Chain of Survival and EMSC

Chapter 35

Administering Intradermal,Subcutaneous, and IntramuscularInjections

Chapter 35

Lesson 35.1

Learning Objectives

Theory

1)Identify the principles for safe and effectiveadministration of intradermal, subcutaneous,and intramuscular injections.

2)List the routes used for administeringparenteral medications and the advantagesand disadvantages of each route forpediatric, adult, and elderly patients.

Slide 3

Learning Objectives

Clinical Practice

1)Choose the appropriate syringe and needlefor the type of injection ordered.

2)Follow Standard Precautions whenadministering injections and disposing ofused equipment.

Slide 4

Injections

Often necessary to inject medication intotissue

Injections cause pain to the patient

Student nurses often uncomfortable withcausing the patient discomfort

Students should learn and practice this skill inthe laboratory to minimize their and patient’sdiscomfort

Slide 5

Figure 35-1: Structure of the skin

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Principles of Parenteral Injections

Use when:

Patient is NPO

Digestive juices counteract oral drugs

Use to:

Hasten the action of the drug

Ensure the delivered dose is accurate

Always:

Select the correct site

Use sterile equipment

Slide 7

Safe, Effective Administration ofParenteral Medications

Use only sterile needles and syringes

Use appropriate-length needle to reach theproper tissue layer

Select injection site carefully to avoid majornerves, blood vessels, and underlying organs

Select injection site relatively free from hair,lesions, inflammation, rashes, moles, andfreckles

Slide 8

Safe, Effective Administration ofParenteral Medications (cont’d)

Establish a plan for rotating injection sites forpatients receiving repeated injections

Obtain assistance as needed in giving aninjection when the patient is a frightened childor an uncooperative adult

Aspirate by pulling back the plunger to avoidinjecting medications into a blood vessel

Slide 9

Safe, Effective Administration ofParenteral Medications (cont’d)

Check for drug allergies before youadminister an injection

Know the medication you will administer andobserve for side effects and therapeuticaction

Slide 10

Routes for Parenteral Administration:Intradermal

Medication is deposited into layers of skin

Usually used for skin testing for TB or otherdiseases (allergy testing)

Use a small needle, with a 15-degree angleof insertion (24, 27, or 29 gauge)

Use a tuberculin syringe

Forms a skin bleb or small bump

Slide 11

Routes for Parenteral Administration:Subcutaneous

Injects small amount of medication (0.5-1 mL)into tissue below the dermal layer intosubcutaneous fat

Usual sites: upper outer portion of the arm,anterior surface of the thigh, or the abdomen

25- or 27-gauge needle, 3/8- to 1/2-inch long

Insulin syringe or tuberculin syringe usually used

A 45- or 90-degree angle used, depending onthe amount of subcutaneous tissue on thepatient

Slide 12

Figure 35-17: Subcutaneousinjection sites

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Routes for Parenteral Administration:Intramuscular

Injected into muscle layer at 90-degree angle

Most common sites: deltoid, dorsogluteal,ventrogluteal, vastus lateralis, and rectusfemoris

Needle usually 19-23 gauge, 1-3 inches long

Volume up to 3 mL for most IM injections, nurseaspirates for blood before injecting medicationto avoid injecting directly into a blood vessel

The absorption time for IM medications chieflydepends on the form of the drug

Slide 14

Intramuscular Route: Z-TrackMethod

May be used any time an intramuscularinjection is given

Used for deep IM injections of drugs such asiron dextran or Vistaril

Reduces pain caused by irritating drugsleaking into subcutaneous tissue

Seals the medication in the muscular layer

See Step 35-5

Slide 15

Figure 35-2: Injection routes

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Syringes

Composed of barrel and plunger with a needle tip madeof plastic (disposable) or glass

3-mL syringe

•Popular because large enough for subcutaneous and mostIM injections

U-100 syringe

•Used with U-100–strength insulin

•Calibrated in units

Tuberculin syringes

•1 mL in size

•Calibrated to measure as small as 0.01-mL drug doses

Unit-dose cartridge

•Requires a special holder for the cartridge and needle

Slide 17

Figure 35-3: Parts of a syringe

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Figure 35-7: Measurement scale ona 3-mL syringe

