1. Administration of Injectable Medications
Chapter 64:
Administration of Injectable Medications

2. Syringes and Needles

3. Types of Syringes and Injection Methods
The safety syringe
*when preparing an injection, the medication is drawn into the barrel section
Needles
*Gauges: 28, 25, 23, 22, 20, 18, 16
Safety syringe
*Point loc device
Needleless system

4. Types of Syringes and Injection Methods
Systems for various injection methods
SC injections
IM injections:1-1.5 inch needle. For deep IM inch needle*
Intradermal injections

5. Preparations
Diluent
*ampule
Vial
Prefilled syringe

6. Reasons for Administration of Medication by Injection
It is the most effective methods of administration.
Any other form of administration is unavailable.
The desired action is achieved quickly.
Dosage accuracy is critical.
The client cannot retain oral medications.
The client is unable or unwilling to swallow oral medications.
The digestive system cannot absorb the drug.

7. Angles of Insertion

8. Intradermal injections
Shallow injections
TB syringes are used
Can identify hundredths of a ml
Can hold 1 ml

9. Subcutaneous injections
Used for small amounts of medication that require slow, systemic absorption
Common meds given SC include: heparin and insulin

10. IM injections Needle sizes Sites for injection Dorsogluteal
Vetrogluteal
Deltoid
Vastus lateralis
Used for IM injections in infants and children younger than 3 (largest muscle mass in this age group)*
Rectus femoris
Z Track
*used for injections that irritate the skin or other body tissues

11. Z-Track or Zig-Zag Method

12. Intravenous Administration
Fluids are administered via the circulatory system
Central line
Peripheral line
Primary, tandem, piggyback infusions
Infusion
Transfusion
Complications when working with IVs
Infiltration, phlebitis, embolism (thrombus), infection (sepsis)

13. Nursing Considerations for IV Administration
Calculate the dosage correctly, double-check all IV push medications.
Confirm that the IV catheter is in the vein and the fluid is flowing freely.
If it appears that the IV is infiltrated, the push should not be given.
If IV push medication is injected into surrounding tissue rather than the vein, serious problems can occur, including an abscess or tissue sloughing.
If an IV push is given too fast, it can cause very serious complications, including death.

14. Administration of Intravenous Medication
Ensure that the label of the medication to be infused states that it is safe for IV administration.
A medication given IV, even though it may be the correct medication and in an IV form, must be also given in the correct dosage.
Never administer IV medications into tubing that is infusing blood or blood products or TPN solutions.

15. Determining Venous Access Sites
Choose a vein by considering its size for the purpose, length of time the vein will be accessed, mobility requirements, and comfort for the client.
Peripheral veins may be partially collapsed in a dehydrated client.
A longer needle may be needed for an obese client.
Special techniques may be required for small children and infants because they have smaller veins.
Access may be difficult in older adults and clients who are very ill.

16. Administration via Piggy Back

17. IV Solutions The most commonly used IV solutions include:
Normal saline (0.9% NS or 0.9% NaCl)
5% Dextrose in normal saline (D5NS)
5% Dextrose in sterile water (D5W)
5% Dextrose in 0.45% normal saline
Signs of infiltration
Swelling or puffiness, coolness, pain at the insertion site (sometimes), feeling of hardness, possible leaking of fluid

18. *Signs of IV Infiltration
Swelling
Coolness
Leaking fluid
Pain

19. Volume-Controlled Infusion
The solution to be used to dilute the medication is supplied in a small bag that is hung on an IV pole and a volume-control device is hung below it.
After priming the tubing, the ordered amount of diluent is run into the volume-control chamber and then, the prescribed medication is injected into the intake port of the chamber.
This infusion is often given piggyback.
The rate of administration must be carefully controlled.

20. Pumps and Controllers Infusion pumps Electronic infusion controllers
Patient-controlled analgesia and portable pumps
Microdrip setup
Regulating the infusion rate
Calculating the rate of infusion
Correct programming of controllers and pumps is the “seventh right” in the guidelines for administration of medications

21. Long-Term Infusions, Central Lines, and Infusion Ports
Types of IVs
Central lines, central venous access devices (CVAD), or central venous catheters
The short central venous catheter
The PICC line
The midline catheter
Infusion ports

22. Total Parenteral Nutrition
Total parenteral nutrition (TPN), formerly known as hyperalimentation, is also called central parenteral nutrition (CPN).
Amino acids, dextrose (10% to 70%), and electrolytes
Lipids (fats), vitamins, and trace elements such as zinc, copper, manganese, or chromium
Infusion of TPN requires insertion of an IV line in a large blood vessel, the internal jugular vein in the neck (an IJ line), or the superior vena cava (SVC line).

23. FLUSH WITH 2-3 ML OF SALINE EVERY 8 HOURS
The Saline Lock
FLUSH WITH 2-3 ML OF SALINE EVERY 8 HOURS

24. Administration via Piggy Back

25. IV Bolus or Push
*Medications may be given by IV “push,” also called a bolus.
The push introduces a concentrated dose of medication directly into the circulatory system.
This injection is given in a short period of time and is not intermittent.
In some cases, a “smart pump” is used.

