Administering Intradermal, Subcutaneous, and Intramuscular Injections

Administering Intradermal, Subcutaneous, and Intramuscular Injections
Chapter 35 Administering Intradermal, Subcutaneous, and Intramuscular Injections Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory
Identify the principles for safe and effective administration of intradermal, subcutaneous, and intramuscular injections. List the routes used for administering parenteral medications and the advantages and disadvantages of each route for pediatric, adult, and elderly patients. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Clinical Practice
Choose the appropriate syringe and needle for the type of injection ordered. Follow Standard Precautions when administering injections and disposing of used equipment. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Injections Often necessary to inject medication into tissue
Injections cause pain to the patient Student nurses often uncomfortable with causing the patient discomfort Students should learn and practice this skill in the laboratory to minimize their and patient’s discomfort Discuss ways in which you can reduce pain caused to a patient when administering a parenteral medication. (1. obtaining appropriate-size needle for patient based on body size, muscle group being used, and type of drug being given; 2. allow the injection site to dry after cleaning with alcohol) A very thin person or a child does not need a 2-inch needle, but rather a 1-inch needle. When practicing medication administration in the lab, understand that real patients have feelings and will let you know if they experience pain. Care should be taken to be as proficient and safe as possible when administering medications. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-1: Structure of the skin
Review the structure of the skin and how giving an injection will be causing a break in the skin integrity. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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 Name two situations in which a patient will be NPO and require parenteral medications. (diagnostic procedures such as CT scan, intubated patient, patient going to surgery) Can you state when issuing parenteral medication is better than oral administration due to the need for rapid absorption? (administration of steroids for respiratory problems such as asthma or bronchospasm, administering vitamin K to counteract elevated coagulation state) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Safe, Effective Administration of Parenteral Medications
Use only sterile needles and syringes Use appropriate-length needle to reach the proper tissue layer Select injection site carefully to avoid major nerves, blood vessels, and underlying organs Select injection site relatively free from hair, lesions, inflammation, rashes, moles, and freckles Why is it important to prepare and administer parenteral medications in a sterile manner? What is the appropriate-sized needle to use when administering intradermal, subcutaneous, and intramuscular injections? (intradermal: 24, 27, or 29 gauge; subcutaneous: 27 gauge, 3/8 to 1/2 inch or 25 gauge, 5/8 inch; intramuscular: 1 to 3 inch) What is the best site to use when administering intradermal, subcutaneous, and intramuscular injections? (intradermal: ventral aspect of the forearm; subcutaneous: upper arm, thigh, abdomen; intramuscular: mid-deltoid, dorsogluteal area) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Safe, Effective Administration of Parenteral Medications (cont’d)
Establish a plan for rotating injection sites for patients receiving repeated injections Obtain assistance as needed in giving an injection when the patient is a frightened child or an uncooperative adult Aspirate by pulling back the plunger to avoid injecting medications into a blood vessel What is fibrosis and why does it develop? (scarring due to repeated injections in the same area) What would you do if a 5-year-old child refuses his immunizations? (demonstrate the procedure on a doll, let the child look at empty vials and syringes, explain that the medicine will help them to stay well, etc.) Name a medication that is administered subcutaneously and does not require aspiration. (heparin) What safety check can help prevent administering the wrong medications? (Six Rights) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Safe, Effective Administration of Parenteral Medications (cont’d)
Check for drug allergies before you administer an injection Know the medication you will administer and observe for side effects and therapeutic action It is imperative that drug allergies be reviewed with patients at every step of the admission process, from the emergency department to the floor. Many times patients neglect to report an allergy. When administering medications, it is critical that the nurse be aware of the purpose and side effects of the drug so that he or she can be alert to adverse effects. How soon after a new medication is given should the nurse assess for side effects? (30 minutes) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Routes for Parenteral Administration: Intradermal
Medication is deposited into layers of skin Usually used for skin testing for TB or other diseases (allergy testing) Use a small needle, with a 15-degree angle of insertion (24, 27, or 29 gauge) Use a tuberculin syringe Forms a skin bleb or small bump What is the maximum amount of medication that can be administered intradermally? Is a 29-gauge needle bigger or smaller than a 24-gauge needle? (smaller—the larger the number of the gauge, the smaller the needle) You have issued a tuberculin test intradermally. When should the patient return to assess the injection site? (48 to 72 hours after the test) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Routes for Parenteral Administration: Subcutaneous
