Injectable Medications

client education

Because clients routinely administer their own insulin at home, client education is critical. Inform patients about insulin sources, insulin types, onset time, peak time, and duration.

1 mL syringe

each tenth of a mL is represented as 1/10, 2/10, 3/19, and so forth, up to 1 mL.

syringe size

for most subcutaneous or intramuscular injections, you'll use a 1-3 mL syringe to administer medication. use the syringe with the calibration that is closest to the volume of medication you will administer.

subcutaneous injections

0.5 mL - 1 mL

Mixing Two Types of Insulin

A provider prescribes 5 units of regular insulin, or Humulin R, and 20 units of NPH insulin, or Humulin N. How should you go about preparing to administer the insulins in the same syringe? To start, determine if you can mix the two types of insulin. This goes for whenever two types of insulin are prescribed for the same time of day. If you can mix the two types of insulin, plan to administer them in the same syringe, so the client receives one injection instead of two. Remember, you can only mix short- or rapid-acting insulin with other insulin.

manufacturers' labels

Reading and interpreting labels - Check dosages - Check unit of measure - Ensure correct formulation for route - Check expiration date - Use single-dose preparations only once - Store in appropriate place

3 mL syringe

calibrated in tenths of a mL, so each mark represents 1/10 of a mL.

the provider prescribes gentamicin 60 mg IM every 8 hr. you have 40 mg/mL and must decide how many mL to give. calculate the appropriate dose using desired over have. (round to the tenth)

desired = 60 mg have = 40 mg quantity = 1 mL desired x quantity / have = X 60 mg x 1 mL / 40 mg = X mL 1.5 = X

A nurse is preparing to administer clindamycin hydrochloride (Cleocin) 600 mg IM divided into 2 equal injections. Available is clindamycin hydrochloride injection 150 mg/mL. How many mL should the nurse administer per injection?

desired = 600 mg have = 150 mg quantity = 1 mL 600 mg x 1 mL / 150 mg = 4 mL 4 mL / 2 (2 equal injections) = 2 mL

subcutaneous injections are used for...

small volumes of medications

tuberculin syringe

use this syringe to administer very small volumes of medication. 1 mL tuberculin syringe - narrow; calibrated in hundredths of a mL; each long mark on the syringe represent 1/10 of a mL.

Choosing a Syringe

A provider prescribes 60 units of NPH insulin. Which syringe should you use? The dose of insulin is greater than 50 units, so you use the 100 unit syringe.

insulin sources

Insulin comes from a variety of sources. The source is important because it can affect the insulin's onset, peak and duration times. Manufactured human insulin is identical to insulin that's produced by the human body. Human insulin analogs are a type of insulin that is modified to alter the rate of absorption and the duration of action.

Insulin Pens

Insulin pens are a convenient way to inject insulin. They have a disposable needle, an insulin-filled cartridge inside, and a dial to measure the dose. For self-administration, the client dials the appropriate dose before injecting the medication. Jet injectors are similar to insulin pens, but these devices inject insulin into the subcutaneous tissue without the use of a needle. They are expensive and may cause the skin to bruise.

Insulin Effectiveness

Onset - refers to when the action of insulin starts. In other words, how long it takes for the insulin to elicit a therapeutic response Peak - the time it takes for insulin to reach the maximum therapeutic level in the body Duration - how long the insulin works, or the length of time that there is enough insulin in the body to elicit a therapeutic response

External Infusion Pumps

An insulin pump delivers regular or rapid-acting insulin subcutaneously over a 24-hour period. The pump is set to infuse insulin at a set basal rate that closely mimics the pancreas's secretion of insulin. The client can program the pump to deliver higher or lower doses of insulin based on the time of day and individual insulin needs. Clients can deliver bolus doses by pressing buttons on the pump to cover carbohydrate intake from meals and snacks. A bolus dose can also cover high blood glucose levels. The insulin pump is small, and a client can wear it in a pocket or on a belt. The pump contains a syringe with insulin. The syringe is connected to a needle that's placed subcutaneously in the skin of the abdomen.

Lower-Dosage Syringes

Use a lower-dosage syringe to administer smaller doses of insulin. Because the calibrations are smaller, these syringes allow you to administer a more accurate dose. These syringes are calibrated in 1-unit increments.

