number of patients using their device(s) incorrectly. However, those using DPIs demonstrated correct technique more often than those using pressurized MDIs. This data speaks to the importance of teaching clients correct technique when using an inhaled medication and, if necessary, the prescriber ordering medication with a device that is easier for the patient to use. Checklist 54 describes the procedure for administering DPI medication.
Checklist 54: Medication by Dry Powder Inhaler (DPI)Disclaimer: Always review and follow your agency policy regarding this specific skill.
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Safety considerations:
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Data sources: Lilley et al., 2016; Perry et al., 2018; The Lung Association of Saskatchewan, 2018; Ramadan & Sarkis, 2017 |
Critical Thinking Exercises
- Your patient is receiving supplemental oxygen through nasal prongs, and needs to receive medication via a nebulizer. Please describe whether or not you would remove the nasal prongs and your reasoning for making this decision.
- Your patient complains that she can’t seem to breathe in at the same time as she depresses her inhaler. What action should you take in this situation to ensure that your patient receives the appropriate dose of her medication by inhaler.
- View the Lung Association of Saskatchewan resources and outline how you would explain use of a discus to a patient.
Attributions
Figure 6.21. Hand held nebulizer by author is licensed under a Creative Commons Attribution 4.0 International License.
Figure 6.22. Nebulizer medication with MAR by author is licensed under a Creative Commons Attribution 4.0 International License.
Figure 6.23 Assorted MDIs by author is licensed under a Creative Commons Attribution 4.0 International License.
Figure 6.24. Screenshot from Living With and Managing Asthma; an educational video by the Heart, Lung and Blood Institute by United States National Institutes of Health: Heart, Lung and Blood Institute is copyright free from the U.S. Department of Health & Human Services.
Figure 6.23. Baby using inhaler and spacer by Phyllis Buchanan is used under a CC BY-SA 2.0 generic license.
Figure 6.25. “Spiriva HandiHaler” brand dry powder inhaler (open) by RonEJ is in the public domain.
Figure 6.26. MDI with MAR by author is licensed under a Creative Commons Attribution 4.0 International License.
Figure 6.27. Spiriva HandiHaler”-brand dry powder inhaler byRonEJ at English Wikipedia is in the public domain.
Figure 6.28. Image of Symbicort Inhaler by One Salient Oversight is in the public domain.


Preparing for Research
10
Overview
This chapter talks about the processes your brain goes through before attempting to write. Through this chapter you will be able to identify writing habits and effective ways to reach an audience and display your point. In this chapter you will be challenged to be creative and use recursive process to display knowledge of rhetoric and the role of reading and writing in critical thinking and establishing reading comprehension.
Reading & Writing as a Researcher
Reading and writing might appear separate but ultimately, they go hand in hand, when responding to any situation, the motivation for asserting a claim in an essay and entering a particular conversation with a selected audience is presenting through that medium. Reading and writing are important components to building reading comprehension, this is not formed through memorization but rather by exercising critical thinking functions. When writing there is a need for conversation, your text should flow which is why there is value to knowledge, experience and interest in text, not solely memorization. Inquiry of academic writing involves the process of annotation, this is known as the first act of composing, it shows traces of responding voices while you’re reviewing, marked text shows signs of critical thinking which involve engaging, questioning, and testing those ideas inquired significance. Although in academic writing you should always address a series of question before writing or responding, these questions are:
- Is this information relevant or significant?
- Is it truthful information and if so how do you know?
- What arguments in response to authority are being made?
- What are the exceptions to the authors argument?
- Is it a legit? Is this sufficient?
- Are there any counter-arguments?
Activity #1
In your own words write 1-2 paragraphs about the different ways to present these six questions in a paper and provide one example of each you have seen in previous writing.
Writing as a Reader Vs Writing as Writer
Reading is a main component of writing. To begin with most of all college writing is based on reading, when reading through texts you are able to see an individual’s writing style, approach and arguments. By being an active reader, you are able to see many types of writing and methods to display information, this gives you an advantage while writing, it allows you to study other writing styles and mimic good habits displayed by other writers in your own text. Someone who is a good academic writer is bound to be a successful critical thinker which results in an active reader.
Writing goes hand in hand with reading, by reading text and understanding it you have done half the work but being able to communicate and display that information intelligently is the other half. When dealing with writing you will always see rhetoric close by, rhetoric is the study of how writers influence readers with language, in addition, there is rhetorical analysis which is when a writer’s purpose is identified in response to a situation by displaying an essay that puts forth claims. Audience: Identified through language intended for a specific genre while considering references and structure. Below are a few things to think about before beinging to write academically: To be culturally literate is to possess the basic information needed to thrive in the modern world. -Hirsch
- Purpose: What a writer is trying to accomplish or a response to a particular situation. What is the writer goal, to think, advocate, raise awareness, change or a combo?