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Figure 35-5: Insulin syringes

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Figure 35-6: Tuberculin syringe

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Needle Gauge and Length

Available in standard sizes from 13 to 30

The larger the number, the smaller the needle

25, 27, or 29 gauge for intradermal injections;25 gauge for subcutaneous injections

21 to 23 gauge for intramuscular injections

Slide 22

Figure 35-8: Needle sizes

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Preparing the Syringe for Use

Use aseptic technique in handling the syringeand needle

Protect surfaces that must remain sterile: theneedle, tip, inner barrel, and plunger

Discard syringe or needle if it becomescontaminated during drug preparation foradministration

Label the syringe with the patient’s name,name of medication, and dose

Slide 24

Figure 35-9: Needle withprotective sheath

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Filter Needles

Medications drawn from an ampule may haveglass in them from the breaking of the ampule

Filter needles should be used whenmedication is withdrawn from ampule to trapthe glass particles

Filter is discarded and new needle attachedto syringe for injecting medication into thepatient

Slide 26

Figure 35-10: Discarding used syringeinto a sharps biohazard container

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Needle Sticks

HIV, hepatitis B, and hepatitis C can be spreadby a needle stick from an infected patient

Safety syringes prevent needle sticks to healthcare workers and should be used whenavailable

If regular syringes must be used, the needlemust not be recapped after injection but takento the nearest sharps disposal unit anddiscarded—never recap a needle

Report all needle sticks

Slide 28

Question 1

What size and gauge needle are used to giveintramuscular injections?

1)1/2- to 1-inch needle that is 23 to 25 gauge

2)1- to 1 1/2-inch needle that is 20 to 23 gauge

3)1/2- to 5/8-inch needle that is 20 to 23 gauge

4)2- to 2 1/2-inch needle that is 20 to 23 gauge

Slide 29

Chapter 35

Lesson 35.2

Learning Objectives

Clinical Practice

3)Aseptically and accurately withdraw andmeasure the ordered dose of a medicationfrom a vial or an ampule.

4)Demonstrate reconstitution of a drug from apowder.

5)Demonstrate the correct method for drawingup two types of drugs, including insulin, inone syringe.

Slide 31

Parenteral Solutions

May be available in:

Ampules

Vials

•Single dose and multidose

Mix-O-Vials

•Medication in powder form and diluent present in twohalves of a vial separated by a rubber stopper

Unit-dose cartridges

•Requires Carpuject or Tubex holders

Slide 32

Figure 35-11: Containers ofparenteral medication

Slide 33

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Ampules

Glass or polyurethane; consist of body, neck, andstem; usually contain a single medication dose

All medication must be in the ampule body beforethe neck is broken

Before opening, medication must be removedfrom the neck or stem

Tap or flick the stem several times with a finger tofree the trapped solution

The open ampule is handled very carefully whenwithdrawing the medication with the filter needle

Slide 34

Figure 35-13: Moving fluid from theneck of the ampule

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Figure 35-14A: Withdrawing fluid froman ampule—ampule inverted

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Figure 35-14B: Withdrawing fluid from anampule—ampule upright and stabilized

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Vials

A small bottle with a rubber stopper attachedby a metal band

May contain one or more dosages ofmedication

Sizes from 1 to 50 mL

May be in powder form requiringreconstitution (label or package insertprovides mixing instructions)

Before mixing two medications in a syringe, checkfor compatibility

Slide 38

Figure 35-15: Drawing medicationfrom a vial

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Reconstituting a Drug

Drugs that are unstable in liquid form areprepared in a powdered form

Solute (the powder) is mixed with a diluent todissolve the drug before drawing up into thesyringe for injection

Diluents are usually sterile water or saline

Follow directions on the vial or package forproper reconstitution

Slide 40

Compatibility of Medications

A reaction occurs when a drug combines withan incompatible drug

Range from color change, precipitation, andclouding to invisible chemical changes renderingthe drug inactive

Charts are often available that outline which drugsare compatible

Slide 41

Figure 35-16A, B: Mixing doses ofinsulin from multidose vials

Slide 42

Chapter 35

Lesson 35.3

Learning Objectives

Theory

2)List the routes used for administeringparenteral medications and the advantagesand disadvantages of each route forpediatric, adult, and elderly patients.(Continued)

3)Recognize the signs and symptoms ofanaphylactic shock.

