Injections: Technique, Documentation and Safety Issues

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Injections Technique, Documentation and Safety
Issues

• Anne Thomas, PhD, APRN-BC, ANP
• Asst. Professor/Coordinator
• Adult Nurse Practitioner Program
• University of Michigan
• annethom_at_umich.edu
• October 22, 2004

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Objectives

• Review current techniques on subcutaneous,
  intradermal and intramuscular injections.
• Discuss current guidelines on patient teaching,
  documentation and consent issues when
  administering vaccines.
• Identify health care professional resources
  available to the provider and client.
• Discuss current regulatory standards for sharps
  disposal.

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Parenteral Drug Administration

• Administering a drug by any nonoral route
• Commonly referred to as an injection to bypass
  the protective effects of the skin and mucous
  membranes
• Intravenous, intramuscular and subcutaneous are
  most common routes

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Advantages of Parenteral Routes

• Drugs can be administered to unconscious,
  uncooperative or nauseous patients.
• Drugs that are normally ineffective, poorly
  absorbed or inactive when taken orally can be
  effectively administered.
• Can be used to slow onset or delay onset of
  action.
• Patient nonadherence can be avoided.

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Disadvantages of Parenteral Administration

• Strict adherence to aseptic technique is
  required.
• Some degree of pain is inevitable.
• Drug effects are often difficult to reverse.
• Inconvenient method if frequent dosing is
  required.

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Selection and Assessment of Injection Site

• Select site (SQ, IM or intradermal) of healthy
  tissue avoid areas with inhibited lymph
  drainage.
• Consider patient age, weight and previous
  injections.
• Consider type of medication being administered.
• Assess pain associated with injection EMLA
  cream, lidocaine mixtures.
• Avoid areas of tissue or muscle atrophy.

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Intramuscular Injections

• Administered deep into skeletal muscles away from
  major nerves and blood vessels
• Produce a longer onset of action than IV infusion
  but faster than subcutaneous injection
• Can inject more volume than subcutaneous or
  intradermal injection

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Intramuscular Injection Administration Clinical
Pointers

• 1. Select appropriate gauge needle prepackaged
  gauges and lengths not always appropriate.
• 2. If medication is irritating, use a new needle
  for injection.

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Intramuscular Injection Administration Clinical
Pointers (cntd)

• 3. Ventrogluteal site is safer and preferred
  over dorsogluteal.
• 4. Do NOT add air to the syringe.
• 5. Dart quickly but inject medication slowly.

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Dorsogluteal Injection Site
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Ventrogluteal Injection Site
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Vastus Lateralis Injection Site
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Deltoid Injection Site
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Z-track Injection Initial
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Z-track Injection Result
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SQ Injections Clinical Tips

• Smaller volumes of aqueous solution or suspension
  is used. Isotonic solutions prevent tissue
  irritation.
• Do NOT massage insulin or heparin injection sites
  because this hastens absorption and promotes
  tissue irritation.
• Injection Map for SQ injections that need to be
  given at regular frequency.
• Inject heparin slowly and without aspirating
  first.

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SQ Injection Angles
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SQ Injection Map
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Administering Intradermal Injections

• Small volumes (lt0.1 ml) injected into the
  vascular dermal layer.
• Do not aspirate or massage after medication
  given.
• Needle point should be visible under skin.
• Mark area on skin as appropriate.

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Intradermal Injection Angle
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Intradermal Wheal
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Needlestick Injury(ANA Fact Sheet on Needlestick
Injuries 2004)

• Health care workers suffer between 600,000 and
  one million conventional needles and sharp
  injuries annually.
• Less than 15 of U.S. Hospitals use safer needle
  device systems.
• FDA issued an alert (not recommendation) in 1992
  to utilize needleless IV systems whenever
  possible in all health care facilities.
• Over 80 of needlestick injuries could be
  prevented with use of safer needle devices.

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Cost and Health Savings from Needlestick
Prevention(ANA Fact Sheet on Needlestick Injury
2004)

• Over 20 infections can be transmitted through
  needlesticks malaria, herpes, HIV, hepatitis,
  tuberculosis, syphilis, etc.
• According to the American Hospital Association, 1
  serious infection from a bloodborne pathogen can
  add up to one million dollars.
• 3000 is spent on every needlestick even if no
  infection occurs.
• Safe needle devices cost only 28 cents more than
  standard devices.

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Websites for Needlestick Safety Measures and
Training

• Centers for Disease Control
• http//www.cdc.gov
• http//cdc.gov/sharpssafety
• http//www.cdc.gov/niosh/topics/bbp/safer/
• American Nurses Association
• http//needlestick.org/
• GAO Report on Costs of Safer Needle Devices
• http//www.gao.gov/new.items/d0160r.pdf

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Vaccine Information Statements (VIS) What You
Need to Know

• Produced by the Centers for Disease Control.
• Available at http//www.cdc.gov
• (select link to vaccines and immunizations).
• Informs the patient or parent about the risks and
  benefits of the vaccine.
• Federal law requires the VISs be given out
  whenever certain vaccines are administered.

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Basic Info About VISs

• All providers, both public and private, must
  distribute prior to each administration of the
  vaccine.
• Requirement of the 1986 National Childhood
  Vaccine Injury Act.

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Vaccine Injury Compensation Program

• As of July 2004, a VIS MUST be given for
• DTaP
• Td
• MMR
• Polio
• Hepatitis B
• Hib
• Varicella
• Pneumococcal Conjugate

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Other VISs Available

• Influenza
• Hepatitis A
• Pneumococcal polysaccharide
• Meningococcal
• Rabies
• Yellow Fever
• Typhoid
• Anthrax
• Smallpox
• These are available and recommended by not
  required unless vaccines are purchased through
  CDC.

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Documentation

• Record in the Patients Permanent Record
• Which VIS was given
• Date of publication
• Date the VIS was given
• Name, address and title of person administering
  the vaccine
• Date of administration
• Vaccine manufacturer
• Vaccine lot number

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VIS Alterations????

• Law requires only those VIS developed by the CDC
  may be used.
• The practices name, address or phone number can
  be added to existing VIS.
• No Federal requirement for written informed
  consent for vaccinations, but state regulations
  will vary.

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How To Get VIS Literature

• The National Immunization Program (NIP)
• http//www.cdc.gov/nip
• State Health Department
• National Immunization Hotline
• 1-800-232-2522 (English)
• 1-800-232-0233 (Spanish)