- Situation: Moves a writer to write, urgency is not always triggered by a single situation; it is multifaceted.
- Claims: Assertion authors must justify and support with evidence and good reason. While it must also include a thesis/main claim which controls the idea of the writers point and crafts the main argument claim and presentation of evidence and assertions.
- Minor Claim: An assertion that requires support and does not shape what the author writes in the remainder of the essay.
- For example inside “Inquiry” a minor claim would be….
Curious Writer
When writing you must be aware that writing is recursive & messy and requires a flexible process. This means that shifting perspectives as you read is positive in developing good writing strategies, for example, a camera with lens uses different angles to capture the desired image. Perspectives taken into consideration should be: Believing, Doubting, Updating, Hunting & Gathering, Interpreting, Pleasure Seeking, Connecting, Reflect & Resisting. However, when writing there is never a “right” way to answer and it is meant to influence creativity, self perspective in relation to the texts subject & genre/medium is also necessary in addressing a text.
Reading Visuals
The process of reading an image goes through the process of: What to know —> Should read to find out —> How should I use what I read?
- Framing,
- Angle,
- Relationship,
- Light,
- Color
- Arrangement
Reading, understanding process and reflect in writing is a way of discovering how you think and should be demonstrated through your writing.
Activity #2
List three ways a person can build reading comprehension?
Activity #3
In a paragraph describe, what is an example of visual reading students would have access to while participating in class?
This chapter is supported by points made in Habits of Mind, that chapter talks about the thinking done before writing in order to make your content appealing.


58 Assignment Solution: Price Controls After a Storm
People often expect government to solve problems that they seem unable to solve on their own. Sometimes this is effective and sometimes it is not. Price controls, either price ceilings or price floors, often have unanticipated side effects. Think about it: passing a law doesn’t by itself make economic problems go away! Such is the case with claims of price gouging, the charging of “excessively high” prices, which was exemplified by what occurred in the wake of an ice storm or other natural disasters.
Imposing a price ceiling below the equilibrium price may create as many problems as it solves. The basic problem is that the demand for power generators is dramatically higher, since the supply of electricity was compromised. At the same time, the supply of generators was less as a result of storm damage and the inability to travel. The question is how to deal with the shortage, that is, how to allocate the limited supply of generators among competing needs and wants. When a price ceiling reduces the legal price of a product, businesses have less incentive to supply the product.
Economically speaking, the law of supply says that at lower prices, the quantity supplied will be lower. At the same time, the law of demand states that at a lower price, the quantity demanded will be higher. This can be seen clearly in the graph. So who gets the limited supply? As Shakespeare said, that is the question. Unfortunately, there is no clear answer to this. It could be first come, first serve. It could be friends of the seller. In many cases, what results are under-the-table payments by consumers willing to violate the law. What is certain is that fewer generators get to consumers than would be the case if the price were allowed to rise. Many would argue that this shortage is not the best outcome.


Learning Objectives
By the end of this section, you will be able to:
Identify the following muscles and give their origins, insertions, actions and innervations:
- Muscles of the pectoral girdle and upper limb
MUSCLES OF THE PECTORAL GIRDLE AND UPPER LIMBS
Muscles of the shoulder and upper limb can be divided into four groups: muscles that stabilize and position the pectoral girdle, muscles that move the arm, muscles that move the forearm, and muscles that move the wrists, hands, and fingers.
Muscles That Position the Pectoral Girdle
The pectoral girdle, or shoulder girdle, consists of the lateral ends of the clavicle and scapula, along with the proximal end of the humerus, and the muscles covering these three bones to stabilize the shoulder joint. The girdle creates a base from which the head of the humerus, in its ball-and-socket joint with the glenoid fossa of the scapula, can move the arm in multiple directions.Muscles that position the pectoral girdle are located either on the anterior thorax or on the posterior thorax (Figure 11.4.15 and Table 11.8). The anterior muscles include the subclavius, pectoralis minor, and serratus anterior. The posterior muscles include the trapezius, rhomboid major, and rhomboid minor. When the rhomboids are contracted, your scapula moves medially, which can pull the shoulder and upper limb posteriorly.