Slide 44

Learning Objectives

Clinical Practice

6)Use the Six Rights of medication administration,including checking for patient drug allergies.

7)Prepare and administer an intradermal injection,using the Six Rights and aseptic technique.

8)Correctly prepare and administer asubcutaneous injection with 100% accuracy.

9)Correctly prepare and administer anintramuscular injection with 100% accuracy.

Slide 45

Learning Objectives

Clinical Practice

10)Locate the appropriate site on a patient togive an intradermal, subcutaneous, orintramuscular injection by identifying correctanatomic landmarks.

11)Evaluate your documentation of injectionsadministered after administration.

Slide 46

Implementation

Intramuscular injections

Used if patient cannot take medicine orally,medication not prepared in oral form, or faster actionis desired

Improper site selection can result in damaged nerves,abscesses, necrosis, sloughing of skin, and pain

Injection sites

•The mid-deltoid muscle is a common for IM injection

•The ventrogluteal area involves the gluteus medius andminimus muscles

•The vastus lateralis muscle

•The rectus femoris muscle

Slide 47

Figure 35-18: Locating site for a mid-deltoid IM injection

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Figure 35-21: Locating the rectusfemoris IM injection site

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Implementation (cont’d)

Intramuscular injections

Airlock technique

•Used for IM injection to clear the needle of medicationand to seal the track so the medication does not flowback

Intramuscular injections in children

•The vastus lateralis and the ventrogluteal sites can beused

•It is preferable to find another way to give medication tochildren because IM injections are painful and traumatic

Slide 50

Figure 35-19: Locating site for aventrogluteal IM injection

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Figure 35-20: Locating the vastuslateralis IM injection site

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Implementation (cont’d)

Intramuscular injections

The Z-track technique

•Reduces pain caused by irritating drugs that leak orescape along the track into subcutaneous tissue whenneedle is withdrawn

•Must be used whenever a deep IM injection of irondextran (DexFerrum) and other irritating solutions aregiven

Slide 53

Figure 35-22: Z-track technique

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Anaphylactic Shock

Anaphylactic shock

Circulatory failure from an allergic reaction

Symptoms

•Urticaria, bronchiolar constriction, edema, and finallycirculatory collapse

Watch for signs of anaphylactic shock and, ifnecessary, administer immediate, lifesavingtreatment

Allergic reactions are more common the second orsuccessive times the medication is received

Slide 55

Things to Remember

Always check for allergies

Know the expected and possible side effectsof all drugs you administer

Date all multidose vials when you open them

Question any order that does not make sensefor your patient

Always follow the Six Rights and five rules

Know your landmarks and injectiontechniques for each type of injection

Slide 56

Question 2

Which of the following is not an appropriate sitefor an intramuscular injection?

1)Dorsogluteal

2)Deltoid

3)Vastus lateralis

4)Dermal

Slide 57

Question 3

Darlene is about to give her patient anintramuscular injection. What angle should theinjection be given?

1)90 degrees

2)45 degrees

3)15 degrees

4)It depends on the size of the needle and sizeof the patient

Slide 58

Question 4

Sylvie is going to give her 1-year-old patient anIM injection. Which is the preferred IM site?

1)Deltoid

2)Vastus lateralis

3)Dorsogluteal

4)Ventrogluteal

Slide 59

Question 5

Michael is going to give his patient an injection ofiron. To help minimize the pain, what can Michaeldo?

1)Use the largest gauge needle that isappropriate.

2)Inject the medication quickly.

3)Use the Z-track technique.

4)Do not tell the patient when he is going to givethe injection.

Slide 60