ch. 34

vial

(a glass or plastic container of parenteral medication with a self-sealing rubber stopper) must be pierced with a needle or a needleless adapter to remove medication. The amount of drug in this may be enough for one or multiple doses. Any unused drug is dated before it is stored for future use. Usually, drugs in are in liquid form, but sometimes they are supplied as powders that must be dissolved.

ampule

(a sealed glass drug container) must be broken to withdraw the medication

Reconstitution

(the process of adding liquid, known as diluent, to a powdered substance) is done before administering the drug parenterally. Common diluents for injectable drugs are sterile water or sterile normal saline.

inner aspect of the forearm

A common site for an intradermal injection is the ___. Other areas that may be used are the back, posterior upper arm, and upper chest

shaking

Biologics are typically refrigerated, whereas insulin is not when the vial is opened. Biologics may be fragile, and vigorous ____ is not recommended.

examine

Carefully ___ orders and vials supplied when administering the drug.

lipoatrophy and lipohypertrophy

Clients who require insulin receive one or more daily injections. Over time, the injection sites tend to undergo changes that interfere with insulin absorption. To avoid ___, the sites are rotated each time an injection is administered.

children and older adults

Clients, particularly ____, should be monitored closely for drug effects

Sometimes it is necessary or appropriate to combine more than one drug in a single syringe. Exact amounts must be withdrawn from each drug container because once the drugs are in the barrel of the syringe, there is no way to expel one without expelling some of the other. Before mixing any drugs, however, the nurse consults a drug reference or compatibility chart because some drugs interact chemically when combined. The chemical reaction often causes formation of a precipitate

Combining Medications in One Syringe:

needlestick injuries

Conventional syringes and needles are being redesigned to avoid ___, thus reducing the risk of acquiring a blood-borne viral disease such as hepatitis B (HBV), hepatitis C (HCV), and HIV/AIDS

-those with plastic shields that cover the needle after its use -those with needles that retract into the syringe -gas-pressured devices that inject medications without needles

Currently, there are three different safety injection devices:

tuberculin syringe

Equipment used for a subcutaneous injection may depend on the type of medication prescribed. Insulin is prepared in an insulin syringe. Heparin is prepared in a ___, or it may be supplied in a prefilled cartridge.

18- to 27-gauge

For most injections, ___ needles are used; the smaller the number, the larger the diameter.

3- to 5-mL

Generally, ____ syringes are used to administer medications by the IM route. A 22-gauge needle that is 1½ to 2 in long is usually adequate for depositing medication in most sites.

very small volumes

Heparin is supplied in multiple-dose vials or prefilled cartridges. The dosages are ___ that may require a tuberculin syringe to ensure accuracy. The nurse removes the needle after withdrawal of the drug from a multidose vial and replaces it with another before administration

-Before administering an injection, the protective cap covering a needle is replaced by using the scoop method -After administering an injection, the needle is left uncapped and deposited in the nearest biohazard container which is usually mounted on the wall within the client's room.

If modified safety injection devices are not available or not used, there are two techniques to prevent needlestick injuries with standard equipment:

date and time; amount on the vial

If the medication will be used for more than one administration, the preparer writes the ___ on the vial label and initials it. In some cases, when the directions provide several options in diluent volumes, the preparer also writes the ____.

The nurse locates the vastus lateralis site by placing one hand above the knee and one hand just below the greater trochanter at the top of the thigh. He or she then inserts the needle into the lateral area of the thigh

Locating the vastus lateralis muscle and spreading the skin at the vastus lateralis site and darting the tissue.

glargine or detemir

Long-acting insulins, also called basal insulins—___(Lantus) or ___ (Levemir)—should never be mixed with any other insulins. Always check with the clinical pharmacist or a reference manual if you question the safety of combining drugs before mixing.

½ to 2½ in.

Needle lengths vary from approximately ____ The tip of the shaft is beveled, or slanted, to pierce the skin more easily.

various lengths and gauges

Needles are supplied in ___

70% & 30%

Pharmaceutical companies provide some combinations of insulin premixed in a single vial. Novolin 70/30 contains ___of an intermediate-acting insulin and ___of a short-acting insulin

prefilled cartridge

Pharmaceutical companies supply some drugs in a ___ (a sealed glass cylinder of parenteral medication). It comes with an attached needle and is made so that it fits in a specially designed syringe

The type of medication The depth of tissue The volume of prescribed drug The viscosity of the drug The size of the client

Several factors are considered when selecting a syringe and a needle:

Report the injury to a supervisor immediately. Document the injury in writing. Identify the client if possible. Obtain HIV and HBV client status results if it is legal to do so. Obtain counseling on the potential for infection. Receive the most appropriate postexposure drug treatment prophylaxis. Be tested for the presence of antibodies at appropriate intervals. Monitor for potential symptoms and obtain a medical follow-up.