20 mL syringe

calibrated in mL, so each short mark represents 1 mL, and each long mark represents 5 mL

intravenous therapy

can be used to provide fluids and electrolytes peripheral short intravenous catheter - less than 3 inches long, and the tip of the catheter rests in a vein in on of the client's extremities peripherally inserted central catheter (PICC line) - one type of central catheter you can use when you need long term IV therapy; the nurse inserts the PICC line peripherally into a vein in the upper arm and threads it so that the tip lies in the superior vena cava central catheter - can be inserted into the subclavian vein in the upper chest or through the internal jugular vein. regardless of the site of insertion, the tip of a central catheter lies in the superior vena cava.

working with insulin

clients require insulin injections when they have an absolute or relative deficiency of insulin Insulin is essential because it promotes the removal of glucose from the blood as well as storage of glycogen in the liver You can administer all types of insulin subcutaneously. Clients can receive insulin either by individual injections or by continuous infusion via an insulin pump. When a client needs a rapid reduction of blood glucose, you can administer insulin by intravenous infusion. There are four types of insulin you can administer intravenously: regular insulin, insulin aspart, or NovoLog, insulin lispro, or Humalog, and insulin glulisine, or Apidra. Insulin is one of the most commonly used injectable medications. SAFETY ALERT: Always check to make sure that the insulin you are planning to administer is appropriate for the route prescribed. When giving insulin intravenously, you must dilute it to the appropriate concentration.

A nurse is preparing to administer heparin 7,000 units subcutaneously every 12 hr. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer?

desired = 7,000 units have = 10,000 units quantity - 1 mL 7000 units x 1 mL / 10000 units = 0.7

Administerting two types of insulin in the same syringe

in this example, you're administering 5 units of regular insulin and 20 units of NPH insulin first, draw 20 units of air into the syringe. next, inject the air into the NPH bottle, taking care to not touch the insulin with the needle. you must keep the insulin bottle upright. then draw 5 units of air into the syringe, and inject the air into the regular insulin vial. now, invert the vial of regular insulin and draw 5 units of insulin. always withdraw the regular insulin first to prevent contamination of the regular insulin with the NPH insulin. finally, re-insert the needle into the NPH insulin vial. invert the vial and carefully withdraw 20 units of NPH insulin. if you withdraw too much insulin, you can't inject it back into the vial; you'll have to discard the syringe and start over.

Intramuscular injections are used for...

larger volume medications

insulin packaging

most insulin is dispensed in vials containing 10 mL of medication

anatomical sites for subcutaneous injections

posterior upper arm, upper back, upper hip, interior thigh

avoid injecting sites with...

skin lesions and/or bony prominences

insulin administration

to administer insulin, you must use a syringe specifically manufactured for this purpose U-100, U-50, U-30 syringes. You can use these syringes to administer subcutaneous insulin to a client. Check the expiration date on the bottle before drawing insulin into the syringe. Before administering, verify the dose with another nurse. When rapid reduction of blood glucose is necessary, you may need to administer intravenous insulin. In most situations, the provider prescribes insulin infused at a slow, continuous rate

administering intramuscular injections...

ventrogluteal - preferred for adults and children because it isn't close to any nerves or blood vessels. vastus lateralis muscle - located on anterior lateral aspect of thigh; preferred site for infants; can tolerate larger quantities of meds & is easily accessible; possible thrombosis of femoral artery, sciatic nerve damage; often more painful than deltoid and gluteal sites. deltoid - located on lateral aspect of upper arm; recommended for immunizations to adults and children; located near many nerves and arteries, so it isn't the best site for intramuscular injections; don't administer more than 1 mL of solution; don't used on infants

choosing a syringe

when choosing a syringe, always choose the one with calibrations that allow for the most accurate dosage measurement

calibrated syringes

when measuring oral liquids and injectable medications, you can use a calibrated syringe to ensure accurate measurements. syringes are calibrated by mL, and depending on the size of the syringe, the calibrations may be in 2/10, 1/10, or 1/100 of a mL. for oral meds, use an oral syringe. they're available in various sizes and are clear or tinted brown to differentiate them for syringes uses for injections.

larger syringes

you will use a 5 mL syringe to administer meds if the volume of the dose is greater than 3 mL you should use 10 mL and 20 mL syringes to add meds to intravenous solutions use a 60 mL syringe to irrigate wounds

A nurse is preparing to draw 0.1 mL of medication into a syringe for a subcutaneous injection. Which of the following syringes should the nurse choose? A. 1 mL syringe B. 30 units syringe C. 5 mL syringe D. 10 mL syringe

