Chapter 35 Administering Intradermal Subcutaneous and Intramuscular Injections

Lesson 35. 1 Injection Sites and Needle Selection Theory 1) Identify the principles for safe and effective administration of intradermal, subcutaneous, and intramuscular injections. 2) List the routes used for administering parenteral medications and the advantages and disadvantages of each route for pediatric, adult, and older adults. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 35. 1 Injection Sites and Needle Selection Clinical Practice 1) Using clinical judgment, choose the appropriate syringe and needle for the type of injection ordered. 2) Follow Standard Precautions when administering injections and disposing of used equipment. Copyright © 2018, 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 Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -1: Structure of the skin Copyright © 2018, 2014, 2009 by Saunders,

Principles of Parenteral Injections Use when: Patient is NPO Ø Digestive juices counteract oral drugs Ø Use to: Hasten the action of the drug Ø Ensure the delivered dose is accurate Ø Always: Select the correct site Ø Use sterile equipment Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Safe, Effective Administration of Parenteral Medications Know the medication you will administer and observe for side effects and therapeutic action. Check for drug allergies before administration of injection. Use only sterile needles and syringes. Select the appropriate length of needle to deposit the medication in the proper tissue layer. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Safe, Effective Administration of Parenteral Medications (cont’d) Label the syringe with the patient’s name, the name of the drug, and the dose. Obtain assistance as needed when the patient is a frightened child or an uncooperative adult. Rotate injection sites for patients receiving repeated injections by establishing a predetermined plan. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Safe, Effective Administration of Parenteral Medications (cont’d) Select an injection site that is relatively free of hair, lesions, inflammation, rashes, moles, and freckles. Select the injection site carefully to avoid major nerves, blood vessels, and underlying organs. Copyright © 2018, 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 Copyright © 2018, 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 m. L) 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 Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -17: Subcutaneous injection sites Copyright © 2018, 2014, 2009 by Saunders, an

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 19 -23 gauge, 1 -3 inches long Volume up to 3 m. L 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 Copyright © 2018, 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 Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -2: Injection routes Copyright © 2018, 2014, 2009 by Saunders, an imprint

Syringes Composed of barrel and plunger with a needle tip made of plastic (disposable) or glass Ø 3 -m. L syringe • Popular because large enough for subcutaneous and most IM injections Ø U-100 syringe • Used with U-100–strength insulin • Calibrated in units Ø Tuberculin syringes • 1 m. L in size • Calibrated to measure as small as 0. 01 -m. L drug doses Ø Unit-dose cartridge • Requires a special holder for the cartridge and needle Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -3: Parts of a syringe Copyright © 2018, 2014, 2009 by Saunders,

Figure 35 -7: Measurement scale on a 3 -m. L syringe Copyright © 2018,

Figure 35 -5: Insulin syringes Copyright © 2018, 2014, 2009 by Saunders, an imprint

Figure 35 -6: Tuberculin syringe Copyright © 2018, 2014, 2009 by Saunders, an imprint

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 Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -8: Needle sizes Copyright © 2018, 2014, 2009 by Saunders, an imprint

Preventing 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 Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Preparing the Syringe for 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 Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -9: Needle with protective sheath Copyright © 2018, 2014, 2009 by Saunders,

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 Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -10: Discarding used syringe into a sharps biohazard container Copyright © 2018,

Question 1 What size and gauge needle are used to give intramuscular injections? 1) 2) 3) 4) 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 Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 35. 2 Administering Parenteral Solutions Clinical Practice 3) Aseptically and accurately withdraw and measure the ordered dose of a medication from a vial or an ampule. 4) Demonstrate reconstitution of a drug from a powder. 5) Demonstrate the correct method for drawing up two types of medications, including insulin, in one syringe. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Parenteral Solutions May be available in: Ampules Ø Vials • Single dose and multidose Ø Mix-O-Vials • Medication in powder form and diluent present in two Ø halves of a vial separated by a rubber stopper Ø Unit-dose cartridges • Requires Carpuject or Tubex holders Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -11: Containers of parenteral medication Copyright © 2018, 2014, 2009 by Saunders,

