ADMINISTRATION OF INJECTIONS

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ADMINISTRATION OF INJECTIONS

• MR.RAMAKANT D. GAIKWAD
• M.Sc.(N), MA (SOCIO)

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Aims of this session

• To understand the reasoning behind the process of
  
• collecting the correct equipment
• administering the correct drug in the correct
  form
• at the correct time
• to the correct person
• in the correct manner

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Objectives of this session

• The safe administration of drugs via
  intramuscular injection - in a safe and
  controlled manner - having assessed risks- and
  - causing minimal physical and psychological
  harm, but, maximum benefit to the patient

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What is an injection?

• Injections are sterile solutions, emulsions or
  suspensions.
• They are prepared by dissolving, emulsifying or
  suspending an active ingredient and any other
  substances in water for injection.
• Injecting is the act of giving medication by use
  of syringe and needle to obtain the desired
  therapeutic effect taking into account the
  patients safety and comfort

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How are drugs for injections presented?

• Single dose preparations
  a pre - prepared volume of
  measured drug, in a syringe for single dose use
  
  i.e. Flu vaccines, Pneumovax and
  B12.
• Multidose preparations
  multi-dose
  preparations contain a antimicrobiacteral
  preservative, are used on more than the one
  occasion and great care is required for its
  administration but especially its storage
  between successive withdrawals
  i.e Insulin

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Where are injectable drugs kept

• The label on the packet should in most cases give
  guidance about storage conditions for individual
  preparations
• Drugs should be stored away from light
• The Cold Chain involves preparations being stored
  between 2 and 8 degrees and has a traceable
  record
• Best Practice ensures all medication is stored in
  a locked cupboard or fridge
• If you are in any doubt about the storage
  requirements for any preparation you should check
  with the lead nurse, Dr or pharmacist

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Why give drugs in injection form

• Injections usually allow rapid absorption
• Can produce blood levels comparable to those of
  intravenous bolus injections
• Injections can be given from 1ml and up to 2mils
  in the Deltoid and up to 5mls in the gluteal
  muscle in adults
• Drugs that are altered or not absorbed by other
  methods of administration

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Needle length and size

• For intramuscular injections e.g flu, pneumonia
  and B12, the needle should be long enough to
  penetrate the muscle and still allow a quarter of
  the needle to remain external to the skin
  (Workman 1999)
• When choosing the needle it is important to
  assess the amount of muscle, subcutaneous fat and
  weight of the patient - which in the majority of
  cases will be a blue needle

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Which is which needle?

• The correct needle is the key to delivering the
  drug to the correct area for the maximum effect
  with the least amount of discomfort
• The colour at the top of the needle reflects its
  size
• the higher the number the smaller the lumen
  (bore)
• Orange needles 25 guage 10mm long (3/8 inch)
  or 16mm long(5/8
  inch) or 25mm long (1 inch)
• Blue needles 23 guage 25mm long 9 (1 inch)
• Green needles 21 guage 38mm long (1.5 inches)

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How do assess the depth of muscle and
subcutaneous fat

• The deltoid and vastus lateralis muscles should
  be grasped between the thumb and forefinger to
  determine the depth of muscle and/or the amount
  of subcutaneous fat at the injection site

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Intramuscular Injections and Pain

• Factors that can cause pain are
• The needle
• The technique
• The speed of the injection
• The solution and composition of the drug
• The volume of the drug
• The approach and attitude of person administering
  the injection
  
  
  
  
  
  (Workman 1999 and
  Torrence (1989)

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Asepsis and reducing the risk of infection

• Good hand washing
• Good hand drying
• Aseptic technique
• Good observation and questioning of the client
• Skin preparation if required

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preparation for the administration of injections

• Protocols/procedure/standards information is
  available
• Hand basin for washing hands and/or alcohol hand
  rub.
• Area for the client to lie down if unwell
• Panic button/phone to call for assistance
• sharps container
• Gloves
• Resuscitation /anaphylaxis equipment/drugs
• Oxygen and appropriate mask if available
• adequate time for procedure

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Equipment for the administration of injections

• Clean tray or receiver in which to place drug and
  equipment
• 21g needle to ease reconstitution and drawing up
  (23g if from a glass ampoule
• Syringe of appropriate size
• Swabs saturated with isopropyl alcohol 70
• Sterile topical swab if drug is presented in
  ampoule form
• Drug to be administered
• Patients prescription to check dose, route and
  timing
• Notes available to record administration in
  accordance with law
• Gloves, Apron

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Procedure for preparation of injections in adults

• Action
• Collect and check all equipment
• Check the the packaging of all equipment is
  intact and drug information leaflet is available
• Wash hands with soap and water or bactericidal
  hand rub
• Prepare the needle, syringe etc on a tray or
  receiver
• Inspect all equipment

• Rationale
• To prevent delays and enable full concentration
  on procedure
• To ensure sterility. If seal or packaging is
  damaged discard information leaflet for guidance
  and prescriptive information
• To prevent contamination of medication and
  equipment
• To check that none is damaged, if so discard

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Preparation cont

• Action
• Consult the patients prescription and ascertain
  the following
• Drug
• Dose is appropriate for the pts age
• date and time (if applicable) of administration
• Route and method of administration
• Diluent as appropriate (if necessary)
• validity of prescription
• Signature of doctor

• Rationale
• To ensure that the patient is given the correct
  drug in the prescribed dose using the appropriate
  diluent (if required) and by the correct route

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Preparation cont

• Action
• check all details with nurse mentor - select the
  drug in the appropriate volume dilution or dosage
  and check expiry date
• Proceed with the preparation of the drug using
  protective clothing if necessary
• Evaluate the patients knowledge of the medication
  being offered. If this knowledge appears to be
  faulty or incorrect refer to nurse mentor
• offer explanation of the use, action, dose and
  potential side effects of the drug involved

