Pharm 5: Administering Injections

-Injection Equipment: -Injection Technique: -NURSING GUIDELINES 34-4: Giving an Injection by the Z-Track Technique

-3- to 5-mL syringes are used to administer medications by the intramuscular route. A 22-gauge needle that is 1½ to 2 in. long is usually adequate for depositing medication in most sites. .... -Injection Technique: -When administering intramuscular injections, nurses use a 90-degree angle for piercing the skin. -* Z-track technique* (a technique for manipulating the tissue to seal a medication, especially an irritant, in the muscle) --NURSING GUIDELINES 34-4: Giving an Injection by the Z-Track Technique • Fill the syringe with the prepared drug and then change the needle. This measure prevents tissue contact with the irritating drug. • Attach a needle at least 1½ to 2 in. long. The correct needle length helps to deposit the drug deep within the muscle. • Add a 0.2-mL bubble of air in the syringe. Air flushes all the medication from the syringe during the injection. • Select a large muscular injection site such as the ventrogluteal site. A large site provides a location with the capacity for depositing and absorbing the drug. • Wash your hands and don gloves. These measures reduce the transmission of microorganisms. • Use the side of the hand to pull the tissue laterally about 1 in. (2.5 cm) until the tissue is taut (see Fig. 34-19A). Taut tissue creates the mechanism for sealing the drug within the muscle. • Insert the needle at a 90-degree angle while continuing to hold the tissue laterally. Correct placement directs the tip of the needle well within the muscle. • Steady the barrel of the syringe with the fingers and use the thumb to manipulate the plunger (see Fig. 34-19B). These measures avoid releasing the tissue held taut by the nondominant hand. • Aspirate for a blood return. Doing so determines whether or not the needle is in a blood vessel. • Instill the medication by depressing the plunger with the thumb. This measure deposits the medication into the muscle. • Wait 10 seconds with the needle still in place and the skin held taut. This duration provides time to distribute the medication in a larger area. • Withdraw the needle and immediately release the taut skin. Doing so creates a diagonal path that prevents leaking into the subcutaneous and dermal layers of tissue (see Fig. 34-19C). • Apply pressure, but do not massage the site. This ensures that the medication remains sealed. • Discard the syringe without recapping the needle. Proper disposal reduces the potential for a needlestick injury. • Remove gloves and wash your hands or perform an alcohol-based hand rub. These measures reduce the transmission of microorganisms. • Document the medication administration. Proper recording maintains a current record of client care.

Administering Heparin:

-Heparin is an anticoagulant drug, meaning that it prolongs the time it takes for blood to clot. Heparin frequently is administered subcutaneously as well as intravenously. -The dosages are very small volumes that may require a tuberculin syringe to ensure accuracy. -low-molecular weight heparins (LMWH) such as enoxaparin (Lovenox). LMWH has the advantage of being prescribed in a consistent daily dose with no or fewer required anticoagulation blood tests, less risk

Injection Equipment: Injection Technique

-Heparin is prepared in a *tuberculin syringe*, or it may be supplied in a prefilled cartridge. A *25-gauge needle* is used most often because medications administered subcutaneously usually are not viscous. Needle lengths may vary from ½ to ⅝ in. .... -obese person who has a 2-in. tissue fold when it is bunched, the nurse inserts the needle at a 90-degree angle. -1-in. fold of tissue, the nurse inserts the needle at a 45-degree angle

Administering Insulin:

-Injectable insulin is supplied and prescribed in a dosage strength called units (U) -The standard dosage strength of insulin is 100 U/mL. .. -Prefilled pen-like devices that facilitate the repeated administration of insulin through a special pen needle are also available. Doses from 0.5 to 80 U by dialing the prescribed amount on the pen. -Only the needle is changed with each injection. The insulin in prefilled pens is stable for up to 30 days. -Containers of insulin are refrigerated until they are opened; thereafter, they are stored at room temperature. -To avoid *lipoatrophy*(the breakdown of subcutaneous fat at the site of repeated insulin injections) and *lipohypertrophy* (the thickening of subcutaneous fat at the site of repeated insulin injections), the sites are rotated each time an injection is administered.

Intramuscular Injections

-Irritating medications commonly are given intramuscularly. -Injections should not be administered into limbs that are paralyzed, inactive, or affected by poor circulation. - absorption from an intramuscular injection occurs more rapidly than from the other parenteral routes.