| Muscles that Position the Pectoral Girdle (Table 11.8) | ||||||
|---|---|---|---|---|---|---|
| Position in the thorax | Movement | Target | Target motion direction | Prime mover | Origin | Insertion |
| Anterior thorax | Stabilizes clavicle during movement by depressing it | Clavicle | Depression | Subclavius | First rib | Inferior surface of clavicle |
| Anterior thorax | Rotates shoulder anteriorly (throwing motion); assists with inhalation | Scapula; ribs | Scapula: depresses; ribs: elevates | Pectoralis minor | Anterior surfaces of certain ribs (2–4 or 3–5) | Coracoid process of scapula |
| Anterior thorax | Moves arm from side of body to front of body; assists with inhalation | Scapula; ribs | Scapula: protracts; ribs: elevates | Serratus anterior | Muscle slips from certain ribs (1–8 or 1–9) | Anterior surface of vertebral border of scapula |
| Posterior thorax | Elevates shoulders (shrugging); pulls shoulder blades together; tilts head backwards | Scapula; cervical spine | Scapula: rotests inferiorly, retracts, elevates, and depresses; spine: extends | Trapezius | Skull; vertebral column | Acromion and spine of scapula; clavicle |
| Posterior thorax | Stabilizes scapula during pectoral girdle movement | Scapula | Retracts; rotates inferiorly | Rhomboid major | Thoracic vertebrae (T2–T5) | Medial border of scapula |
| Posterior thorax | Stabilizes scapula during pectoral girdle movement | Scapula | Retracts; rotates inferiorly | Rhomboid minor | Cervical and thoracic vertebrae (C7 and T1) | Medial border of scapula |
Muscles That Move the Humerus
Similar to the muscles that position the pectoral girdle, muscles that cross the shoulder joint and move the humerus bone of the arm include both axial and scapular muscles (Figure 11.4.16 and Figure 11.4.17). The two axial muscles are the pectoralis major and the latissimus dorsi. The pectoralis major is thick and fan-shaped, covering much of the superior portion of the anterior thorax. The broad, triangular latissimus dorsi is located on the inferior part of the back and has multiple points of origin including the lumbosacral fascia attached to the inferior 6 thoracic vertebrae, the inferior 3 ribs, the iliac crest and inferior angle of the scapula.
The rest of the shoulder muscles originate on the scapula and help to move the arm. The deltoid is the major abductor of the arm but also facilitates flexing and medial rotation, as well as extension and lateral rotation. The subscapularis originates on subscapular fossa and medially rotates the arm. Named for their locations, the supraspinatus (originating from the supraspinous fossa) and the infraspinatus (originating from the infraspinous fossa) abduct the arm, and laterally rotate the arm, respectively. The thick and flat teres major is inferior to the teres minor and extends the arm, and assists in its adduction and medial rotation. The long teres minor laterally rotates the arm. Finally, the coracobrachialis flexes and adducts the arm.
The tendons of the subscapularis, supraspinatus, infraspinatus, and teres minor connect the scapula to the humerus, forming the rotator cuff (musculotendinous cuff), the circle of tendons around the shoulder joint. Although the shoulder joint allows a great deal of freedom of movement due to the shallow glenoid cavity it is extremely vulnerable to downward dislocation. The muscles and tendons of the rotator cuff provide stability to the joint. When baseball pitchers undergo shoulder surgery it is usually on the rotator cuff, which becomes pinched and inflamed, and may tear away from the bone due to the repetitive motion of bringing the arm overhead to throw a fast pitch.
Muscles That Move the Forearm
The forearm, made of the radius and ulna bones, has four main types of action at the hinge of the elbow joint: flexion, extension, pronation, and supination. When the forearm faces anteriorly, it is supinated. When the forearm faces posteriorly, it is pronated. The forearm flexors include the biceps brachii, brachialis, and brachioradialis. The extensors are the triceps brachii and anconeus. The pronators are the pronator teres and the pronator quadratus, and the supinator turns the forearm anteriorly.
The biceps brachii, brachialis, and brachioradialis flex the forearm. The two-headed biceps brachii crosses the shoulder and elbow joints to flex the forearm, also taking part in supinating the forearm at the radioulnar joints and flexing the arm at the shoulder joint. Deep to the biceps brachii, the brachial is a synergist in forearm flexion. Finally, the brachioradialis can flex the forearm quickly or help lift a load slowly. These muscles and their associated blood vessels and nerves form the anterior compartment of the arm (anterior flexor compartment of the arm) (Figure 11.4.18 and Figure 11.4.19).