Injects small amount of medication (0.5-1 mL) into tissue below the dermal layer into subcutaneous 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 on the amount of subcutaneous tissue on the patient Name two medications that can be given subcutaneously. (examples: heparin, insulin, allergy extract) Why is the abdomen a good place to administer certain subcutaneous medications? (The abdomen provides the most reliable, steady absorption.) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-17: Subcutaneous injection sites
Discuss each of significant part of giving an injection. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Routes for Parenteral Administration: Intramuscular
Injected into muscle layer at 90-degree angle Most common sites: deltoid, dorsogluteal, ventrogluteal, vastus lateralis, and rectus femoris Needle usually gauge, 1-3 inches long Volume up to 3 mL for most IM injections, nurse aspirates for blood before injecting medication to avoid injecting directly into a blood vessel The absorption time for IM medications chiefly depends on the form of the drug Which intramuscular site is the best site for administering medication to infants and the elderly? (vastus lateralis muscle for infants; ventrogluteal and vastus lateralis for elderly) Which injection site can cause sciatic nerve injury if medication is administered incorrectly? (dorsogluteal) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Intramuscular Route: Z-Track Method
May be used any time an intramuscular injection is given Used for deep IM injections of drugs such as iron dextran or Vistaril Reduces pain caused by irritating drugs leaking into subcutaneous tissue Seals the medication in the muscular layer See Step 35-5 What needle size and length would you use when administering a medication using the Z-track method? What if the patient is morbidly obese? (The airlock method should be used with the Z-track method because it prevents medication leakage.) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-2: Injection routes
Discuss each of the significant components of each injection route. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Syringes Composed of barrel and plunger with a needle tip made of plastic (disposable) or glass 3-mL syringe Popular because large enough for subcutaneous and most IM 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 Syringes are made of plastic or glass. The plastic ones are disposable, whereas glass syringes can be sterilized and reused. Disposable syringes are used almost exclusively in North America because they are convenient, safe, and economical. Some syringes are prefilled with medications such as heparin, Lovenox, morphine, and insulin (mini pen). What are two brands of a unit-dose cartridge? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-3: Parts of a syringe
Give syringes to students and have them look at each part as you discuss the parts and how they assist in medication administration. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-7: Measurement scale on a 3-mL syringe
Most 3-mL syringes have two scales Tenths of a milliliter (0.1 mL) Minim scale Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-5: Insulin syringes
Discuss how this syringe is different from the 3-mL syringe. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-6: Tuberculin syringe
How is a tuberculin syringe different from an insulin syringe? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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 A needle is a metal tube through which liquid medication flows. It consists of a hub fitting onto the end of a syringe, a hollow shaft (also called a cannula), and a bevel (slanted part of the needle tip) ending in a sharp point. The inner part of the cannula is the lumen. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-8: Needle sizes Have students compare each of the needle sizes and discuss why one size is more appropriate than another for specific patients. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Preparing the Syringe for Use
Use aseptic technique in handling the syringe and needle Protect surfaces that must remain sterile: the needle, tip, inner barrel, and plunger Discard syringe or needle if it becomes contaminated during drug preparation for administration Label the syringe with the patient’s name, name of medication, and dose Most needles are disposable and used only once. Steel needles can be sterilized and reused. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-9: Needle with protective sheath
Discuss the safety features of this type of needle. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Filter Needles Medications drawn from an ampule may have glass in them from the breaking of the ampule Filter needles should be used when medication is withdrawn from ampule to trap the glass particles Filter is discarded and new needle attached to syringe for injecting medication into the patient Once an ampule is opened, the medication must be used. Any unused portion must be discarded. Always remember to discard the filter needle after use. A filter needle cannot be used to administer an injection. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-10: Discarding used syringe into a sharps biohazard container
Discuss this type of container and how to properly dispose of a syringe. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Needle Sticks HIV, hepatitis B, and hepatitis C can be spread by a needle stick from an infected patient Safety syringes prevent needle sticks to health care workers and should be used when available If regular syringes must be used, the needle must not be recapped after injection but taken to the nearest sharps disposal unit and discarded—never recap a needle Report all needle sticks Always use Standard Precautions and maintain sterile technique when administering medications. Many institutions have a needleless system in place. This helps protect employees by decreasing the risk of needle sticks. Recapping needles increases your risk of a needle stick and for contacting blood-borne pathogens. In the event of a needle stick, follow the institution’s guidelines for reporting this injury. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 1 What size and gauge needle are used to give intramuscular injections? 1/2- to 1-inch needle that is 23 to 25 gauge 1- to 1 1/2-inch needle that is 20 to 23 gauge 1/2- to 5/8-inch needle that is 20 to 23 gauge 2- to 2 1/2-inch needle that is 20 to 23 gauge Answer: 2 Rationale: The appropriate size needle and gauge for an intramuscular injection is 1- to 1 1/2-inch needle and 20 to 23 gauge. Intradermal injections use 1/2- to 1-inch needles and 23 to 25 gauge. Subcutaneous injections use 1/2- to 5/8-inch needles and 20 to 23 gauge. You should never use a 2 1/2-inch needle. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Aseptically and accurately withdraw and measure the ordered dose of a medication from a vial or an ampule. Demonstrate reconstitution of a drug from a powder. Demonstrate the correct method for drawing up two types of drugs, including insulin, in one syringe. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Parenteral Solutions May be available in: Ampules Vials Mix-O-Vials
