Injections

• Subcutaneous (SC) injections


  • Administered into the adipose tissue layer just below the epidermis and dermis
  • Tissue has few blood vessels, so drugs administered by this route have a slow, sustained rate of absorption
  • Sites for SC injections include the outer aspect of the upper arm, the abdomen, anterior aspects of the thighs, upper back, and upper ventral gluteal area
• Administering an SC injection


  1. Use a 25 to 30 gauge, 3/8 in. to 5/8 in. needle

  2. Inject at a 45- to 90-degree angle based on the amount of subcutaneous tissue present

  3. Usually, no more than 1 ml of medication is given subcutaneously
• Pinching the skin during administration


  • Advised for thinner patients to lift the adipose tissue up and away from the underlying muscle and tissue
  • Elevating or pinching the skin has been found to increase the risk of injury, as the needle may pierce the opposite side of the skin fold and enter the skin of the health care worker
• Abdomen


  • Best location for an SC injection if a patient has little peripheral SC tissue
  • If patient is obese, use a needle that is long enough to insert through the tissue at the base of the skin fold

  
• Medication administration steps


  1. Check accuracy and completeness of each medication administration record (MAR) with prescriber's medication order

  2. Review pertinent information related to medication: action, purpose, normal dose, route, side effects, adverse reactions, time of onset, peak of action and nursing implications

  3. Assess patient's medical and medication history and history of allergies

  4. Check date of expiration for medication

  5. Assess patient symptoms or condition for which medication has been prescribed

  6. Prepare the materials needed

  7. Obtain the appropriate medication. Read the MAR and prepare medications for one client at a time. Select the proper medication from the unit stock/ patient's medication drawer

  8. Compare the label of the medication against the order on the patient's MAR/ CMAR. Check the expiration date and perform calculations. Return expired medications to the pharmacy

  9. Bring medications to patient's bedside and keep in sight at all times

  10. Wash hands

  11. Identify the patient using two identifiers (1.e name and birth date or name and account number.) Compare identifiers with information on the patient's medical record

  12. Explain the procedure and purpose to the patient and family

  13. Provide privacy

  14. Re-check again the medication against the MAR at the patient's bedside

  15. Select the injection site

  16. Help patient to comfortable position

  17. Cleanse the skin using a firm circular motion starting at the center and widening the circle outward. Allow the area to dry thoroughly

  18. Hold cotton between third and fourth fingers of non-dominant hand

  19. Uncap the needle with by pulling it straight off

  20. Grasp and bunch the area surrounding the injection site

  21. Hold the syringe as dart, palm down between thumb and forefinger of dominant hand

  22. Insert the needle quickly at 45 to 90 degree angle while firmly grasping the site

  23. After the needle is inserted, release the tissue. Immediately move your non dominant hand to steady the lower end of the syringe. Slide your dominant hand to the end of the plunger. Avoid moving the syringe

  24. Inject medication slowly and steady

  25. Withdraw the needle quickly. Using the dry cotton, apply gentle pressure to the site after the needle is withdrawn. Do not massage

  26. Assist patient to comfortable position

  27. Discard uncapped needle or needle enclosed in safety shield and attached syringe into puncture-proof and leak-proof receptacle

  28. Remove gloves and perform hand hygiene. Care for equipment

  29. Document the administration of medication. (medication, time injected, route, site and nursing assessments)

  30. Return to room and ask if patient feels any acute pain, burning, numbness, or tingling at injection site

  31. Conduct appropriate follow up such as desired effect (e.g., relief of pain, sedation, lowered blood sugar, a prothrombin time within pre-established limits), any adverse effects (e.g., nausea, vomiting, skin rash) and clinical signs of side effects

  32. Observe patient's response to medication at times that correlate with onset, peak, and duration of medication

  33. Ask patient to explain purpose and effects of medication to evaluate patient's understanding of information given
• Intradermal injections (ID)


  Injections administered into the dermis, just below the epidermis
• Intradermal injections


  • Have the longest absorption time of all parenteral routes
  • Used for sensitivity tests, such as TB, allergy, and local anesthesia tests
  • Used for administering insulin or heparin drugs
• Advantage of ID tests

  Body reaction is easy to visualize, and the degree of reaction can be assessed
• Common sites for ID injections


  • Inner surface of the forearm
  • Upper back, under the scapula
• Choose an injection site that is free from lesions, rashes, moles, or scars, which may alter the visual inspection of the test results
• Equipment for ID injections


  • Tuberculin syringe calibrated in tenths and hundredths of a millilitre
  • 1/4 to 1/2 in., 26 or 27 gauge needle

  
• Dosage of an ID injection

  Usually under 0.5 ml
• Angle of administration for an ID injection

  5 to 15 degrees
• Once the ID injection is completed, a bleb (small blister) should appear under the skin

  
• Steps to administer an intradermal injection

  1. Check accuracy and completeness of each medication administration record (MAR) with prescriber's medication order

  2. Review pertinent information related to medication: action, purpose, normal dose, route, side effects, adverse reactions, time of onset, peak of action and nursing implications

  3. Assess patient's medical and medication history and history of allergies. Know his or her normal response to an allergy

  4. Check date of expiration for medication

  5. Assess patient symptoms or condition for which medication has been prescribed
• Steps to administer an intradermal injection (continued)

  1. Prepare the materials needed

  2. Obtain the appropriate medication. Read the MAR and prepare medications for one client at a time. Select the proper medication from the unit stock/ patient's medication drawer

  3. Compare the label of the medication against the order on the patient's MAR/ CMAR. Check the expiration date and perform calculations. Return expired medications to the pharmacy