Muscles That Move the Wrist, Hand, and Fingers
Wrist, hand, and finger movements are facilitated by two groups of muscles. The forearm is the origin of the extrinsic muscles of the hand. The palm is the origin of the intrinsic muscles of the hand.
Extrinsic Muscles of the Hand
The muscles in the anterior compartment of the forearm (anterior flexor compartment of the forearm) originate on the humerus and insert onto different parts of the hand. These make up the bulk of the forearm. From lateral to medial, the superficial anterior compartment of the forearm includes the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis. The flexor digitorum superficialis flexes the hand as well as the digits at the knuckles, which allows for rapid finger movements, as in typing or playing a musical instrument (see Figure 11.4.20 and Table 11.9). However, repetitive movement with poor ergonomics can irritate the tendons of these muscles as they slide back and forth with the carpal tunnel of the anterior wrist and pinch the median nerve, which also travels through the tunnel, causing Carpal Tunnel Syndrome. The deep anterior compartment produces flexion and bends fingers to make a fist. These are the flexor pollicis longus and the flexor digitorum profundus.
The muscles in the superficial posterior compartment of the forearm (superficial posterior extensor compartment of the forearm) originate on the humerus. These are the extensor radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and the extensor carpi ulnaris.
The muscles of the deep posterior compartment of the forearm originate on the radius and ulna. These include the abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indicis (see Figure 11.4.20).
The tendons of the forearm muscles attach to the wrist and extend into the hand. Fibrous bands called retinacula sheath the tendons at the wrist. The flexor retinaculum extends over the palmar surface of the hand while the extensor retinaculum extends over the dorsal surface of the hand.
Intrinsic Muscles of the Hand
The intrinsic muscles of the hand both originate and insert within it (Figure 11.4.21). These muscles allow your fingers to make precise movements for actions, such as typing or writing. These muscles are divided into three groups. The thenar muscles are on the radial aspect of the palm. The hypothenar muscles are on the ulnar aspect of the palm, and the intermediate muscles are midpalmar.
The thenar muscles include the abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, and the adductor pollicis. These muscles form the thenar eminence, the rounded contour of the base of the thumb, and all act on the thumb. The movements of the thumb play an integral role in most precise movements of the hand.
The hypothenar muscles include the abductor digiti minimi, flexor digiti minimi brevis, and the opponens digiti minimi. These muscles form the hypothenar eminence, the rounded contour of the little finger, and as such, they all act on the little finger. Finally, the intermediate muscles act on all the fingers and include the lumbrical, the palmar interossei, and the dorsal interossei.
| Intrinsic Muscles of the Hand (Table 11.9) | ||||||
|---|---|---|---|---|---|---|
| Muscle | Movement | Target | Target motion direction | Prime mover | Origin | Insertion |
| Thenar muscles | Moves thumb toward body | Thumb | Abduction | Abductor pollicis brevis | Flexor retinaculum; and nearby carpals | Lateral base of proximal phalanx of thumb |
| Thenar muscles | Moves thumb across palm to touch other fingers | Thumb | Opposition | Opponens pollicis | Flexor retinaculum; trapezium | Anterior of first metacarpal |
| Thenar muscles | Flexes thumb | Thumb | Flexion | Flexor pollicis brevis | Flexor retinaculum; trapezium | Lateral base of proximal phalanx of thumb |
| Thenar muscles | Moves thumb away from body | Thumb | Adduction | Adductor pollicis | Capitate bone; bases of metacarpals 2–4; front of metacarpal 3 | Medial base of proximal phalanx of thumb |
| Hypothenar muscles | Moves little finger toward body | Little finger | Abduction | Abductor digiti minimi | Pisiform bone | Medial side of proximal phalanx of little finger |
| Hypothenar muscles | Flexes little finger | Little finger | Flexion | Flexor digiti minimi brevis | Hamate bone; flexor retinaculum | Medial side of proximal phalanx of little finger |
| Hypothenar muscles | Moves little finger across palm to touch thumb | Little finger | Opposition | Opponens digiti minimi | Hamate bone; flexor retinaculum | Medial side of fifth metacarpal |
| Intermediate muscles | Flexes each finger at metacarpo-phalangeal joints; extends each finger at interphalangeal joints | Fingers | Flexion | Lumbricals | Palm (lateral sides of tendons in flexor digitorum profundus) | Fingers 2–5 (lateral edges of extensional expansions on first phalanges) |
| Intermediate muscles | Adducts and flexes each finger at metacarpo-phalangeal joints; extends each finger at interphalangeal joints | Fingers | Adduction; flexion; extension | Palmar interossei | Side of each metacarpal that faces metacarpal 3 (absent from metacarpal 3) | Extensor expansion on first phalanx of each finger (except finger 3) on side facing finger 3 |
| Intermediate muscles | Abducts and flexes the three middle fingers at metacarpo-phalangeal joints; extends the three middle fingers at interphalangeal joints | Fingers | Abduction; flexion; extension | Dorsal interossei | Sides of metacarpals | Both sides of finger 3; for each other finger, extensor expansion over first phalanx on side opposite finger 3 |
Chapter Review
The clavicle and scapula make up the pectoral girdle, which provides a stable origin for the muscles that move the humerus. The muscles that position and stabilize the pectoral girdle are located on the thorax. The anterior thoracic muscles are the subclavius, pectoralis minor, and the serratus anterior. The posterior thoracic muscles are the trapezius, levator scapulae, rhomboid major, and rhomboid minor. Nine muscles cross the shoulder joint to move the humerus. The ones that originate on the axial skeleton are the pectoralis major and the latissimus dorsi. The deltoid, subscapularis, supraspinatus, infraspinatus, teres major, teres minor, and coracobrachialis originate on the scapula.
