NUR101 - Chp. 34 - Parenteral (Injectable) Medications

The nurse is preparing to administer a tuberculin test. At which angle is the nurse expected to instill the drug?

15-degree angle * 5 - 15 degree angle for intradermal tests.

What helps when determining the gauge of the needle?

- Type of medication. - Depth of tissue. - Volume of prescribed drug. - Viscosity (thickness) of drug. - Size of the patient.

Reducing Injection Discomfort

- Use the smallest-gauge needle appropriate. - Change the needle before administering a drug that is irritating to tissue. - Select a site that is free of irritation. - Rotate injection sites. - Numb the skin with an ice pack before the injection. - Insert & withdraw the needle without hesitation. - Instill the medication slowly & steadily. - Use the Z-track technique for IM injections. - Apply pressure to the site during needle withdrawal.

The client is scheduled to receive an intramuscular medication every week. The young client states, "I'm afraid of needles," when the nurse is preparing to administer the first intramuscular medication. The nurse states:

"Do not look at the needle."

The nurse just completed a refresher course on parenteral drug administration. Which statement by the nurse indicates that teaching was effective?

"Reconstitution is the process of adding liquid, known as diluent, to a powdered substance."

Which statement by a client indicates to the nurse that teaching was effective regarding the different parts of a syringe?

"The plunger is the part of the syringe that moves back and forth to withdraw and instill medication."

An adult with diabetes receives 20 units of insulin each morning and evening. How will the nurse teach the client to administer the insulin?

"Use an insulin syringe and give 20 units."

Novolin 70/30

- 70% Intermediate-acting insulin. - 30% Short-acting insulin.

A nurse is preparing to administer heparin subcutaneously to a client. What would the nurse most likely do? Select all that apply.

- Change the needle after filling the syringe. - Rotate the sites with each injection.

A nurse is preparing to withdraw sterile water from a multiuse vial to be used as a diluent for a powdered medication. The vial has been used previously. Place the steps in the order that the nurse would perform them.

- Clean the rubber stopper with an alcohol swab. - Fill the syringe with an equal volume of air as that to be withdrawn. - Pierce the rubber stopper with the tip of the needleless syringe. - Instill the air into the vial. - Invert the vial.

How can the patient assist in minimizing the pain associated with injections?

- Deep breathing & other relaxation techniques. - Avoid watching when the injection is given. - Ambulate or move the extremity where the injection was given as much as possible.

What precautions should you take when administering a subcutaneous injection in the abdomen?

- Rotate injection sites (such as with insulin). - Keep injections an inch from a previous site. - Avoid a 2-in central area around the umbilicus.

When reconstitution of a drug is necessary, the drug label lists:

- Type of diluent to use. - Amount of diluent to add. - Dosage per volume after reconstitution. - Directions for storing the drug.

What is the injection limit for the deltoid muscle?

1 mL d/t small capacity.

The nurse is teaching a client with diabetes about insulin pen injection. The nurse will teach that the insulin in prefilled pens is stable for how long?

1 month (30 days).

Insulin Pen

Hard plastic cylinder that looks much like a fountain pen that contains a prefilled reservoir of insulin. The dose of insulin is dialed & displayed in a window at the end of the syringe.

The nurse is preparing to administer dimenhydrinate 50 mg intramuscular to a client. Place in order, the steps the nurse will follow when using the Z-track technique to administer the drug? Use all options.

1. Fill the syringe with the prepared drug and then change the needle. 2. Select the ventrogluteal site. 3. Use the side of the hand to pull the tissue laterally about 1 inch (2.5 cm) until the tissue is taut. 4. Insert the needle at a 90-degree angle while continuing to hold the tissue laterally. 5. Aspirate for blood return and instill the medication. 6. Withdraw the needle and apply pressure to the site.

What steps should you follow if an accidental needlestick injury occurs?