A. CORRECT. The nurse should choose a 1 mL syringe to draw 0.1 mL of medication. This syringe is marked in tenths and hundredths, and is the appropriate choice for very small amounts of medication. B. INCORRECT. A 30 unit insulin syringe is not marked in mL, so the nurse should not use it to administer this medication. C. INCORRECT. The nurse should not choose a 5 mL syringe because it is marked in 0.2 mL, and therefore it is not possible to accurately draw 0.1 mL of solution. D. INCORRECT. The nurse should not choose a 10 mL syringe because it is marked in 0.2 mL, and therefore it is not possible to accurately draw 0.1 mL of solution.

a nurse is preparing to draw 1.7 mL of medication into a syringe for an IM injection. which of the following syringes is appropriate for the nurse to choose? A. 1 mL syringe B. 3 mL syringe C. 5 mL syringe D. 10 mL syringe

A. INCORRECT. it is too small to draw 1.7 mL of medication. the nurse would need to draw the medication into 2 syringes, which requires 2 injections and is not appropriate practice B. CORRECT. this syringe is large enough to hold the entire amount of medication but small enough for accurate measurement C. INCORRECT. should not choose a 5 mL syringe to draw 1.7 mL because it is calibrated in 0.2 increments. therefore, it isn't possible to accurately draw 1.7 mL of solution D. INCORRECT. should not choose a 10 mL syringe to draw 1.7 mL because it is calibrated in 0.2 increments. therefore, it isn't possible to accurately draw 1.7 mL of solution

Insulin Syringes

Always administer insulin in a syringe that matches the concentration. A common way to administer U-100 insulin is subcutaneously with a U-100 insulin syringe. Most U-100 syringes are calibrated to 2-unit marks. Note that you can use this syringe to administer a wide range of insulin dosages.

Peak Action of Insulin Types

INSULIN TYPE TRADE NAME ONSET PEAK DURATION rapid-acting Insulin lispro less than 0.5-1 hr 3-4 hr (Humalog) 15 min short-acting regular insulin 0.5-1 hr 2-3 hr 5-7 hr (Humulin R) intermediate- NPH insulin 1-2 hr 4-12 hr 18-24 hr acting (Humulin N) long-acting insulin glargine 1 hr none 24 hr (Lantus) SAFETY ALERT: Always remember that the prescribed type and amount of insulin varies depending upon the individual client's type of diabetes and its severity. Self-monitoring of glucose and periodic laboratory measurement of the client's glycosylated hemoglobin, also known as Hemoglobin A1c, assist the provider in deciding on a therapeutic insulin dosage for the client.

measuring insulin

The standard way to measure insulin is in units. In the United States, insulin is available in two concentrations. The most common concentration is U-100, which means there are 100 units of insulin in 1 mL of solution. In some situations, such as clients with severe insulin resistance who require very large doses, a U-500 concentration is available. This means that each mL of solution contains 500 units of insulin. U-500 insulin is not frequently prescribed, and you can only administer by subcutaneous injection.

Types of Insulin

There are many types of insulin preparations. All of them function as a substitute for naturally occurring insulin in the human body.However, they differ in regard to their onset, peak, and duration of action. RAPID-ACTING INSULIN - This type of insulin begins to work approximately 10-15 minutes after administration. - Rapid-acting insulin has the most rapid onset of action, as well as the shortest duration, of all the insulin preparations. - Administer rapid-acting insulin immediately before a meal, and make sure that the client eats a meal after it's administered to prevent the client from experiencing hypoglycemia. - Rapid-acting insulin preparations are clear, and you can administer them either subcutaneously or intravenously. - There are currently three types of rapid-acting insulin preparations: insulin lispro, also known as Humalog, insulin aspart, known as NovoLog, and insulin glulisine, known as Apidra. REGULAR OR SHORT-ACTING INSULIN - begins to work approximately 30 minutes after administration - Humulin R and Novolin R are trade names for regular insulin. - Regular insulin is clear, and you can administer it either subcutaneously or intravenously, though use of the intravenous route is reserved for specific situations such as diabetic ketoacidosis. INTERMEDIATE-ACTING INSULIN - begins to work approximately 1-2 hours after administration - NPH insulin, or Humulin N, is a type of intermediate-acting insulin. It's a suspension with protein, which delays the onset and duration. It also looks cloudy. It's the only insulin preparation that's a suspension, and the only one that requires agitation before it's drawn into the syringe. NPH insulin must be administered subcutaneously and is often mixed with regular insulin - Insulin detemir, or Levemir, is another intermediate-acting insulin. It's human insulin analog with a slower onset and longer duration than NPH insulin. - The appearance of insulin detemir is clear, and you must administer it subcutaneously. Do not mix it with any other insulin. LONG-ACTING INSULIN - insulin glargine - has a duration of at least 24 hours - can be administered in the morning, afternoon, or evening; should be given at the same time every day PREMIXED INSULIN COMBINATIONS - These are useful for clients who have difficulty mixing insulin because of poor eyesight or manual dexterity. - These combination products contain one intermediate-acting insulin and one rapid-acting or short-acting insulin. - Here are some examples: Humulin 70/30 is a combination of 70% NPH insulin and 30% regular insulin; NovoLog Mix 70/30 is a combination of 70% insulin aspart protamine and 30% insulin aspart; Humalog Mix 75/25 is a combination of 75% insulin lispro protamine and 25% insulin lispro. - Humulin 50/50 is a combination of 50% NPH insulin and 50% regular insulin