The forearm flexors include the biceps brachii, brachialis, and brachioradialis. The extensors are the triceps brachii and anconeus. The pronators are the pronator teres and the pronator quadratus. The supinator is the only one that turns the forearm anteriorly.
The extrinsic muscles of the hands originate along the forearm and insert into the hand in order to facilitate crude movements of the wrists, hands, and fingers. The superficial anterior compartment of the forearm produces flexion. These muscles are the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and the flexor digitorum superficialis. The deep anterior compartment produces flexion as well. These are the flexor pollicis longus and the flexor digitorum profundus. The rest of the compartments produce extension. The extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris are the muscles found in the superficial posterior compartment. The deep posterior compartment includes the abductor longus, extensor pollicis brevis, extensor pollicis longus, and the extensor indicis.
Finally, the intrinsic muscles of the hands allow our fingers to make precise movements, such as typing and writing. They both originate and insert within the hand. The thenar muscles, which are located on the lateral part of the palm, are the abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, and adductor pollicis. The hypothenar muscles, which are located on the medial part of the palm, are the abductor digiti minimi, flexor digiti minimi brevis, and opponens digiti minimi. The intermediate muscles, located in the middle of the palm, are the lumbricals, palmar interossei, and dorsal interossei.
Review Questions
Critical Thinking Questions
- The tendons of which muscles form the rotator cuff? Why is the rotator cuff important?
- List the general muscle groups of the shoulders and upper limbs as well as their subgroups.
Glossary
- abductor digiti minimi
- muscle that abducts the little finger
- abductor pollicis brevis
- muscle that abducts the thumb
- abductor pollicis longus
- muscle that inserts into the first metacarpal
- adductor pollicis
- muscle that adducts the thumb
- anconeus
- small muscle on the lateral posterior elbow that extends the forearm
- anterior compartment of the arm
- (anterior flexor compartment of the arm) the biceps brachii, brachialis, brachioradialis, and their associated blood vessels and nerves
- anterior compartment of the forearm
- (anterior flexor compartment of the forearm) deep and superficial muscles that originate on the humerus and insert into the hand
- biceps brachii
- two-headed muscle that crosses the shoulder and elbow joints to flex the forearm while assisting in supinating it and flexing the arm at the shoulder
- brachialis
- muscle deep to the biceps brachii that provides power in flexing the forearm.