1. Report the injury to a supervisor immediately. 2. Document the injury in writing. 3. Identify the patient if possible. 4. Obtain HIV & HBV patient status results is it is legal to do so. 5. Obtain counseling on the potential for infection. 6. Receive the most appropriate postexposure drug treatment prophylaxis. 7. Be tested for the presence of antibodies at appropriate intervals. 8. Monitor for potential symptoms & obtain a medical follow-up.

What are the current three safety injection devices used to avoid needlestick injuries?

1. Those with plastic shields that cover the needle after its use. 2. Needles that retract into the syringe. 3. Gas-pressured devices that inject medications w/o needles.

A nurse needs to administer an intradermal tuberculin skin test injection to a client. What is the most suitable angle when administering an intradermal injection?

10-degree angle * Nurse should hold the syringe almost parallel to the skin at a 5-15-degree angle with the bevel pointing upward. This facilitates delivering the medication between the layers of the skin and advances the needle to the desired depth.

The nurse is administering a subcutaneous injection to a thin, frail older adult who has about 1 inch (2.5 cm) of tissue when the skin is bunched. When entering the skin, the nurse would insert the needle at which angle?

45 degrees * Thin client who has a 1-inch (2.5-cm) fold of tissue = 45-degree angle. * Normal-sized or obese person with a 2-inch (5-cm) tissue fold = 90-degree angle.

A nurse is preparing to administer an intradermal injection. What would be most appropriate for the nurse to do?

Hold the syringe at a 10- to 15-degree angle.

What are the 4 injection routes for parenteral administration?

Intradermal, Subcutaneous, Intramuscular, & Intravenous.

A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which guidelines for needle selection might they discuss?

As the gauge number becomes larger, the diameter of the needle and the lumen become smaller. * An obese person requires a longer needle to reach muscle tissue than does a thin person. When giving an injection, the viscosity of the medication directs the choice of needle gauge. The size of the syringe is directed by the amount of the medication to be given.

The Z-track technique is utilized during drug administration by which route?

Intramuscular * Prevent leakage of medication into the needle track, thus minimizing discomfort.

The nurse has provided education to a client who has been newly diagnosed with type 2 diabetes and requires insulin. When the nurse is administering insulin for the first time, the client states, "I am really afraid that the injection is going to hurt." What action will the nurse take to promote client comfort when injecting insulin?

Ask the client to choose the site for injection. * After the client is provided with education about the type 2 diabetes and injection sites have been reviewed, asking the client to choose the site of the first injection gives the client a sense of control and independence. This can reduce the client's fear and feeling of loss of control as the client accepts a new diagnosis and seeks to make sense of how to manage the disease.

Low-Molecular-Weight Heparins (LMWHs)

Advantage being it is prescribed in a consistent daily dose with no or fewer required anticoagulation blood tests, has less risk for side effects than standard heparin, & can be self-administered outside the hospital. * Ex: Enoxaparin (Lovenox)

How do you dispose of a used needle into a biohazard/sharps container?

After administering an injection, the needle is left uncapped & deposited in the sharps container, needle first.

Heparin

Anticoagulant drug - it prolongs the time it takes for blood to clot. ** Change needle after drawing up medication prior to administering to patient.

Lipoatrophy

Breakdown of subcutaneous fat at the site of repeated insulin injections.

Regarding insulin.... "Cold & clammy, need some...?"

Candy!! Hypoglycemic symptom. * Symptom since patient would be exemplifying discomfort. *

A nurse is preparing to draw up two prescribed medications into one syringe. The medications are contained in vial A and vial B. Which would be important for the nurse to do first?

Check to ensure that the two medications are compatible. * First make sure that the drugs are compatible. Then clean the tops of both vials with an antiseptic, aspirate a volume of air equal to the dose of vial A medication, and inject that air into vial A. After removing the syringe from vial A, the nurse would then aspirate a volume of air equal to the dose of vial B medication and inject that air into vial B.

Which assessment should be conducted by the nurse before the nurse administers tuberculin intradermal injection?