Preparing Insulin

-Some preparations of insulin contain an additive that delays its absorption. Insulin and the additive tend to separate on standing. Therefore, when preparing other than rapid-acting and short-acting insulin or the long-acting insulin glargine (Lantus), the nurse*rotates the vial between the palms to redistribute the additive and insulin*before filling the syringe. -When injected within 15 minutes of being combined, they act as if they had been injected separately. Rapid-acting insulin and short-acting insulin, which are additive free, are often combined with an intermediate-acting insulin. -*The long-acting insulin, glargine*, is *never mixed with any other type of insulin* ... NURSING GUIDELINES 34-3: Mixing Insulins • Roll the vial of insulin containing an additive between the palms. Rolling between the palms mixes the insulin without damaging the protein molecules. • Cleanse the rubber stoppers of both vials of insulin. Cleaning removes colonizing microorganisms. • Instill an amount of air equal to the volume that will be withdrawn from the vial containing the insulin with the additive. Do not insert the needle into the insulin itself (see Fig. 34-13A, B). These measures avoid coating the needle. • Withdraw the needle and use the same syringe to repeat the previous step, but this time invert and withdraw the prescribed number of additive-free insulin units (see Fig. 34-13C). Clear insulin is always placed in the syringe before adding the cloudy insulin to avoid altering the additive-free insulin within the vial. • Ask another nurse to check the label on the insulin and the number of units in the syringe. An additional check helps to prevent a medication error. • Swab the rubber stopper of the other vial and pierce it with the needle of the partially filled syringe. This step facilitates withdrawing the other type of insulin. • Withdraw the specified number of units from the vial containing the insulin with the additive. Doing so prepares the full prescribed dose. • Ask another nurse to check the label on the insulin and the number of units in the syringe. This step prevents a medication error. • Administer within 15 minutes of mixing. Prompt administration avoids equilibration. * MIXING INSULINS • Some insulin may come premixed in a single vial • Stable - can administer without worry about equilibration • Novolin 70/30 • Humulin 50/50 *

-Subcutaneous Injections:

-Subcutaneous Injections: A 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. -The volume of a subcutaneous injection is usually *up to 1 mL.* The subcutaneous route is commonly used to administer *insulin and heparin.* -The preferred site for giving a subcutaneous injection of insulin and heparin is the *abdomen*. When using the abdomen, *avoid a 2-in. central area around the umbilicus.* -Injection sites are rotated a finger's width apart (about 1 in.) from a previous site to avoid repeatedly injecting into the same area in a short amount of time. Rotating sites avoids tissue injury. -The rate of drug absorption at various subcutaneous sites from *fastest to slowest is the abdomen, arms, thighs, and upper buttocks.*

-PARENTERAL ADMINISTRATION EQUIPMENT-

-Syringes: All syringes contain a *barrel* (the part of the syringe that holds the medication), a *plunger* (the part of the syringe within the barrel that moves back and forth to withdraw and instill the medication), and a *tip* or hub (the part of the syringe to which the needle is attached; Fig. 34-1). Syringes are calibrated in milliliters (mL) or cubic centimeters (cc), and units (U). -Needles: The *shaft* (the length of the needle) depends on the depth to which the medication will be instilled. Needle lengths vary from approximately *½ to 2½ in.* The tip of the shaft is beveled, or slanted, to pierce the skin more easily. *Filter needles* that provide a barrier for glass particles are available when withdrawing medication from a glass ampule. -Gauge: The needle gauge (diameter) refers to its width. For most injections, 18- to 27-gauge needles are used; *the smaller the number, the larger the diameter.* For example, an 18-gauge needle is wider than a 27-gauge needle. Several factors are considered when selecting a syringe and needle: • The type of medication • The depth of tissue • The volume of prescribed drug • The viscosity of the drug • The size of the client

REDUCING INJECTION DISCOMFORT

-The nurse can use the following alternative techniques to reduce discomfort associated with injections: • Use the smallest gauge needle that is 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 and withdraw the needle without hesitation. • Instill the medication slowly and steadily. • Use the Z-track technique for intramuscular injections. • Apply pressure to the site during needle withdrawal. • Massage the site afterward, if appropriate.