- brachioradialis
- muscle that can flex the forearm quickly or help lift a load slowly
- coracobrachialis
- muscle that flexes and adducts the arm
- deep anterior compartment
- flexor pollicis longus, flexor digitorum profundus, and their associated blood vessels and nerves
- deep posterior compartment of the forearm
- (deep posterior extensor compartment of the forearm) the abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, extensor indicis, and their associated blood vessels and nerves
- deltoid
- shoulder muscle that abducts the arm as well as flexes and medially rotates it, and extends and laterally rotates it
- dorsal group
- region that includes the extensor digitorum brevis
- dorsal interossei
- muscles that abduct and flex the three middle fingers at the metacarpophalangeal joints and extend them at the interphalangeal joints
- extensor carpi radialis brevis
- muscle that extends and abducts the hand at the wrist
- extensor carpi ulnaris
- muscle that extends and adducts the hand
- extensor digiti minimi
- muscle that extends the little finger
- extensor digitorum
- muscle that extends the hand at the wrist and the phalanges
- extensor indicis
- muscle that inserts onto the tendon of the extensor digitorum of the index finger
- extensor pollicis brevis
- muscle that inserts onto the base of the proximal phalanx of the thumb
- extensor pollicis longus
- muscle that inserts onto the base of the distal phalanx of the thumb
- extensor radialis longus
- muscle that extends and abducts the hand at the wrist
- extensor retinaculum
- band of connective tissue that extends over the dorsal surface of the hand
- extrinsic muscles of the hand
- muscles that move the wrists, hands, and fingers and originate on the arm
- flexor carpi radialis
- muscle that flexes and abducts the hand at the wrist
- flexor carpi ulnaris
- muscle that flexes and adducts the hand at the wrist
- flexor digiti minimi brevis
- muscle that flexes the little finger
- flexor digitorum profundus
- muscle that flexes the phalanges of the fingers and the hand at the wrist
- flexor digitorum superficialis
- muscle that flexes the hand and the digits
- flexor pollicis brevis
- muscle that flexes the thumb
- flexor pollicis longus
- muscle that flexes the distal phalanx of the thumb
- flexor retinaculum
- band of connective tissue that extends over the palmar surface of the hand
- hypothenar
- group of muscles on the medial aspect of the palm
- hypothenar eminence
- rounded contour of muscle at the base of the little finger
- infraspinatus
- muscle that laterally rotates the arm
- intermediate
- group of midpalmar muscles
- intrinsic muscles of the hand
- muscles that move the wrists, hands, and fingers and originate in the palm
- latissimus dorsi
- broad, triangular axial muscle located on the inferior part of the back
- lumbrical
- muscle that flexes each finger at the metacarpophalangeal joints and extend each finger at the interphalangeal joints
- opponens digiti minimi
- muscle that brings the little finger across the palm to meet the thumb
- opponens pollicis
- muscle that moves the thumb across the palm to meet another finger
- palmar interossei
- muscles that abduct and flex each finger at the metacarpophalangeal joints and extend each finger at the interphalangeal joints
- palmaris longus
- muscle that provides weak flexion of the hand at the wrist
- pectoral girdle
- shoulder girdle, made up of the clavicle and scapula
- pectoralis major
- thick, fan-shaped axial muscle that covers much of the superior thorax
- pectoralis minor
- muscle that moves the scapula and assists in inhalation
- pronator quadratus
- pronator that originates on the ulna and inserts on the radius
- pronator teres
- pronator that originates on the humerus and inserts on the radius
- retinacula
- fibrous bands that sheath the tendons at the wrist
- rhomboid major
- muscle that attaches the vertebral border of the scapula to the spinous process of the thoracic vertebrae
- rhomboid minor
- muscle that attaches the vertebral border of the scapula to the spinous process of the thoracic vertebrae
- rotator cuff
- (also, musculotendinous cuff) the circle of tendons around the shoulder joint
- serratus anterior
- large and flat muscle that originates on the ribs and inserts onto the scapula
- subclavius
- muscle that stabilizes the clavicle during movement
- subscapularis
- muscle that originates on the anterior scapula and medially rotates the arm
- superficial anterior compartment of the forearm
- flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor digitorum superficialis, and their associated blood vessels and nerves
- superficial posterior compartment of the forearm
- extensor radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, and their associated blood vessels and nerves
- supinator
- muscle that moves the palm and forearm anteriorly
- supraspinatus
- muscle that abducts the arm
- teres major
- muscle that extends the arm and assists in adduction and medial rotation of it
- teres minor
- muscle that laterally rotates and extends the arm
- thenar
- group of muscles on the lateral aspect of the palm
- thenar eminence
- rounded contour of muscle at the base of the thumb
- triceps brachii
- three-headed muscle that extends the forearm
Solutions
Answers for Critical Thinking Questions
- The biceps femoris, semimembranosus, and semitendinosus form the hamstrings. The hamstrings flex the leg at the knee joint.
- The rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius form the quadriceps. The quadriceps muscles extend the leg at the knee joint.
This work, Anatomy & Physiology, is adapted from Anatomy & Physiology by OpenStax, licensed under CC BY. This edition, with revised content and artwork, is licensed under CC BY-SA except where otherwise noted.
Images, from Anatomy & Physiology by OpenStax, are licensed under CC BY except where otherwise noted.
Access the original for free at https://openstax.org/books/anatomy-and-physiology/pages/1-introduction.