Checking for documented allergies to food or drugs. ** Key word in the question - "assessment" **

Filter Needles

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

The nurse is preparing to administer a client's intramuscular injection and intends to use the technique shown. What potential benefit of this technique should the nurse describe?

Decreased irritation and pain in subcutaneous tissue. * Pictured is the Z-Track Technique * * Allows the medication to be administered into the muscle tissue with no tracking of medication in the subcutaneous tissues as the needle is removed, resulting in less pain and irritation.

The nurse administered 10 units of a short-acting insulin to a client. Forty-five minutes after administration, the client reported weakness and had cold and clammy skin. The nurse failed to act appropriately when the nurse:

Delayed evaluating response to the medication until now. * The nurse is to evaluate response to the medication in 30 minutes. ** "Cold & clammy, need some candy!" **

The client has a history of bilateral mastectomy and is prescribed an intramuscular medication. The intramuscular site that is contraindicated for use in this client is:

Deltoid. * If a client has had a mastectomy, the nurse is to avoid the deltoid muscle in the affected arm.

Needle Gauge

Diameter; refers to needle width. * The smaller the number, the larger the diameter. * Ex: 18g is wider than a 27g.

Biohazard Container (Sharps Container)

Disposal container usually mounted on the wall within the patient's room for used sharp items.

The nurse is assessing a client with diabetes who has poor vision. Which feature of the insulin pen makes it beneficial for this client?

Each unit of insulin is accompanied by a clicking sound in the pen.

Advantages of insulin pens:

Easier to learn how to use than a syringe & vial; easily transported on one's person; insulin is self-contained within the pen; large variety of insulin types available; dose is easily read with large numbers.

Subcutaneous Injection Sites

Fastest to Slowest: 1. Abdomen 2. Outer back area of the upper arm, where it is fleshier. 3. Outer areas of the thigh. 4. "Wallet area" of the buttocks.

Which component of a syringe's needle does the nurse recognize that refers to width?

Gauge

A nurse is administering an intramuscular injection of a viscous medication using the appropriate-gauge needle. What does the nurse need to know about needle gauges?

Gauges range from 14 to 29, with 14 being the largest. * The gauge is determined by the diameter of the needle and ranges from 14 to 29. As the diameter of the needle increases, the gauge number decreases (a 14-gauge needle is, therefore, larger than a 29-gauge needle). A viscous medication requires a larger-gauge needle for injection.

Vial

Glass or plastic container of parenteral medication with a self-sealing rubber stopper that must be pierced with a needle or needleless adapter to remove medication. * Single dose vial vs Multidose vial.

A nurse is withdrawing a dose of heparin from a vial and notices that a significant volume of air is mixed with the medication that is now in the syringe. How can the nurse increase the pressure in the vial to reduce the chance of bubbles in the syringe?

Inject air into the vial equal in volume to the medication that will be withdrawn.

An adult client who has type 1 diabetes receives subcutaneous injections of Humulin R insulin before each meal and at bedtime. The nurse is careful to rotate the injection sites because:

Injecting insulin repeatedly in the same site can cause the breakdown of subcutaneous fat. * To avoid lipoatrophy (breakdown of subcutaneous fat at the site of repeated insulin injections) and lipohypertrophy (thickening of subcutaneous fat at the site of repeated insulin injections), the sites used for insulin injection are rotated each time an injection is administered.

Subcutaneous Injections

Injections beneath the skin but above the muscle; 45 - 90 degree angle for needle depending on patient size & site. * Ex: Insulin or heparin injection.

Intradermal Injections

Injections between the layers of the skin; 10-15 degree angle for needle; common site is inner aspect of the forearm. * Ex: TB or allergy testing.

Intramuscular Injections

Injections in the muscle tissue; 90-degree angle for needle; up to 3mL of medication into one muscle/muscle group.

Intravenous Injections

Injections instilled into veins.

Intradermal Injection Sites

Inner aspect of the forearm, back, posterior upper arm, upper chest.

How does an insulin pump work?

