1. Parenteral Medications Unit XIII Keith Rischer, RN, MA, CEN, CCRN

2. Definitions Parenteral Intradermal (ID) Subcutaneous Intramuscular (IM) Intravenous (IV)

3. If not done correctly… A drug response that is too rapid or too slow Nerve injury with associated pain Localized bleeding Tissue necrosis Sterile abscess Decreased therapeutic effect

4. Syringes Syringe Parts Tip Barrel Flange Plunger Safety Shield

5. Syringes Risks Syringe Sizes Hypodermic Insulin TB 3cc rige

6. Needles Parts of the Needle Hub Shaft Bevel Lumen Sheath

7. Length 1/2 to 1 1/2 Intradermal 25 to 27g Three eighths to five eighths of an inch Subcutaneous 25 to 27g Three eighths to five eighths of an inch Intramuscular 20 to 25g One half to 1 1/2 inches Needles

8. Safe Administration Handwashing Gloving Asepsis 6 Rights Allergies Sites Knowledge of Meds Check for Tissue Injury Recapping Needles Sharps Container Needle Sticks

9. Safety Shield

10. Selection of Injection Site Amount and character of medication What is the amount and condition of the muscle mass? What is the frequency of the injection?

11. Preparing an Injection Ampules Vials Multi dose vials Carpujects

12. Reconstituting Medications Make sure correct solution Roll gently If viscous use 18g needle

14. Site Preparation Hand hygiene Prevent contamination Syringe Needle Cleanse site Alcohol swab Chloroprep Apply gloves

15. Intradermal Injection Indications Needle Size Syringe Size Angle of insertion Amount Site Inner Forearm Upper Back

16. Subcutaneous Injection Advantage Disadvantage Needle Size Syringe Size Angle Amount

17. Sub-q Injection Sites Upper Arm Anterior Thigh Upper Back Lower Back Abdomen

18. Sub-q Heparin DO: Abd. only 3/8 25/26 g. 90 degree angle DO NOT: Inject into an area of ecchymosis Aspirate prior to injection Massage area following injection

19. Intra-Muscular Injection: IM Advantage Disadvantage Needle Size Syringe Size Angle Amount Z-Track

20. IM Sites: Ventrogluteal Site Location Risk Position Uses

21. IM Sites: Vastus Lateralis Site Location Risk Position Uses

22. IM Sites: Vastus Lateralis: Infant

23. Site Location Risk Position Uses IM Sites: Deltoid

24. Determining Site & Needle Size Amount & Characteristic of Medication Amount & Condition of Muscle Mass Frequency of Injection Type of Medication Age Recommended Route

25. Comfortable Injections Appropriate Needle Position of Client Relax muscle Proper Injection Site Rotate sites Insert Needle Quickly Hold syringe steady Diversion Z-Track

26. IM Injection: Z Track Pull skin laterally 1- 1.5 Hold taut w/nondominant hand Release skin after needle removed Less pain and more effective delivery

27. Complications of IM Injections Infection Lipodystrophy Nerve Damage Ecchymosis

28. Diabetes Mellitus: Patho Insulin is secreted by the Islets of Langerhans (Beta Cells) Insulin lowers blood glucose levels after meals Insulin moves glucose from the blood into the muscle, fat, liver, and cells Types I-IDDM II-NIDDM

29. Diabetes Mellitus Normal Blood Glucose 99 mg/dl – upper level of normal Hemoglobin A1c Type II Medications Stimulates the pancreas to release more insulin and to increase sensitivity of body cells to insulin Given twice daily, before meals Glyburide (Diabeta) Glucophage (Metformin) Rosiglitazone (Avandia)

30. Insulin: Subcutaneous (35-10, p.743 P&P) Rapid-acting (lispro, aspart- Novolog) Short-acting (Regular) (CLEAR) Intermediate-acting (NPH) (CLOUDY) Long-acting Glargine (Lantus)*

31. Insulin: Nursing Implications Monitor & assess for hypoglycemia Anxiety/restlessness Tremors Diaphoretic Cool/pale Altered LOC Confusion…lethargy…unconscious Glucagon 1mg dose-may repeat in 15 Give subq or IM if unresponsive

32. Insulin: Subcutaneous Given 1-4 times daily Room Temperature for 30 Minutes Gently roll, look for flocculation Must use syringe that matches the insulin (U- 100) Verify dosages with another Nurse If mixing do not keep in syringe longer than 15 minutes

33. Drawing Up 2 Insulins

34. Blood Glucose Monitoring Done 2-4 times per day if on subq insulin Done 3-4 times per week if on oral hypoglycemic (Oral Diabetic) therapy Sliding Scale

35. Heparin Mechanism of action Low dose Prevents conversion of prothrombin to thrombin High dose Prevents conversion of fibrinogen to fibrin

36. Table Scenarios: 1. Heparin 5000 units subcut. For 65 yr old male who weighs 220 lbs 2. Morphine 4 mg IM for 88 yr female who weighs 92 lbs 3. Regular Insulin 10 units for 45 yr male who weighs 160 lbs 4. Ketorolac (Toradol) 60 mg IM for 60 yr male who weighs 310 lbs 5. Mantoux 0.1cc ID for 25 yr female nurse as part of yearly screening 6. Heparin 20,000 units/ml 12,000 units bid…amount? 7. Dilaudid 10 mg/ml 4 mg IM now…amount? 8.Ondansetron 4 mg/ml 6 mg IM now 9. Glucose 354 NPH 20 units with low dose scale… 10. Glucose 266 NPH 15 units with high dose