13.1 Mobility Introduction
Open Resources for Nursing (Open RN)
Learning Objectives
- Identify factors putting clients at risk for mobility problems
- Identify cues related to mobility problems
- Identify the effects of immobility on body systems
- Describe nursing interventions to prevent complications of immobility
- Contribute to a plan of care for clients with mobility alterations
Sit on a sturdy chair with your legs and arms stretched out in front of you, and then try to stand. This basic mobility task can be impaired during recovery from major surgery or for clients with chronic musculoskeletal conditions. Mobility, which includes moving one’s extremities, changing positions, sitting, standing, and walking, helps avoid degradation of many body systems and prevents complications associated with immobility. Nurses assist clients to be as mobile as possible, based on their individual circumstances, to achieve their highest level of independence, prevent complications, and promote a feeling of well-being. This chapter will discuss nursing assessments and interventions related to promoting mobility.


Homestyle Meatloaf
| Number of portions: 2 | Prep time: 15 minutes | Total time: 1 hour 45 minutes |
Ingredients
- 2 tsp (10 mL) canola oil, divided
- 1 small onion, finely chopped
- 2 medium carrots, shredded
- 1 lb (454 g) raw extra lean ground beef
- 2 large eggs
- 1 medium zucchini, shredded
- ½ cup whole wheat breadcrumbs
- 1 tsp black pepper
- 2 tbsp (30 mL) Worcestershire sauce
- ½ cup (125 mL) no sodium added tomato sauce
Sides
- 1 medium sweet potato
- 2 cups broccoli florets, chopped
Directions
- Preheat oven to 400°F (200°C). Grease a 9 x 5-inch (1.9 L) loaf pan with 1 tsp oil.
- Heat remaining tsp of oil in a medium skillet over medium heat.
- Cook onions for 3-4 minutes until translucent.
- Add carrot and cook until softened, approximately 3 minutes.
- Combine cooked carrots and onions, ground beef, eggs, zucchini, bread crumbs, black pepper, and Worcestershire in a large bowl; mix well using your hands. Press meat mixture into the prepared loaf pan.
- Bake for 75-90 minutes, or until cooked through.
- Wrap sweet potato in foil. Add the sweet potato to the oven and bake for 45 minutes.
- Steam broccoli until tender, 5-8 minutes.
- Spread tomato sauce on the top of the meatloaf once cooked and continue baking until bubbling, about 5 more minutes.
- Remove meatloaf and sweet potato from oven. Let meatloaf rest for 10 minutes before slicing into 8 slices.
- Slice sweet potato in half lengthwise.
- Divide sweet potato and broccoli between two plates and serve with meatloaf.
| Nutrient | Per portion |
| Calories | 418 kcal |
| Protein | 34 g |
| Carbohydrates | 38 g |
| Fat | 15 g |
| Fibre | 8 g |
| Sodium | 346 mg |


Review Questions
REVIEW QUESTIONS
1. Which of the following is not important in preventing backflow of blood?
a chordae tendineae
b papillary muscles
c AV valves
d endocardium
2. Which valve separates the left atrium from the left ventricle?
a mitral
b tricuspid
c pulmonary
d aortic
3. Which of the following lists the valves in the order through which the blood flows from the vena cava through the heart?
a tricuspid, pulmonary semilunar, bicuspid, aortic semilunar
b mitral, pulmonary semilunar, bicuspid, aortic semilunar
c aortic semilunar, pulmonary semilunar, tricuspid, bicuspid
d bicuspid, aortic semilunar, tricuspid, pulmonary semilunar
4. Which chamber initially receives blood from the systemic circuit?
a left atrium
b left ventricle
c right atrium
d right ventricle
5. The ________ layer secretes chemicals that help to regulate ionic environments and strength of contraction and serve as powerful vasoconstrictors.
a pericardial sac
b endocardium
c myocardium
d epicardium
6. The myocardium would be the thickest in the ________.
a left atrium
b left ventricle
c right atrium
d right ventricle
7. In which septum is it normal to find openings in the adult?
a interatrial septum
b interventricular septum
c atrioventricular septum
d all of the above
8. Which of the following is unique to cardiac muscle cells?
a Only cardiac muscle contains a sarcoplasmic reticulum.
b Only cardiac muscle has gap junctions.
c Only cardiac muscle is capable of autorhythmicity
d Only cardiac muscle has a high concentration of mitochondria.
