Injections

Different routes of injections and their procedure techniques

1. Injections Mr. Mahesh Chand Nursing Tutor MTIN

2. What is an injection? Injections are sterile solutions, emulsions or suspensions. They are prepared by dissolving, emulsifying or suspending an active ingredient and any other substances in water for injection. Injecting is the act of giving medication by use of syringe and needle to obtain the desired therapeutic effect taking into account the patients safety and comfort

3. Types of Injections Parenteral medication: administration of a medication by injection into body tissues Subcutaneous (SC) – into tissue below dermis of skin Intramuscular (IM) – into the body muscle Intravenous (IV) – into a vein Intradermal (ID)– into the dermis just under the epidermis

4. Purposes of Injection To get rapid and systematic effect of the drug. To provide the needed effect even when the client is unconscious. Assure that the total dosage will be administered and the same will be absorbed for the systemic actions of the drug . To obtain a local effect at the sight of injection e.g. xylocaine, tuberculin test. To restore blood volume by replacing the fluids. To give nourishment when it can’t be taken by mouth.

5. Syringes Three main parts: Barrel – chamber that holds the medication Plunger – part within the barrel that moves back and forth to withdraw and instill medication Tip – part that the needle is attached to

6. Which is which needle? The correct needle is the key to delivering the drug to the correct area for the maximum effect with the least amount of discomfort The colour at the top of the needle reflects its size the higher the number the smaller the lumen(bore) .

7. Equipment for the administration of injections Clean tray in which to place drug and equipment N eedle to ease reconstitution and drawing up Syringe of appropriate size Swabs saturated with isopropyl alcohol 70% Sterile topical swab if drug is presented in ampoule form Drug to be administered Patients prescription to check dose, route and timing Notes available to record administration in accordance with law Gloves , Apron

8. Clinical room preparation for the administration of injections Protocols/procedure/standards information is available . Hand basin for washing hands and/or alcohol hand rub. Area for the client to lie down . Panic button/phone to call for assistance Gloves Resuscitation /anaphylaxis equipment/drugs Oxygen and appropriate mask if available adequate time for procedure

9. Asepsis and reducing the risk of infection Good hand washing Good hand drying Aseptic technique Good observation and questioning of the client Skin preparation if required

10. The 7 Rights of Drug Administration Right client Right medication Right dose Right route Right time Right reason Right documentation

11. IV Medication Am p ul es Vials

12. Dr a w in g U p M e d i c a t i o n From an Ampules Wash hands and gather equipment. Grasp the stem with an alcohol swab

13. Co n ti n u e D r a w in g U p Medication From an Ampules Snap off the ampoule’s neck away from the hands and face

14. Co n ti n u e D r a w in g U p Medication From an Ampules Uncap the needle and insert the needle into the ampule. Avoid touching the rim with the needle.

15. Co n ti n u e D r a w in g U p Medication From an Ampules Invert the ampule, insert the needle into the solution and aspirate.

16. Co n ti n u e D r a w in g U p Medication From an Ampules Remove the needle cap and draw an amount of air into the syringe that is equal to the amount of medication that will be withdrawn from the vial

17. Drawing Up Medication From a Vial  Insert the needle keeping it above the solution

18. C on t in u e D r a w in g U p Medication From a Vial Invert the vial at eye level

19. C on t in u e D r a w in g U p Medication From a Vial Hold the needle upright and re-check the syringe’s contents for presence of air

20. INTRADERMAL INJECTIONS

21. INTRADERMAL INJECTION  It is the introduction via needle of tiny amounts of fluid into layers of skin.  It provides a local, rather than systemic effect.  Syringe used is 1ml tuberculin syringe because of a very small amount of drug needed.  Needle used is a short (1/4 to 5/8 inch), fine gauge (g25-27). Indications:  For diagnostic purposes (allergies and sensitivities to drugs )  For administering tuberculin testing

22. INTRADERMAL INJECTION  Intradermal literally means “between the skin layers” and injection is administered just under the epidermis .  Syringe is positioned at15 ˚ angle .  Small volumes, usually 0.01 to 0.05ml, are injected because of the small tissue space.