preventing needle-stick injuries

a needle-stick injury exposes you to a number of blood borne pathogens, including hepatitis B, hepatitis C, and the human immunodeficiency virus (HIV). to prevent these injuries, use needlessness devices whenever possible. if you have to use a syringe with a needle, you can reduce your risk of injury by using safety syringes and by following the proper procedures for disposing needles. safety syringe - has a mechanism that protects you from needle-stick injury; available as either active or passive devices passive device - doesn't require action by the nurse; for example, once you use the device, the needle retracts into the barrel, then you can manually pull the guard over the needle active device - requires action by the nurse; with this type of syringe, you must activate the safety device after use by pushing the lever upward there are also some meds available in pre-filled syringes with a needle guard that's activated after you inject the medication dispose of all needles into the sharps container immediately after use. if the sharps container is full, get a new one, don't force the syringe into the container. never leave needles and syringes at the client's bedside, and never place them in your pocket or in the waste can. never recap, bend, or break a used needle.

you are preparing digoxin (lanolin) 0.125 mg by IB bolus daily. you have 250 mcg/mL and must decided how many mL to give. calculate the appropriate dosage using desired over have. (round to the tenth)

desired = 0.125 mg have = 250 mcg quantity = 1 mL you need to convert mg to mcg (1 mg = 1,000 mcg) 1 mg / 1000 mcg = 0.125 mg / X mcg (cross multiply) X = 0.125 x 1000 X = 125 mcg OR 0.125 mg = 125 mcg (0.125 x 1000) desired x quantity / have = X 125 mcg x 1 mL / 250 mcg = X mL 0.5 = X

A provider prescribes atropine 0.6 mg subcutaneous 30 min prior to surgery. Available is atropine injection 0.4 mg/mL. How many mL should the nurse administer?

desired = 0.6 mg have = 0.4 mg quantity = 1 mL 0.6 mg x 1 mL / 0.4 mg = 1.5 mL

A provider prescribes cyanocobalamin (Cyanoject) 1 mg IM weekly. Available is cyanocobalamin injection 1,000 mcg/mL. How many mL should the nurse administer?

desired = 1 mg have = 1,000 mcg quantity = 1 mL 1,000 mcg = 1 mg 1 mg x 1,000 mcg = 1,000 mcg 1000 mcg x 1 mL / 1000 mcg = 1 mL

A nurse is preparing to administer lorazepam (Ativan) 2 mg IV bolus. Available is lorazepam injection 4 mg/mL. How many mL should the nurse administer?

desired = 2 mg have = 4 mg quantity = 1 mL 2 mg x 1 mL / 4 mg = 0.5 mL

A provider prescribes ondansetron (Zofran) 4 mg IV bolus every 8 hr PRN for nausea. Available is ondansetron injection 2 mg/mL. How many mL should the nurse administer?

desired = 4 mg have = 2 mg quantity = 1 mL 4 mg x 1 mL / 2 mg = 2 mL

A provider prescribes digoxin (Lanoxin) 400 mcg IV one-time bolus. Available is digoxin injection 0.25 mg/mL. How many mL should the nurse administer?

desired = 400 mcg have = 0.25 mg quantity = 1 mL 1 mcg = 0.001 mg (1 / 1000) 400 mcg = 0.4 mg 400 mcg x 1 mL / 250 mcg = 1.6 mL

A provider prescribes progesterone (Progestaject) 5 mg IM daily for 6 days. Available is progesterone injection 50 mg/mL. How many mL should the nurse administer?

desired = 5 mg have = 50 mg quantity = 1 mL 5 mg x 1 mL / 50 mg = 0.1 mL