Single dose and multidose Mix-O-Vials Medication in powder form and diluent present in two halves of a vial separated by a rubber stopper Unit-dose cartridges Requires Carpuject or Tubex holders Ampules are single-dose vials for one-time use only. When opening an ampule, use a gauze or alcohol pad around the neck of the vial. Single-dose vials must be discarded, even if all the medication is not used. Multidose vials can be used several times but once opened, must be properly labeled with date and time. Insulin is an example of a multidose vial. Some antibiotics and corticosteroids are in Mix-O-Vials. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-11: Containers of parenteral medication
Have students handle containers of parenteral medications. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Ampules Glass or polyurethane; consist of body, neck, and stem; usually contain a single medication dose All medication must be in the ampule body before the neck is broken Before opening, medication must be removed from the neck or stem Tap or flick the stem several times with a finger to free the trapped solution The open ampule is handled very carefully when withdrawing the medication with the filter needle What type of needle must be used when withdrawing medications from an ampule? (filter) Name a medication that is supplied in an ampule. (digoxin) How do you break an ampule that is not pre-scored? If you do not use all the medication in an ampule, can the remainder be saved for the next dose? (no) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-13: Moving fluid from the neck of the ampule
Have students watch as you remove fluids from the neck of the ampule Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-14A: Withdrawing fluid from an ampule—ampule inverted
Illustrate how to withdraw fluids from an ampule. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-14B: Withdrawing fluid from an ampule—ampule upright and stabilized
Illustrate how to withdraw fluids from an ampule. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Vials A small bottle with a rubber stopper attached by a metal band
May contain one or more dosages of medication Sizes from 1 to 50 mL May be in powder form requiring reconstitution (label or package insert provides mixing instructions) Before mixing two medications in a syringe, check for compatibility Always check drug compatibility by checking a compatibility chart or asking the pharmacist. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-15: Drawing medication from a vial
Illustrate how to withdraw fluids from a vial. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Reconstituting a Drug Drugs that are unstable in liquid form are prepared in a powdered form Solute (the powder) is mixed with a diluent to dissolve the drug before drawing up into the syringe for injection Diluents are usually sterile water or saline Follow directions on the vial or package for proper reconstitution Some drugs are stable at room temperature for a designated amount of time and must be administered within that time frame. The package insert will provide information on what solution a powdered drug should be reconstituted with. If you are unsure about reconstituting a drug, contact the pharmacist. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Compatibility of Medications
A reaction occurs when a drug combines with an incompatible drug Range from color change, precipitation, and clouding to invisible chemical changes rendering the drug inactive Charts are often available that outline which drugs are compatible When medications are compatible, you inject an amount of air equal to the desired dose of each drug into their respective vials. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-16A, B: Mixing doses of insulin from multidose vials
Illustrate how mix doses of insulin from multidose vials Discuss the use of preloaded multidose vials. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory
List the routes used for administering parenteral medications and the advantages and disadvantages of each route for pediatric, adult, and elderly patients. (Continued) Recognize the signs and symptoms of anaphylactic shock. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Use the Six Rights of medication administration, including checking for patient drug allergies. Prepare and administer an intradermal injection, using the Six Rights and aseptic technique. Correctly prepare and administer a subcutaneous injection with 100% accuracy. Correctly prepare and administer an intramuscular injection with 100% accuracy. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Locate the appropriate site on a patient to give an intradermal, subcutaneous, or intramuscular injection by identifying correct anatomic landmarks. Evaluate your documentation of injections administered after administration. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Implementation Intramuscular injections