Insulin is continuously released in small amounts & can release an additional amount manually after a meal or snack from the device through a catheter attached to a needle in the skin; acts similar to a natural pancreas.

A client with allergies has been advised to have an allergy test. The nurse needs to administer an injection to the client for allergy testing. Which injection route is most suitable for allergy testing?

Intradermal * Commonly used for tuberculin tests and allergy testing because they are administered between the layers of the skin.

A nurse is performing a sensitivity test on a client. What would be the best type of injection to use for this procedure?

Intradermal * Intradermal injections are administered into the dermis, just below the epidermis. The intradermal route has the longest absorption time of all parenteral routes. For this reason, intradermal injections are used for sensitivity tests, such as tuberculin and allergy tests, and local anesthesia. The advantage of the intradermal route for these tests is that the body's reaction to substances is easily visible, and degrees of reaction are discernible by comparative study.

Deltoid Injection Site

Lateral aspect of the upper arm; smaller muscle than others, thus, least used IM injection site. * Used for children beginning at age 4 as well as for adults. * Injections limited to 1mL for this injection site d/t small capacity.

Shaft of the Needle

Length of the needle; depends on the depth to which the medication will be instilled.

Dorsogluteal Injection Site

Located in the gluteus maximus muscle in the buttocks.

glargine (Lantus)

Long-acting insulin. * NEVER mixed with any other type of insulin.

Parenteral Route

Medications given by injection.

Rectus Femoris Injection Site

Middle third of the anterior aspect of the thigh with the patient sitting or supine. * May be used for infants

Disadvantages of insulin pens:

More expensive than insulin vials; cannot mix different types of insulin (clear to cloudy); not covered by some insurance plans.

When administering heparin subcutaneously, the nurse should:

Never aspirate. * When administering heparin subcutaneously, the nurse should never aspirate, due to the anticoagulant effects and the consequent risk for bleeding.

Advantages of the Ventrogluteal Injection Site

No large nerves or blood vessels, usually less fatty & cleaner because fecal contamination is rare at this site.

Lumen of the Needle

Opening of the needle.

Barrel

Part of the syringe that holds the medication.

Tip

Part of the syringe to which the needle is attached.

Plunger

Part of the syringe within the barrel that move back & forth to withdraw & instill medications.

In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action?

Place the date on the vial and retain for future use.

Reconstitution

Process of adding liquid, known as diluent, to a powdered substance prior to administering the drug parenterally. * Reconstituting a drug just before it is needed ensures maximum potency.

The nurse is administering an intramuscular injection to a client who is immunocompromised due to the side effects of chemotherapy. When administering the injection, which action is most important for the nurse to take?

Ready the injection site by rubbing it with an alcohol swab in a circular motion for 15 seconds. * Ensure sterility is maintained while the medication is being prepared and during the injection. The nurse will first wash the client's skin with soap and water if it has been soiled with dirt, drainage, or fecal matter/urine. Although it is important to follow agency policy for skin preparation, the nurse will use an alcohol swab to rub for 15 seconds and then let the area dry for 30 seconds. When preparing the injection site, the nurse will move the alcohol swab from the center of the site outward in a 2 in (5 cm) radius. This action will kill pathogens on the surface of the skin, preventing them from entering through the break in skin integrity caused by the needle.

Prefilled Cartridge

Sealed glass cylinder of parenteral medication; comes with an attached needle.

Ampule

Sealed glass drug container that must be broken to withdraw the medication.

Intradermal (Tuberculin)

Size of Syringe: 1 mL calibrated in 0.01 mL Sizes of Needles: 25 - 27g, 1/2 - 5/8 inch.

Insulin, given subcutaneously

Size of Syringe: 1 mL calibrated in units. Sizes of Needles: 25- or 27g, 1/2 - 5/8 inch.

Subcutaneous

Size of Syringe: 1, 2, 2.5, or 3 mL calibrated in 0.1 mL Sizes of Needles: 23-, 25-, or 26g, 1/2 - 5/8 inch.