Should an accidental injury occur, health care providers should follow these recommendations:

blunt substitutes

Some syringes contain ___ for needles that can pierce laser-cut rubber ports.

other than insulin

Subcutaneous medications ___should never be given using an insulin syringe

milliliters (mL) or cubic centimeters (cc), and units (U)

Syringes are calibrated in

a barrel, a plunger , and a tip

Syringes contain

dialed and displayed in a window at the end of the syringe

The dose of insulin is ___. When selecting the prescribed dose, each unit of insulin is accompanied by a clicking sound in the pen, which is advantageous for diabetic patients with low vision.

the ventrogluteal, the vastus lateralis, the rectus femoris, and the deltoid.

The four IM injection sites are named for the muscles into which the medications are injected:

glargine

The long-acting insulin, ____, is never mixed with any other type of insulin.

syringe and a needle

The major equipment used to administer parenteral drugs consists of a

stable for up to 30 days

The pen automatically resets the dose window to zero following the injection. The insulin in prefilled pens is ___

abdomen

The preferred site for giving a subcutaneous injection of insulin is the ____. Rotating within one injection site, preferably the abdomen, is recommended rather than rotating to a different area with each injection

fastest to slowest

The rate of drug absorption varies at the different sites in the body, from ___. The site with the fastest absorption rate is the abdomen, then, in order to the slowest: the outer back area of the upper arm, where it is fleshier; the outer areas of the thigh; and the "wallet area" of the buttocks. Exercising an arm or leg after a subcutaneous injection in these areas can increase blood flow and hasten drug absorption from those areas

the thumb and fingers

The tissue is usually bunched between ___before administering the injection to avoid instilling insulin within the muscle. Bunching is unnecessary when injecting insulin with an insulin pen because the needle is only 5-mm long and unlikely to enter a muscle.

insulin and heparin

The volume of a subcutaneous injection is usually up to 1 mL. The subcutaneous route is commonly used to administer _____

intradermal injections, subcutaneous injections, intramuscular injections and intravenous injections

There are four injection routes for parenteral administration are? Each site requires a slightly different injection technique

rotates

Therefore, when preparing other than rapid- and short-acting insulin or the long-acting insulin glargine (Lantus), the nurse ___ the vial between the palms to redistribute the additive and insulin before filling the syringe.

prescribed dose

They are candidates for using an insulin pen or a loading gauge that prevents filling a syringe with more than the ____. Sight centers are a good resource for obtaining assistive devices to facilitate self-administration of insulin.

principles of asepsis and infection control

This chapter discusses techniques for administering injections. The preparation and administration of injections follow the:

90-degree angle

To reach subcutaneous tissue in a normal-sized or obese person who has a 2-in tissue fold when it is bunched, the nurse inserts the needle at a ____.

45-degree angle

To reach subcutaneous tissue, For thin clients who have a 1-in fold of tissue, the nurse inserts the needle at a ____

bloodborne

Transmission of ____ pathogens has been linked to multiple client use of the insulin pen. Pens should be clearly labeled for each client and separated from each other if used institutionally

onset, peak effect, and duration of action.

Types of insulin vary in their ___

30 to 50 units

Typically, low-dose insulin syringes are used to deliver insulin dosages of ____ or less. A standard insulin syringe can administer up to 100 units of insulin

deltoid or ventrogluteal sites for IM injections.

When administering an IM injection, adequate muscle mass and movement are needed to promote distribution of the medication. Keep in mind that with an elderly client, muscle mass may be decreased. If this client also has impaired mobility, any site that will not receive sufficient movement should be avoided. Therefore, for an elderly client with impaired mobility, use the ___

10- to 15-degree

When giving an intradermal injection, the nurse instills the medication shallowly at a ____ angle of entry

bind and become equilibrated

When mixed together, insulins tend to ___. This means that the unique characteristics of each are offset by those of the other. For this reason, most types of insulin are combined just before administration

The type of diluent to use The amount of diluent to add The dosage per volume after reconstitution Directions for storing the drug

When reconstitution is necessary, the drug label lists:

filtering performed by the liver does not occur

When the parenteral route is used for drug administration, the drug ____ Therefore, more active drug will be in the circulation and the intended and adverse drug effects can be more pronounced than when a drug is taken orally.

2-in

When using the abdomen for subQ. avoid a ___ central area around the umbilicus.