Modified Safety Injection Equipment

-There are three different safety injection devices: (1) those with plastic shields that cover the needle after its use (2) those with needles that retract into the syringe, and (3) gas-pressured devices that inject medications without needles. -Before administering an injection, the protective cap covering a needle is replaced by using the *scoop method* (the technique of threading the needle within the cap without touching the cap itself; Fig. 34-3). After administering an injection, the needle is left uncapped and deposited in the nearest biohazard container, which is usually at the client's bedside.

-parenteral route:

-parenteral route means a route of drug administration other than oral or through the gastrointestinal tract. *commonly used when referring to medications given by injection.*

-tuberculin syringe: -Injection Technique:

-tuberculin syringe holds 1 mL of fluid and is calibrated in 0.01-mL increments (Fig. 34-9). It is used to administer *intradermal injections.* -A *25- to 27-gauge* needle measuring a half-inch in length is commonly used when administering an intradermal injection. ... -Injection Technique When giving an intradermal injection, the nurse instills the medication shallowly at a *10- to 15-degree* angle of entry

Pharmacologic Considerations

A few products are available that produce anesthesia when applied to the skin or mucous membranes. One example is eutectic mixture of local anesthetic (EMLA), which reduces or eliminates the local discomfort of invasive procedures that pierce the skin. It can take 60 to 120 minutes after application for EMLA cream to take effect.

Drug preparation :

Drug preparation involves withdrawing medication from an *ampule or vial or assembling a prefilled syringe cartridge.* ....................... -Ampule (a sealed glass drug container) must be broken to withdraw the medication. *NURSING GUIDELINES 34-1: Withdrawing Medication from an Ampule* • Select an appropriate syringe and filter needle. Proper equipment ensures appropriate drug administration and prevents aspirating glass particles within the barrel of the syringe. • Tap the top of the ampule. Tapping distributes all the medication to the lower portion of the ampule. • Protect your thumb and fingers with a gauze square or alcohol swab. These devices reduce the potential for injury. • Snap the neck of the ampule away from your body. Doing so avoids accidental injury. • Insert the filter needle into the ampule. Avoid touching the outside of the ampule. These methods ensure sterility of the needle. • Invert the ampule (see Fig. 34-5). Inversion facilitates withdrawing the medication. • Pull back on the plunger. This step fills the syringe. • Remove the needle from the ampule when the volume has been withdrawn. This prepares for drug administration. • Tap the barrel of the syringe near the hub. Tapping moves air toward the needle. • Push carefully on the plunger. Pushing expels air or excess medication. • Empty the unused portion of medication from the syringe. Doing so prevents illegal drug use. • Discard the glass ampule in a puncture-resistant container. Proper disposal prevents accidental injury. • Remove the filter needle and attach a sterile needle for administering the injection. These techniques prevent injecting glass particles into the client. • Scoop the needle within its protective cap or extend a guard that recesses the needle. These measures reduce the risk of a needlestick injury. ........................ -vial (a glass or plastic container of parenteral medication with a self-sealing rubber stopper --NURSING GUIDELINES 34-2: Withdrawing Medication from a Vial • Select an appropriate syringe and needle. The correct equipment ensures appropriate drug administration. • Remove the metal cover from the rubber stopper. This step facilitates inserting the needle or needleless adaptor. • Clean a preopened vial with an alcohol swab. Alcohol swabs remove colonizing microorganisms. • Fill the syringe with a volume of air equal to the volume that will be withdrawn from the vial. This step provides a means for increasing pressure within the vial. • Pierce the rubber stopper with the needle or tip of a needleless syringe and instill the air. Doing so facilitates the withdrawal of the drug. • Invert the vial, hold, and brace it while pulling on the plunger (see Fig. 34-6). This step locates medication near the tip of the needle or needleless adaptor to facilitate its withdrawal. • Remove the needle or adaptor when the desired volume has entered the barrel of the syringe. Doing so leaves the remaining drug for additional administrations. • If the medication is a controlled substance such as a narcotic, aspirate the entire contents from the vial. Full aspiration prevents illegal drug use. • Discard any excess medication; if the drug is a narcotic, have someone witness this action. These measures comply with federal laws to prevent illegal drug use. • Cover the needle or needleless adaptor and care for the used supplies as described in the guidelines for withdrawing from an ampule. Nurses follow aseptic and safety principles. • Date and initial the vial if the remaining drug will be used in the near future. Doing so supports the principles of asepsis. .................................. -Reconstitution- (the process of adding liquid, known as diluent, to a powdered substance) is done before administering the drug parenterally. EX *sterile water or sterile normal saline.* When reconstitution is necessary, the drug label lists the following: • The type of diluent to use • The amount of diluent to add • The dosage per volume after reconstitution • Directions for storing the drug -prefilled cartridge- (a sealed glass cylinder of parenteral medication).

