1 Second semester Chapter 34 Parenteral Medications Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications

2 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Parenteral Administration Equipment The parenteral route means a route of drug administration other than oral or through the gastrointestinal tract.

3 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Parenteral Administration Equipment Syringes: all syringes contain a barrel, a plunger, and a tip or hub Calibrated in milliliters (mL), cubic centimeters (cc), units (U), and in some cases minims (m)

4 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Parenteral Administration Equipment (cont’d) Needles are supplied in various lengths and gauges –Shaft: length of the needle –Gauge: diameter of the needle Lengths vary from approximately 0.5 to 2.5 inches Needle gauge refers to 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.

5 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications

6 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Factors considered when selecting syringes and needles The type of medications The depth of tissues The volume of prescribed drugs The viscosity of the drugs The size of the client

7 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications common sizes of syringes and needles

8 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Parenteral Administration Equipment (cont’d) Modified safety injection equipment Avoids needlestick injuries to reduce the risk for acquiring a blood-borne viral disease such as hepatitis or AIDS Techniques with standard equipment to prevent needlestick injuries: 1.Before administering an injection, the protective cap covering a needle is replaced by using the scoop method 2.After administering an injection, the needle is left uncapped and deposited in the nearest biohazard container

9 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Safety Injection Devices A.A syringe with a circular sleeve that cover the needle B.A syringes with an articulated levered shield that glides over the needle after it is used

10 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Drug Preparation Ampule: sealed glass drug container Vial: glass or plastic container of parenteral medication with a self-sealing rubber stopper Reconstitution: process of adding liquid, known as diluent, to a powdered substance Prefilled cartridges

11 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Ampule, Vial, and Prefilled Cartridge

12 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Injection Routes There are four injection routes for parenteral administration: 1.Intradermal injections (between the layers of the skin), 2.Subcutaneous injections (beneath the skin but above the muscle), 3.Intramuscular injections (in muscle tissue), and 4.Intravenous injections (instilled into veins; Fig. 34-8).Fig. 34-8

13 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Injection routes: A.: intradermal B.: subcutaneous C.: intramuscular and subcutaneous in other than thin persons and D.: intravenous

14 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications 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. Injection Sites A common site for an intradermal injection is the inner aspect of the forearm. Other areas that may be used are the back and upper chest

15 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Injection Equipment A tuberculin syringe holds 1 mL of fluid and is calibrated in 0.01-mL increments (Fig. 34-9).Fig It is used to administer intradermal injections. A 25- to 27-gauge needle measuring a half- inch in length commonly is 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

16 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications 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 commonly is used to administer insulin and heparin.

17 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Injection Sites The preferred site for giving a subcutaneous injection of insulin and heparin is the abdomen. Additional or alternative injection sites for insulin are the outer back area of the upper arm, where it is fleshier, and outer areas of the thigh and upper buttocks. Rotating within one injection site, preferably the abdomen, is recommended rather than rotating to a different area with each injection The rate of drug absorption at various subcutaneous sites from fastest to slowest is abdomen, arms, thighs, and buttocks.

18 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Injection Equipment Insulin is prepared in an insulin syringe A 25- gauge needle is used most often Injection Technique To reach subcutaneous tissue in a normal- sized or obese person who has a 2-inch tissue fold when it is bunched, the nurse inserts the needle at a 90-degree angle. The tissue usually is bunched between the thumb and fingers before administering the injection to avoid instilling insulin within the muscle.

19 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Figure Angles and needle lengths for subcutaneous injections. Subcutaneous injection sites

20 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Intramuscular Injections An intramuscular 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 commonly are given intramuscularly. Injection Sites The five common intramuscular injection sites are named for the muscles into which the medications are injected: dorsogluteal, ventrogluteal, vastus lateralis, rectus femoris, and deltoid.

21 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications

22 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Dorsogluteal Site The dorsogluteal site is the upper outer quadrant of the buttocks and is a common location for intramuscular injections. The primary muscle in this site is the gluteus maximus, which is large and therefore can hold a fair amount of injected medication with minimal postinjection discomfort. This site is avoided in clients younger than 3 years because their muscle is not sufficiently developed.

23 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications If the dorsogluteal site is not identified correctly, damage to the sciatic nerve with subsequent paralysis of the leg can result, To locate the appropriate landmarks : 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.

24 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Ventrogluteal Site The ventrogluteal site uses the gluteus medius and gluteus minimus muscles in the hip for injection. This site has several advantages over the dorsogluteal site: it has no large nerves or blood vessels, and it is usually less fatty and cleaner because fecal contamination is rare at this site. The ventrogluteal site is also safe for use in children. 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 (Fig ).Fig 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, middle finger, and iliac crest.

25 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Ventrogluteal Site

26 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Vastus Lateralis Site 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 usually are absent in this area, 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 (Fig ).Fig He or she then inserts the needle into the lateral area of the thigh (Fig ).Fig Figure Locating the vastus lateralis muscle. Figure Spreading the skin at the vastus lateralis site and darting the tissue

27 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Rectus Femoris Site 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 (Fig ).Fig Figure Location of rectus femoris injection site.

28 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Deltoid Site The deltoid site in the lateral aspect of the upper arm (Fig ) is the least-used intramuscularFig 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.

29 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications There is a risk for 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.

30 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Reducing Injection Discomfort 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 method for intramuscular injections. Apply pressure to the site during needle withdrawal. Massage the site afterward, if appropriate.

31 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications The Z-track technique. Performing the Z-track method Place gloved fingers on the skin surface and pull the overlying skin and subcutaneous tissue approximately cm (1 to 1 ½ inches) laterally to the side. (See Figure A) Holding the skin taut with the non dominant hand, insert the needle at a 90 degree angle at the spot where the finger was initially placed before displacing the skin laterally. (See Figure B) Aspirate for blood return with the dominant hand only (practice of nurse makes this step easy). If there is no blood return on aspiration, inject the drug slowly, followed by the air. Air clears the clears the needle of the medication and prevents tracking of the medication through the subcutaneous layers upon needle withdrawal. (Air-lock technique) Wait for 10 seconds before withdrawing the needle to allow the medication to disperse evenly. Slowly remove the needle. Release the skin taut. A zigzag needle track is created (by sliding of the tissue planes across each other) preventing the escape of medication from the muscle tissue. (See Figure C) Instruct the patient never to wear tight or constricting clothing because it can force out the injected medication to the subcutaneous layers. Do not massage the site. Encourage the patient to mobilize (walk or move in bed) to facilitate the absorption of medication. Discard the needles and syringe in an appropriate sharps container. Always remember, never to recap the syringe to avoid needle-stick accidents. Remove gloves. Document medication, dosage, date, time and site of injection on the patient’s chart.

32 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Nursing Implications Acute Pain Anxiety Fear Risk for Trauma Deficient Knowledge Ineffective Therapeutic Regimen Management

33 Second semester Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Parenteral Medications Sample Documentation Time and date ( 11/21/2015 5:42:58 PM) Tuberculin skin test administered intradermal in left forearm with no immediate unexpected effects. Instructed to return in 48 hours for inspection of site Signature/ Title