Uncapped

____syringes and all sharps are deposited in a puncture-proof container

Intradermal injections

are commonly used for diagnostic purposes. Examples include tuberculin tests and allergy testing. Small volumes, usually 0.01 to 0.05 mL, are injected because of the small tissue space.

Filter needles

contain a membrane that acts as a barrier blocking the entrance of glass shards when withdrawing medication from a glass ampule

bruising

for administering Heparin, certain modifications are necessary for the prevention of ___ in the area of the injection. The nurse changes the needle after filling the syringe with the dose of heparin, that is, before injecting the client. The injection site is not cleaned with an alcohol wipe. The nurse does not aspirate with the plunger. The needle is left in place for 5 seconds.

pressing

for administering heparin, bleeding or oozing following the injection can be controlled by ___ on the injection site with gauze, but it is never rubbed because this can increase the tendency for local bleeding. He or she rotates the sites with each injection to avoid a previous area where there has been local bleeding

Insulin pens

have simplified how clients self-administer their medication. it is a hard plastic cylinder that looks much like a fountain pen, hence its name. A disposable needle is attached to the pen each time it is used. Needles used on these are generally 31-gauge and a very short length (3/16 to 5/16 in

tuberculin syringe

holds 1 mL of fluid and is calibrated in 0.01-mL increments. It is used to administer intradermal injections. A 25- to 27-gauge needle measuring half an inch in length is commonly used when administering an intradermal injection.

The deltoid site

in the lateral aspect of the upper arm, is the least used IM injection site because it is a smaller muscle than the others. It is used for children beginning at age 4 as well as for adults. Because of its small capacity, IM injections into this site are limited to 1 mL of solution.

subcutaneous injections (subQ)

injections beneath the skin but above the muscle

intradermal injections

injections between the layers of the skin

intramuscular injections

injections in muscle tissue

intravenous injections

injections instilled into veins

Drug preparation

involves withdrawing medication from an ampule or vial or assembling a prefilled syringe cartridge

The parenteral route

is a route of drug administration other than oral or through the gastrointestinal tract. The preparation and administration of injections follow the principles of asepsis and infection control.

insulin pump

is a small, programmable, computerized device that contains 180 to 315 units of rapid-acting insulin that can be refilled from vials. The infusion set and infusion site are changed every 2 to 3 days.

subcutaneous injection

is administered more deeply than an intradermal injection. Medication is instilled between the skin and muscle and absorbed fairly rapidly; the medication usually begins acting within 15 to 30 minutes of administration.

Heparin

is an anticoagulant drug, meaning that it prolongs the time it takes for blood to clot. It is frequently administered subcutaneously as well as intravenously. Its unique characteristics require special techniques when using the subcutaneous route for administration.

Parenteral

is commonly used when referring to medications given by injection.

Intramuscular (IM) injection

is the administration of up to 3 mL of medication into one muscle or muscle group. Because deep muscles have few nerve endings, irritating medications are commonly given IM. Injections should not be administered into limbs that are paralyzed, inactive, or affected by poor circulation. If an older client has had a mastectomy or has a vascular site for hemodialysis, the arm on the affected side should be avoided, if possible.

barrel

is the part of the syringe that holds the medication

precipitate

liquid that contains solid particles

needle gauge (diameter)

refers to its width

the rectus femoris

site is in the anterior aspect of the thigh. This site may be used for infants. The nurse places an injection in this site in the middle third of the thigh with the client sitting or supine

insulin syringe

syringe that is calibrated in units and holds a volume of 0.5 to 1 mL of medication

lipoatrophy

the breakdown of subcutaneous fat at the site of repeated insulin injections

prefilled reservoir of insulin

the insulin cylinder contains a

the shaft of a needle

the length of the needle, depends on the depth to which the medication will be instilled

tip

the part of the syringe to which the needle is attached

plunger

the part of the syringe within the barrel that moves back and forth to withdraw and instill the medication

scoop method

the technique of threading the needle within the cap without touching the cap itself

lipohypertrophy

the thickening of subcutaneous fat at the site of repeated insulin injections

the ventrogluteal site

uses the gluteus medius and gluteus minimus muscles in the hip for injection. This site has several advantages; it has no large nerves or blood vessels, and it is usually less fatty and cleaner because fecal contamination is rare at this site. This is the favored injection site for adults, but it is also safe for use in children. Its main disadvantage is that there is only a small area for administering the injection. 90 degree angle

the vastus lateralis site

uses the vastus lateralis muscle—one of the muscles in the quadriceps group of the outer thigh. Large nerves and blood vessels are usually absent in this area, which makes it safer.