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 Ø 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 Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -13: Moving fluid from the neck of the ampule Copyright © 2018,

Figure 35 -14: Withdrawing fluid from an ampule—ampule upright and stabilized Copyright © 2018,

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 m. L May be in powder form requiring reconstitution (label or package insert provides mixing instructions) Ø Before mixing two medications in a syringe, check for compatibility Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -15: Drawing medication from a vial Copyright © 2018, 2014, 2009 by

Reconstituting a 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 Copyright © 2018, 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 Ø Charts are often available that outline which drugs are compatible Ø Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -16 A, B: Mixing doses of insulin from multidose vials Copyright ©

Lesson 35. 3 Injections Theory 2) List the routes used for administering parenteral medications and the advantages and disadvantages of each route for pediatric, adult, and older patients. (Continued) 3) Summarize the signs and symptoms of anaphylactic shock. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 35. 3 Injections Clinical Practice 6) Use the Six Rights of medication administration, including checking for patient drug allergies. 7) Prepare and administer an intradermal injection, using the Six Rights and aseptic technique. 8) Correctly prepare and administer a subcutaneous injection with 100% accuracy. 9) Correctly prepare and administer an intramuscular injection with 100% accuracy. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 35. 3 Injections Clinical Practice 10) Locate the appropriate site on a patient to give an intradermal, subcutaneous, or intramuscular injection by identifying correct anatomic landmarks. 11) Evaluate your documentation of injections administered after administration. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Implementation Intradermal injections Ø Most frequently used for tuberculosis or allergy testing A small amount of solution is injected Ø Solutions are capable of producing severe reactions Ø Ø A tuberculin syringe and a short needle, ¼ to ½ inch in length, are used Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Implementation Subcutaneous injections Used for a variety of medications, including insulin, heparin, and some preoperative medications and narcotics to relieve pain Ø Preferred sites are the lateral surfaces of the upper arm or the anterior and lateral aspects of the thigh Ø Ø Encourage patients to be actively involved with medication administration Copyright © 2018, 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 Ø Improper site selection can result in damaged nerves, abscesses, necrosis, sloughing of skin, and pain Ø Injection sites Ø • 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 Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -18: Locating site for a middeltoid IM injection Copyright © 2018, 2014,

Figure 35 -21: Locating the rectus femoris IM injection site Copyright © 2018, 2014,

Implementation (cont’d) Intramuscular injections Ø Airlock technique • Used for IM injection to clear the needle of medication and to seal the track so the medication does not flow back Ø 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 Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -19: Locating site for a ventrogluteal IM injection Copyright © 2018, 2014,

Figure 35 -20: Locating the vastus lateralis IM injection site Copyright © 2018, 2014,

Implementation (cont’d) Intramuscular injections Ø 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 (Dex. Ferrum) and other irritating solutions are given Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 35 -22: Z-track technique Copyright © 2018, 2014, 2009 by Saunders, an imprint

Anaphylactic Shock Anaphylactic shock Circulatory failure from an allergic reaction Ø Symptoms • Urticaria, bronchiolar constriction, edema, and finally Ø circulatory collapse Watch for signs of anaphylactic shock and, if necessary, administer immediate, lifesaving treatment Ø Allergic reactions are more common the second or successive times the medication is received Ø Copyright © 2018, 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 Copyright © 2018, 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? 1) 2) 3) 4) Dorsogluteal Deltoid Vastus lateralis Dermal Copyright © 2018, 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? 1) 2) 3) 4) 90 degrees 45 degrees 15 degrees It depends on the size of the needle and size of the patient Copyright © 2018, 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? 1) 2) 3) 4) Deltoid Vastus lateralis Dorsogluteal Ventrogluteal Copyright © 2018, 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? 1) 2) 3) 4) 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. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.