  4. Bring medications to patient's bedside and keep in sight at all times
• Steps to administer an intradermal injection (continued)

  1. Wash hands

  2. Identify the patient using two identifiers (1.e name and birth date or name and account number.) Compare identifiers with information on the patient's medical record

  3. Explain the procedure and purpose to the patient and family

  4. Provide privacy

  5. Re-check again the medication against the MAR at the patient's bedside
• Steps to administer an intradermal injection (continued)


  1. Explain to the client that the medication will produce a small wheal/ bleb. The client will feel a slight sting as the medicine enters dermis

  2. Select the injection site: forearm about a hand's width above the wrist and three or four finger widths below the antecubital space. Refrain from using sites that are hairy, tender, inflamed or swollen and with lesions

  3. Assist patient to appropriate position. Have the patient extend elbow and support it with forearm on flat surface

  
• Steps to administer an intradermal injection (continued)

  1. Cleanse the skin using a firm circular motion starting at the center and widening the circle outward. Allow the area to dry thoroughly

  2. Uncap the needle with non-dominant hand by pulling it straight off

  3. Using non-dominant hand, spread the skin and taut over the injection site

  
• Steps to administer an intradermal injection (continued)


  1. Using the dominant hand, hold the syringe between thumb and forefinger with bevel up

  2. Insert needle with bevel up at 5- 15 degree angle. Place the needle flat almost against patient's skin. Advance needle through epidermis to approximately 3 mm (1/8 inch) below skin surface. Once needle is in place steady the lower end of the syringe and slide hand to plunger. Stabilize the hub of needle with thumb of non-dominant hand

  
• Steps to administer an intradermal injection (continued)

  1. Inject medication slowly. Normally you feel resistance. If there is no resistance, this indicates that needle is too deep; remove and begin again

  2. While injecting medication, notice that small bleb approximately 6 mm (1/4 inch) in diameter (resembling mosquito bite) appears on surface of skin. Instruct patient that this is a normal finding

  3. Withdraw needle quickly at the same angle that it was inserted. Do not recap and engage safety shield

  
• Steps to administer an intradermal injection (continued)

  1. Blot the site with dry gauze if necessary. Do not massage site. Remind patient not to rub or scratch the site

  2. Assist patient to comfortable position

  3. Discard uncapped needle or needle enclosed in safety shield and attached syringe into puncture-proof and leak-proof receptacle

  4. Draw a perimeter circle around the wheal/ bleb using black ink pen carefully

  5. Remove gloves and perform hand hygiene. Care for equipment

  
• Steps to administer an intradermal injection (continued)


  1. Document the administration of medication. (medication, time injected, route, site and nursing assessments)

  2. Evaluate the patient's response to the medication/ testing substance within an appropriate time frame

  3. Evaluate the condition of the site depending on the test done. Measure the area of redness and induration in millimeters at the largest diameter and document findings

  4. Read site within appropriate amount of time, designated by type of medication or skin test administered together with physician
• Parenteral


  Refers to the path by which medication comes in contact with the body
• Parenteral medications


  • Enter the body by injection through the tissue and circulatory system
  • Are absorbed more quickly
  • Are used with patients who are nauseated, vomiting, restricted from taking oral fluids, or unable to swallow
• Parenteral medications


  • Can be effective and safe when prepared and administered correctly
  • Have numerous risks associated with administering them as they are invasive and absorbed readily and quickly into the body
• Routes for parenteral medications

  • Subcutaneous (SC)
  • Intradermal (ID)
  • Intramuscular (IM)
  • Intravenous (IV)
• Subcutaneous (SC) injection


  • Places medication/solution the loose connective tissue just under the dermis

  
• Intradermal (ID) injection


  • Places the medication into the dermis just under the epidermis
• Intramuscular (IM) injection


  • Places the medication into the body of a muscle
• Intravenous (IV) injection


  • Places the medication/solution into a vein through an existing IV line or a short venous access device (saline lock)
  • Medications can be given as an IV bolus, as an intermittent (piggyback) medication, or in a large volume continuous infusion
• To administer parenteral medications safely, it is imperative to understand how to prevent an infection, prevent medication errors, prevent a needle-stick injury, and prevent discomfort to the patient
• Unsafe injection practices have resulted in patient exposure to infections leading to outbreaks of infectious diseases due to deficient health care practices
• Injectable medications must be given in a safe manner to maintain sterility of equipment and prevent the transmission of infectious diseases between patients and health care workers
• The research and development of intramuscular drug delivery has gained significant momentum in pharmaceutical industry during past several decades
• Intramuscular (IM) drug delivery

  • Is associated with high safety and efficacy profiles
  • Is well-suited for extended-release drugs, especially those that require large injection volumes
• Intramuscular (IM) injections


  • Deposit medications into the muscle fascia, which has a rich blood supply, allowing medications to be absorbed faster through muscle fibres than they are through the subcutaneous route
• Intramuscular (IM) injection site


  • Is used for medications that require a quick absorption rate but also a reasonably prolonged action
  • Can absorb larger volumes of solution, which means a range of medications, such as sedatives, anti-emetics, hormonal therapies, analgesics, and immunizations, can be administered intramuscularly in the community and acute care setting
• Intramuscular (IM) injections


  • Muscle tissue is less sensitive than subcutaneous tissue to irritating solutions and concentrated and viscous medications
• Technique of IM injections

  1. An IM site is chosen based on the age and condition of the patient and the volume and type of medication injected

  2. Needle size is chosen based on the weight of the patient, age, amount of adipose tissue, medication viscosity, and injection site