9. The influx of which ion accounts for the plateau phase?
a sodium
b potassium
c chloride
d calcium
10. Which portion of the ECG corresponds to repolarization of the atria?
a P wave
b QRS complex
c T wave
d none of the above: atrial repolarization is masked by ventricular depolarization
11. Which component of the heart conduction system would have the slowest rate of firing?
a atrioventricular node
b atrioventricular bundle
c bundle branches
d Purkinje fibers
12. The cardiac cycle consists of a distinct relaxation and contraction phase. Which term is typically used to refer ventricular contraction while no blood is being ejected?
a systole
b diastole
c quiescent
d isovolumic contraction
13. Most blood enters the ventricle during ________.
a atrial systole
b atrial diastole
c ventricular systole
d isovolumic contraction
14. The first heart sound represents which portion of the cardiac cycle?
a atrial systole
b ventricular systole
c closing of the atrioventricular valves
d closing of the semilunar valves
15. Ventricular relaxation immediately follows ________.
a atrial depolarization
b ventricular repolarization
c ventricular depolarization
d atrial repolarization
16. The force the heart must overcome to pump blood is known as ________.
a preload
b afterload
c cardiac output
d stroke volume
17. The cardiovascular centers are located in which area of the brain?
a medulla oblongata
b pons
c mesencephalon (midbrain)
d cerebrum
18. In a healthy young adult, what happens to cardiac output when heart rate increases above 160 bpm?
a It increases.
b It decreases.
c It remains constant.
d There is no way to predict.
19. What happens to preload when there is venous constriction in the veins?
a It increases.
b It decreases.
c It remains constant.
d There is no way to predict.
20. Which of the following is a positive inotrope?
a Na+
b K+
c Ca2+
d both Na+ and K+


Environmental Sciences Resources
Agriculture / Arboriculture / Urban Forestry
- Advanced Technologies and Artificial Intelligence in Agriculture (2023)
- Agricultural Knowledge Intelligent Service Technology: A Review (2023)
- Agricultural Technology Knowledge Intelligent Question-Answering System Based on Large Language Model (2023)
- AI-Assisted Sustainable Farming: Harnessing the Power of ChatGPT in Modern Agricultural Sciences and Technology (2023)
- Artificial intelligence is key to the evolution of Florida agriculture (2024)
- Artificial intelligence research in agriculture: a review (2022)
- Artificial intelligence solutions enabling sustainable agriculture: A bibliometric analysis (2022)
- Bayer Pilots Unique Generative AI Tool for Agriculture (2024)
- Benefits of Integrating ChatGPT into Precision Agriculture (2024)
- ChatAgri: Exploring potentials of ChatGPT on cross-linguistic agricultural text classification (2023)
- ChatGPT in the context of precision agriculture data analytics (2023)
- Cropin unveils ‘akṣara’ micro language model for climate-smart agriculture, targeting the Global South (2024)
- Generative AI: A game changer for ASABE professionals (2024)
- Harnessing AI: Revolutionizing Dairy Farming with ChatGPT (2024)
- Importance of chat GPT in Agriculture: According to chat GPT (2023)
Greenhouse / Nursery
Natural Resource Management
Water Science
- Deep learning in water protection of resources, environment, and ecology: achievement and challenges (2024)
- Exploratory Analysis of Water Quality in a Small Urbanized Watershed Using Deep Learning (2023)
- Leveraging Deep Learning and Language Models in Revolutionizing Water Resource Management, Research, and Policy Making: A Case for ChatGPT (2023)
- Revolutionizing water treatment, conservation, and management: Harnessing the power of AI-driven ChatGPT solutions (2023)
- Roles and Challenges of ChatGPT and Similar Generative Artificial Intelligence for Achieving the Sustainable Development Goals (SDGs) (2024)


C. Wesley
LOVE Divine, all loves excelling,
Joy of Heaven, to earth come down;
Fix in us Thy humble dwelling,
All Thy faithful mercies crown.
Jesus, Thou art all compassion,
Pure, unbounded love Thou art;
Visit us with Thy salvation,
Enter every longing heart.
2
Come, Almighty, to deliver;
Let us all Thy grace receive;
Suddenly return, and never,
Nevermore Thy temples leave.
Thee would we be always blessing,
Serve Thee as Thy hosts above,
Pray and praise Thee without ceasing,
Glory in Thy perfect love.
3
Finish, then, Thy new creation,
Pure and spotless may we be;
Let us see our whole salvation
Perfectly secured by Thee:
Changed from glory into glory,
Till in heaven we take our place;
Till we cast our crowns before Thee,
Lost in wonder, love, and praise.