23. INTRADERMAL INJECTION  Most commonly used site: Inner surface of the forearm  Subscapular region of the back can be used as well as deltoid region .

24. INTRADERMAL INJECTION REMEMBER:  Mixture of drug and water for skin testing: 0.9cc of distilled water/sterile water and 0.1cc of the drug.  Inject the solution intradermally and just enough to form a wheal.  Encircle the site correctly and write the time whe n to check the injection site to determine reaction to the drug.  Check the site after 30 minutes for signs of reaction.  If negative, document it as ANST (After Negative Skin test) (-); if positive, ANST (+)

25. INTRADERMAL INJECTION REMEMBER:  A positive result may b e ma n ifested b y a ny o f the following:  Red d ening o f the si t e accompanied with mar ked elevation  Increase in circumference of the wheal  Presence of itchiness on the site

26. PROCEDURE  Prepare all the equipment needed: 1cc syringe, disposable needle (aspirating needle), sterile water, drug to be tested, wet and dry cotton balls and ballpen.  W ash hands an d obs e rve a pprop r i a te i n fect i o n control measures.  Introduce yourself and verify the client’s identity.  Explain to the client what you are going to do, why it is necessary and how the client can cooperate.  Prepare needed materials aseptically.  Check the label of the drug three times.

27. PROCEDURE  Prep a re t h e medicat i on to b e used for skin test i n g (e.g ampule or vial)  Aspirate 0.9cc of distilled water/sterile water and 0.1cc of the drug using the tuberculin syringe with the aspirating needle.  Mix the drug and the distilled water in the syringe.  Replace the aspirating needle with g25 needle.  Expel excess air.  Place the syringe o n the tray t o gether w i t h the w e t and dry cotton balls.

28. PROCEDURE  Confirm again patient’s identity.  Locate the appropriate site for skin testing.  Cleanse the med i al surface o f t he forearm b y us i ng firm, circular motion from inner to outer portion.  Allow the skin to dry before injecting the drug.  Place hand in non-dominant hand of the patient.  Remove needle cap and holds syringe at 15 degree angle from skin with bevel up.  Stret ch the skin and t e ll the patient that he/she wi l l feel a prick as needle is inserted.

29. PROCEDURE  Inject the solution intradermally and just enough to form a wheal.  Remove the needle quickl y but gently at the same angle used for injection.  Wipe with dry cotton ball but do not press the injection site.  Encircle the site correctly and write the time when to check the injection site to determine reaction to the drug. Check the site after 30 minutes.

30. Subcutaneous injection

31. Insulin is the most important drug in the subcutaneous injections

32. SUBCUTANEOUS INJECTION s  Subcutaneous tissue lies between the epidermis and the muscle.  Subcutaneous route is used for slow, sustained absorption of medication.  SC or SQ Indications:  Used commonly for insulin injection  Heparin

33. SUBCUTANEOUS INJECTION  Common sites used for S Q route: Outer aspect of the upper arm Abdomen(from below the costal margin to the iliac crests) Anterior aspects of the thigh Upper back Upper ventral or dorsogluteal area

34. SUBCUTANEOUS INJECTION R E MEMBE R : syringe i n the dominant  Hold hand between the thumb and forefinger.  In ject the nee d le quickly a t an a n gle of depending 45 to 90 degree, o n the amount and turgor of the tissue and the length of the needle.

35. Insulin Indications Type I diabetes mellitus, type II diabetes mellitus, hyperkalemia, DKA/diabetic coma MOA Stimulating peripheral glucose uptake and inhibiting hepatic glucose production Patient Info  Hypoglycemia (BG < 70 mg/dL) esp with higher doses – Anxiety, blurred vision, palpitations, shakiness, slurred speech, sweating  Weight gain Insulin Indications Type I diabetes mellitus, type II diabetes mellitus, hyperkalemia, DKA/ MOA Stimulating peripheral glucose uptake and inhibiting hepatic glucose production Patient Info Hypoglycemia (BG < 70 mg/dL) esp with higher doses – Anxiety, blurred vision, palpitations, shakiness, slurred speech, sweating