Used if patient cannot take medicine orally, medication not prepared in oral form, or faster action is 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 and minimus muscles The vastus lateralis muscle The rectus femoris muscle How quickly can an IM injection provide onset of action? In the past the dorsogluteal (gluteal pertaining to the buttocks), site was used; however, it is no longer recommended because of the high potential for injury to the sciatic nerve and the blood vessels. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-18: Locating site for a mid-deltoid IM injection
Discuss how to locate the appropriate site of the mid-deltoid intramuscular injection. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-21: Locating the rectus femoris IM injection site
Discuss how to locate the appropriate site of the rectus femoris intramuscular injection Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Implementation (cont’d)
Intramuscular injections Airlock technique Used for IM injection to clear the needle of medication and to seal the track so the medication does not flow back Intramuscular injections in children The vastus lateralis and the ventrogluteal sites can be used It is preferable to find another way to give medication to children because IM injections are painful and traumatic When giving a deltoid injection to a child, the injection should be given in the thickest part of the muscle; the needle should point at a slight angle toward the shoulder. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-19: Locating site for a ventrogluteal IM injection
Discuss how to locate the appropriate site of the ventrogluteal intramuscular injection Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-20: Locating the vastus lateralis IM injection site
Discuss how to locate the appropriate site of the vastus lateralis intramuscular injection. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Implementation (cont’d)
Intramuscular injections The Z-track technique Reduces pain caused by irritating drugs that leak or escape along the track into subcutaneous tissue when needle is withdrawn Must be used whenever a deep IM injection of iron dextran (DexFerrum) and other irritating solutions are given Reduces pain caused by irritating drugs that leak or escape along the track into subcutaneous tissue when needle is withdrawn. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35-22: Z-track technique
Discuss how to locate the appropriate site of a Z-track intramuscular injection. Explain the difference between the methods of giving intramuscular injections. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Anaphylactic Shock Anaphylactic shock
Circulatory failure from an allergic reaction Symptoms Urticaria, bronchiolar constriction, edema, and finally circulatory collapse Watch for signs of anaphylactic shock and, if necessary, administer immediate, lifesaving treatment Allergic reactions are more common the second or successive times the medication is received Anaphylaxis can be a life-threatening emergency. This condition has to be dealt with immediately. If untreated, the patient may suffer a cardiac arrest, resulting in death. When issuing parenteral medications, be sure to observe the patient within 30 minutes of drug administration. If an anaphylactic reaction is going to occur, it will most likely occur within 30 minutes of administration. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Things to Remember Always check for allergies
Know the expected and possible side effects of all drugs you administer Date all multidose vials when you open them Question any order that does not make sense for your patient Always follow the Six Rights and five rules Know your landmarks and injection techniques for each type of injection The nurse is the patient’s best advocate. It is important for the nurse to keep the safety of the patient in mind. Putting patient safety first decreases the risk of liability. Don’t be afraid to ask questions or clarify an order. Always remember to document interventions. Remember, if it is not documented, it was not done. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 2 Which of the following is not an appropriate site for an intramuscular injection? Dorsogluteal Deltoid Vastus lateralis Dermal Answer: 4 Rationale: The dermis is a layer of the skin; the dermal site is not appropriate for an intramuscular injection. The appropriate sites for intramuscular injections are dorsogluteal, ventrogluteal, deltoid, vastus lateralis, and rectus femoris. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 3 Darlene is about to give her patient an intramuscular injection. What angle should the injection be given? 90 degrees 45 degrees 15 degrees It depends on the size of the needle and size of the patient Answer: 1 Rationale: The angle of an intramuscular injection is 90 degrees. Subcutaneous injections are given between 45 and 90 degrees depending on the size of the patient and size of the needle. Intradermal injections are given at a 15-degree angle. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 4 Sylvie is going to give her 1-year-old patient an IM injection. Which is the preferred IM site? Deltoid Vastus lateralis Dorsogluteal Ventrogluteal Answer: 2 Rationale: The vastus lateralis muscle is the preferred site in infants and very small children. It is located in the thigh. The deltoid is located in the arm. The dorsogluteal and ventrogluteal are in the buttocks area. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 5 Michael is going to give his patient an injection of iron. To help minimize the pain, what can Michael do? Use the largest gauge needle that is appropriate. Inject the medication quickly. Use the Z-track technique. Do not tell the patient when he is going to give the injection. Answer: 3 Rationale: The Z-track technique reduces pain caused by irritating drugs such as iron. You would use the smallest needle that is appropriate, inject the medication slowly, and always let patients know when they are going to receive an injection. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Administering Intradermal, Subcutaneous, and Intramuscular Injections

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Administering Intradermal, Subcutaneous, and Intramuscular Injections

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