• Rationale
• To minimise any risk of error - to reduce wastage
  and expiry date ensures drug is safe to give and
  is still pharmacologically effective
• The patient has a right to information about
  treatment

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Prefilled Syringes

• Action
• Check storage conditions
• check name and expiry date or signs of damage to
  the packaging
• on removing from packaging check name expiry date
  and syringe for any damage
• check vaccine is free from particles and colour
  is correct
• If you feel that the fixed needle length is not
  appropriate discuss with lead nurse, do not
  transfer drug into another syringe
• expell air from syringe
• place in receiver until ready to administer

• Rationale
• To ensure the drug is kept in the appropriate
  manner
• to ensure sterility
• to ensure client/patient does not receive
  unstable or contaminated medication
• vaccine not given into the muscle can be painful
  and have a reduced effect
• to ensure the correct amount of drug is in the
  syringe
• to ensure sterility is maintained help reduce
  risk of needlestick

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Single Dose Ampoules of Solution

• Action
• Inspect solution for particles and colour if
  either or both present discuss appropriate
  methods for discarding with nurse mentor
• Tap the neck of the ampoule gently
• Cover the neck of the ampoule with a sterile
  topical swab and snap top off. If difficult use a
  file
• Check solution for glass fragments discard if
  present

• Rationale
• Ensure the patient does not receive contaminated
  or unstable drugs
• To ensure the solution is at the bottom of the
  ampoule
• To aid asepsis. To prevent aerosol formation or
  contact which may lead to sensitivity/reaction,
  prevent injury to the nurse
• To ensure risk of injecting foreign material into
  the patient

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Ampoules continued

• Action
• Withdraw the solution, the ampoule can be tilted
  if required with a needle with a gauge no larger
  than 21G
• Re sheath needle, tap syringe to dislodge any
  air bubbles. Expel air
• place in receiver until ready to use
• Note replacing sheath on needle should NOT be
  confused with resheathing needles AFTER use

• Rationale
• To avoid drawing up air and any glass particles
• prevent aerosol formation and ensure correct
  amount of drug is in the syringe
• maintains sterility and prevents dropping the
  syringe and reduces potential risk of needle
  stick injury

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Anxious Patients and Fainters

• Adopt a calm and sympathetic approach
• Prepare the vaccine if possible out of the sight
  of the patient
• where possible keep the conversation going to
  distract the patient
• If possible ask nervous friends to leave,
  discourage large groups of supporters
• explanation that an injection is not the same as
  having a blood sample taken
• The bigger they are the harder they fall
• Fainting more common in those who have not eaten
• If in doubt lay them down

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Skin Preparation

• Should the skin appear dirty it should be cleaned
  with soap and water.
• Should the client/patient have reduced immunity
  the skin can be cleaned with an alcohol
  preparation prior to the injection - but - the
  alcohol must be allowed to evaporate as it can
  affect the preparation and/or sting on
  administration of the preparation

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Just before you give the injection

• Action
• fully expose the limb fully
• Encourage the patient to relax the muscle, by
  hanging the arm by their side or on their lap
• Patients should sit or lay down for their
  injection
• Quickly review the pre injection

• Rationale
• The injection may be given to low and end up as
  subcut. A tight sleeve can have the same effect
  as a tourniquet and encourage bleeding at the
  injection site
• To reduce discomfort and promote distribution of
  the drug
• Reduce risk of injury to the patient and the
  HCA/nurse from falls and needle stick injury
• To reduce the risk of error and promote patient
  safety

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When not to give an injection

• The client/patient is unable to confirm their
  identity using a variety of methods
• The client is unsure and records cannot confirm
  if the client has received the vaccine previously
  
• The Client withdraws or refuses to consent
• Incorrect storage of vaccine, past expiry date
• There is no prescription for the patient
• The prescription does not state the clients name,
  drug, time, dose or route of administration or
  the writing is illegible
• If patients have a temperature
• Pregnancy
• If clients report a severe local reaction or
  systemic reaction to the preceding dose refer to
  nurse mentor

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Technique for Intramuscular (IM) Injection

• Action
• Hold the skin firmly (not bunched) with the free
  hand
• Introduce the needle at a 90 degree angle leaving
  a third of the shaft exposed
• Aspirate (draw back) the plunger to ensure a
  blood vessel has not been penetrated. If blood is
  aspirated remove the needle, change it and start
  again

• Rationale
• To allow easy entry of the needle through the
  skin and displace the subcutaneous fat
• To ensure the needle penetrates the muscle and
  facilitate removal of the needle should it break
• To ensure the needle is in the right place.

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IM injection contd.

• ACTION
• Inject the drug slowly
• Withdrawn the needle quickly and evenly and apply
  pressure to any bleeding point
• Record the administration of the drug according
  to policy and procedure
• Dispose of needle and syringe according to policy
  and procedure
• Ensure patient is feeling well prior to discharge

• RATIONAL
• To prevent pain. To ensure even distribution of
  the drug
• To prevent Haematoma formation (bruising)
• To maintain records, comply with law, prevent
  duplication, promote continuity of care
• To ensure safe disposal and reduce risk of injury
  to self and others
• To reduce risk of injury

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Site on the Deltoid for Intramuscular Injections
(IM)
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An Intramuscular Injection
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When It Goes Wrong

• You give the wrong drug
• You give the right drug to the wrong person
• The client/patient faints
• The client remembers a previous bad reaction to a
  previous injection
• The client/patient complains
• The client/patient tells you post injection that
  they may be pregnant/on steroids/having
  chemotherapy or radiation

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• Thank you