Intramuscular

Size of Syringe: 3 or 5 mL calibrated in 0.2 mL Sizes of Needles: 20 - 23g, 1.5 or 2 inch.

Bevel of the Needle

Slanted portion of the needle that provides access into the vein. ** BEVEL UP!

Insulin Pump

Small, programmable, computerized device that contains 180-315 units of rapid-acting insulin that can be refilled from vials.

Precipitate

Solid particles originally dissolved in liquid.

What are common diluents for injectable drugs?

Sterile water or Sterile normal saline.

The most common route of insulin administration is:

Subcutaneous or Intravenous.

Insulin Syringe

Syringe that is calibrated in units & holds a volume of 0.5 - 1 mL of medication.

Z-Track Technique

Technique for manipulating the tissue to seal a medication in the muscle; zig-zag technique. * Stretch the muscle laterally forming a "Z."

Scoop Method (To prevent needlestick injuries)

Technique of threading the needle within the cap w/o touching the cap itself.

The nurse is preparing to administer an IM injection in the vastus lateralis site. Where will the nurse administer the medication?

The anterolateral aspect of the thigh. * The vastus lateralis site is in the anterior aspect of the thigh, in which the nurse places the injection in the middle third of the thigh and is often used for infants.

A client is ordered to receive an intramuscular injection of medication. When preparing to administer the injection, the nurse selects the ventrogluteal site based on which reason?

The area is free of major blood vessels and fat. * Considered the safest and least painful site.

Which statement best describes the nurse's rationale for selecting the ventrogluteal site when using the Z-track technique for administering an injection?

The ventrogluteal site provides a location with the capacity for depositing and absorbing the drug.

Lipohypertrophy "HYPER"

Thickening of subcutaneous fat at the site of repeated insulin injections.

What is the best explanation from the nurse as to why a client must return to the unit in 48 hours after having a tuberculin skin test intradermal?

To determine the extent to which the client responded to the drugs. * This allows the nurse to observe the area for signs of local reaction in which the standard time is 24-48 hours.

What kind of syringe is heparin prepared in?

Tuberculin or prefilled cartridge.

The nurse is preparing to withdraw liquid medication from an ampule for injection into an IV. What is the appropriate action for the nurse to take when withdrawing the medication?

Use a filter needle to withdraw the medication. * Filter needles should be used whenever withdrawing medication for injection from an ampule, due to the risk of glass particles being aspirated into the syringe. The filter needle contains a membrane that acts as a barrier by blocking the entrance of glass shards.

Ventrogluteal Injection Site

Uses the gluteus medius & gluteus minimus muscles in the hip for injection. * Favored for adults, but also safe for children.

Vastus Lateralis Injection Site

Uses the vastus lateralis muscle - one of the muscles in the quadriceps group of the outer thigh. * Desirable site for infants & small children or patients who are thin or debilitated with poorly developed gluteal muscles.

The client is a 9-month-old infant who is to receive an intramuscular injection. Which muscle is best for administration of this medication?

Vastus Lateralis * The deltoid and dorsogluteal muscles are not well developed in infants and children. The ventrogluteal muscle may be used for children, not infants.

A nurse needs to administer a prescribed injection to a toddler. Which injection site is most suitable for the client?

Vastus lateralis site * Most desirable for administering injections to infants and small children, as well as clients who are thin or debilitated with poorly developed gluteal muscles.

A nurse needs to administer a prescribed injection to an older adult client with impaired mobility. Which intramuscular site is preferred for administering an injection to older adult clients?

Ventrogluteal * The ventrogluteal or deltoid muscles may be the preferred intramuscular sites for older adult clients experiencing impaired mobility. This site has the potential of retaining greater muscle mass longer than other sites. It is also usually less painful for the client.

What are the 4 IM injection sites?

Ventrogluteal, Vastus Lateralis, Rectus Femoris, & Deltoid.

Syringes are calibrated in:

milliliters (mL), cubic centimeters (cc), & units (U).