26. Venipuncture (Phlebotomy)
Definition
The process of puncturing a vein for the purpose of obtaining a blood specimen or establishing an IV access site
Equipment
Vacutainer system
Butterfly needle

27. NURSING PROCEDURES
INJECTIONS

28. Nasogastric Tubes Verify placement using 2 methods
Aspirate tube and instill ml of air into tube while auscultating
Instill each med separately and flush with 5 ml of water
Clamp tube for 30 min after medications

29. Types of CVAD’s Non-tunneled Catheters Central Lines: Single, Double
or Triple Lumen
Peripherally Inserted
Central Catheters
(PICC)-good for client receiving postop fluids
Tunneled Catheters
Broviac-smaller and used for IV infusions
Groshong
Implanted Venous
Access Devices
Non-tunnelled CVAD’s are inserted into the internal jugular, subclavian or femoral veins. These devices are normally used for five to 10 days. The purpose of these devices include the administration of multiple infusions, in the event of emergency access and administering anesthetic agents (Hamilton, 2006, p. 43). Central venous pressure (CVP) may also be measured using the triple lumen catheters (TLC’s)
Tunnelled CVAD’s are inserted into the subclavian or jugular vein, however, a femoral insertion may also be used. These devices provide long-term venous access use for chemotherapy, total parenteral nutrition (TPN), or antibiotic therapy (Hamilton, 2006, p. 43).
Implanted ports can be inserted into the subcutaneous tissues of the chest, abdomen, or arm. Implanted ports are designed for long-term use and patients who are active can continue to enjoy sports (Hamilton, 2006, p. 44).
Peripherally inserted central catheters (PICC’s) are inserted peripherally into the basilic, cephalic or median cubital vein with the catheter tip resting in the lower third part of the superior vena cava (Hamilton, 2006, p. 44). PICC’s may be inserted by a trained Registered Nurse (RN). The PICC’s were originally developed for neonatal use due to the flexibility and small diameter of these catheters (Phillips, 2005). PICC’s are also the choice of catheters for home care agencies due to long-term IV therapy in this setting. According to the Infusion Nurses Society, radiographic (X-ray) confirmation of the catheter tip should be done prior to initiating intravenous (IV) therapy (Gorski & Czaplewski, 2004).

30. Nursing Care of CVAD’s Pneumothorax (CDC, 2011) S/S Tachycardia
Complications
Hemothorax
Embolism-stop IV infusion if air in tubing!
Infection-primary complication
PICC’s seldom get infected
Staph skin infections
Tunneled catheters have decreased risk of infection
Cardiac tamponade
Hemorrhage
Pneumothorax
S/S
Tachycardia
Hypotension
Dyspnea
Agitation
Oxygen desaturation
Asymmetry of chest movement
Hemothorax occurs when blood enters the pleural cavity after trauma to the vein during catheter insertion. The signs and symptoms (s/s) include sudden chest pain, tachycardia and hypotension. Air embolism occurs when air enters the venous system during central line insertion caused by an open catheter or faulty device. The s/s of air embolism include dyspnea, hypotension and tachycardia. Cardiac tamponade occurs when the right atrium or ventricle is perforated by catheter tip erosion. Fluid accumulates between the heart and pericardium which increased pressure on the myocardium and prevents the heart from beating normally. Hemorrhage may occur during CVAD insertion related to prolonged clotting factors. The placement of CVAD into large vessels permits the possibility of excessive hemorrhage. Patients at risk for infections include those that are immunosuppresed, age, lack of adequate nutrition, break in skin integrity, antibiotic therapy and multiple invasive procedures (Hamilton, 2006).
A pneumothorax can occur when the pleural membrane is accidentally punctured during CVAD insertion. Pneumothorax is the most serious complication of CVAD insertion and is diagnosed by chest x-ray following insertion (Hamilton, 2006).
(CDC, 2011)

31. Nursing Education with CVAD’s
Monitoring CVP’s
**Blood draws-use a 10 ml syringe and place in a vacutainer
Heparin may be used after lab draw and NS flush to decrease the risk of blood clots
A fibrinolytic agent may be used to restore patency of a clotted catheter
Check medication compatibility
Flush before and after each medication to prevent precipitate formation

32. Total Parenteral Nutrition
Total parenteral nutrition (TPN), formerly known as hyperalimentation, is also called central parenteral nutrition (CPN).
Amino acids, dextrose (10%–70%), and electrolytes
Lipids (fats), vitamins, and trace elements such as zinc, copper, manganese, or chromium
Measure glood glucose
Monitor v/s q 4 hours**
Infusion of TPN requires insertion of an IV line in a large blood vessel, the internal jugular vein in the neck (an IJ line), or the superior vena cava (SVC line).
Performed under aseptic conditions!