36. Insulin (cont) Administration: Subcutaneous injection Rotate site Check blood sugars regularly Storage: Refrigerate until use Once vial is punctured, it is good for 28 days and can be left at room temperature (except for glargine which is 90 days)

37. Insulin Dosing Normal insulin secretion Long - acti n g Long-acting & Short-acting 70/30 pr e -mi x ed

38. Insulin (cont) Cautions/Severe Adverse Reactions Severe hypoglycemia (seizure/coma) (BG < 40 mg/dL) Edema CONTRAINDICATIONS Severe hypoglycemia Allergy or sensitivity to any ingredient of the product

39. INTRAMUSCULAR INJECTION

40. INTRAMUSCULAR INJECTION

41. SITES ACCEPTABLE FOR IM INJECTION

42. Deltoid    Palpate lower edge of acromion process. Place 4 fingers across the deltoid muscle with the top finger along the a cr o m i o n p r o c e ss . T h i s forms the base of a triangle. Draw an imaginary line at the axilla. This forms the apex of the triangle.  Injection site is the center of the triangle, 3 finger widths (1-2 inches) below the acromion process.

43. DELTOID MUSCLE

44. GLUTEUS MAXIMUS    Locate the posterior iliac spine. Locate the greater trochanter. Draw an imaginary line between these two landmarks.  Injection site is above and lateral to the line.  Most dangerous site because of sciatic nerve location

45. GLUTEUS MEDIUS  Palm of hand on greater trochanter of femur.  Index finger on anterior superior iliac spine (hip bone).  Middle finger extended toward iliac tubercle.  Injection site lies within the triangle formed by the index and middle fingers

46. Vastus Lateralis  One hand above the knee.  One hand below the greater trochanter.  Locate midline of anterior thigh and midline of lateral thigh.  Injection site is the lateral area of the thigh

47. Institute of Nursing Theory and Practice, Prague 2007 VASTUS LATERALIS

48. INTRAMUSCULAR INJECTION REMEMBER:  3cc syringe can be used for I IM injection with g22 or 23 needle; 1-2 inches long .  Position the needle at 90˚ angle.  Do not forget to aspirate the plunger once injected to check for blood. (To determine if a blood vessel was hit)  Inject medication slowly ( To minimize pain)

49. INTRAMUSCULAR INJECTION R E MEMBE R : Apply pressure to site and massage after (To prevent hematoma and prevent oozing of blood and for proper absorption of the medicine.

50. PROCEDURE  Prepare needed materials aseptically.  Check the label of the drug three times.  Prepare the medication.  Position the patient and locate the site correctly.  Cle a nse the site usi n g circu l ar mot i o n f r o m i n n er to outer portion and allow it to dry.  Place a swab between fingers of non-dominant hand.  Pinch or spread tissue and insert needle quickly at 90 degrees angle in a dartlike position.

51. PROCEDURE  Pull back the plunger to check for blood.  Inject the medication slowly if no blood appears.  Withdraw needle quickly.  A p p ly pressure an d dry co t ton ball to the site and massage.  Leave the client in a comfortable position.  Dispo s e the syri ng e an d other mat e r ials used properly, wash hands and document the procedure.

52. Z-track IM Administration Method used with irritating medications . E.g. Iron Used to “trap” medication in muscle and prevent “tracking” of solution through tissues.

53. Z-track IM Administration Prepare medication Change needle after drawing up med Gather supplies Identify site Do gloves Cleanse site with alcohol Displace skin laterally 1-1 ½ inches from injection site While holding skin, insert needle with a darting motion, at a 90° angle.

54. Z-track IM Administration Stabilize needle with thumb and forefinger. Aspirate . If no blood, then inject medication slowly and steady Wait 10 seconds Quickly withdrawal needle Then release skin Cover site with swab and DO NOT MASSAGE DO NOT RECAP. Activate safety feature. Place needle in sharps container uncapped Remove gloves