Injection Sites:

Injection Sites The five common intramuscular injection sites are named for the muscles into which the medications are injected: the dorsogluteal, the ventrogluteal, the vastus lateralis, the rectus femoris, and the deltoid. .. -Dorsogluteal site is the upper outer quadrant of the buttocks. The primary muscle in this site is the gluteus maximus. *This site is avoided in clients younger than 3 years of age because this muscle is not yet sufficiently developed.* --damage to the sciatic nerve with subsequent paralysis of the leg can result. To locate the appropriate landmarks, perform the following (Fig. 34-14): • Divide the buttock into four imaginary quadrants. • Palpate the posterior iliac spine and the greater trochanter. • Draw an imaginary diagonal line between the two landmarks. • Insert the needle superiorly and laterally to the midpoint of the diagonal line. ............................... -ventrogluteal site uses the gluteus medius and gluteus minimus muscles in the hip for injection. it has no large nerves or blood vessels, and it is usually less fatty and cleaner because fecal contamination is rare at this site --To locate the ventrogluteal site: • Place the palm of the hand on the greater trochanter and the index finger on the anterior-superior iliac spine • Move the middle finger away from the index finger as far as possible along the iliac crest. • Inject into the center of the triangle formed by the index finger, the middle finger, and the iliac crest. .... -vastus lateralis- site uses the vastus lateralis muscle—one of the muscles in the quadriceps group of the outer thigh. *It is a particularly desirable site for administering injections to infants and small children and clients who are thin or debilitated with poorly developed gluteal muscles.* --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 ....... rectus femoris: site is in the anterior aspect of the thigh. This site may be used for infants. .... deltoid site, in the lateral aspect of the upper arm (Fig. 34-18), is the least used intramuscular injection site because it is a smaller muscle than the others. It is used only for adults because the muscle is not sufficiently developed in infants and children. Because of its small capacity, intramuscular injections into this site are limited to *1 mL of solution.* --There is a risk of damaging the radial nerve and artery if the deltoid site is not well identified. To use this site safely: • Have the client lie down, sit, or stand with the shoulder well exposed. • Palpate the lower edge of the acromion process. • Draw an imaginary line at the axilla. • Inject in the area between these two landmarks. *The deltoid or ventrogluteal muscles may be the preferred intramuscular sites for older adults experiencing impaired mobility. The dorsogluteal site should be avoided because of the risk for damage to the sciatic nerve with diminished musculature*

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

Should an accidental injury occur, health care workers should follow these recommendations: • Report the injury to a supervisor. • Document the injury in writing. • Identify the client if possible. • Obtain HIV and hepatitis B virus 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.

TABLE 34-1: Common Sizes of Syringes and Needles

TABLE 34-1: Common Sizes of Syringes and Needles T-YPE OF INJECTION --SIZES OF SYRINGES ---SIZES OF NEEDLES .............................. -Intradermal (tuberculin) --1 mL calibrated in 0.01 mL or in minims ---25, 26, or 27 gauge, ½- to ⅝;-in. -Subcutaneous --1, 2, 2.5, or 3 mL calibrated in 0.1 mL ---23, 25, or 26 gauge, ½- or ⅝-in. -Insulin, given subcutaneously --1 mL calibrated in units ---25, 2, or 27 gauge, ½- or ⅝-in. -Intramuscular --3 or 5 mL calibrated in 0.2 mL ---20, 21, 22, or 23 gauge, 1½- or 2-in.

There are four injection routes for parenteral administration:

There are four injection routes for parenteral administration: -intradermal injections (injections between the layers of the skin), -subcutaneous injections (injections beneath the skin but above the muscle), -intramuscular injections (injections in muscle tissue), and -intravenous injections (injections instilled into veins; ... Intradermal Injections -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. -A common site is the inner aspect of the forearm. and back and upper chest. ...