21506VIC MEDICATION ADMINISTRATION

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21506VICMEDICATION ADMINISTRATION

• INJECTIONS

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Intramuscular injection

• Skeletal muscle highly vascular and its
  capillaries contain small pores that enables
  substances of small molecular weight to pass
  through into the bloodstream

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Intramuscular injection

• Several muscles of the body have considerable
  mass and are able to be injected with quantities
  of up to several millilitres of fluid, generally
  without undue discomfort

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Intramuscular injection

• The gluteus medius of the buttocks is the best
  muscle to use in this respect
• The deltoid muscle has a richer blood supply so
  good for rapid absorption, but size limit should
  be no more than 1-2 ml

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Intramuscular injection

• Intramuscular injections are not always given for
  quick action
• If the drug is mixed with an oil absorption is
  slower. This type of injection is known as depot

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Intramuscular injection

• Exercise causes an increase in skeletal muscle
  blood flow improves absorption of a drug
• Main danger from im injection is damage to
  nerves, especially in gluteal injections
• Pain and sterile abscess can occur with im

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INJECTIONS

• Parenteral administration of medications
• Administered by injection
• An invasive procedure
• Performed using aseptic techniques
• Requires certain skills
• Has a rapid effect

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Preventing infection during injection

• Prevent skin contamination
• Wash skin with soap water when soiled with
• Dirt
• Blood
• Faeces
• Drainage
• Swab with an alcohol swab using a circular motion
  starting at the centre and moving out in a 5 cm
  radius

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Preventing infection during injection

• Prevent needle contamination
• Avoid letting needle touch contaminated surface (
  edge of ampoule, hand , needle cap counter or
  table top, patients hand)
• Swab tops of vials with an alcohol swab
• If needle is contaminated change needle
• If you touch your hand on the needle change
  needle

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Preventing infection during injection

• Prevent syringe contamination
• Avoid touching
• length of plunger
• Inner part of barrel
• Tip or nozzle of barrel

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TYPES OF SYRINGES

• Tuberculin
• Marked in 0.01 (hundreds)
• Good for preparing small amounts of solution, or
  small precise dosages
• Insulin
• Marked in units
• Made in
• 30 units
• 50 units
• 100 units

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EQUIPMENT

• Appropriate syringe
• Luer
• Marked in 0.1 (tenths)
• Luer-lok
• Marked in 0.1 (tenths)

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Comparison of angles of insertion for
intramuscular (90degrees),subcutaneous
(45degrees) and intradermal (15degrees)
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HYPODERMIS OR SUBCUTANEOUS LAYER

• Functions
• Stores lipids
• Insulation
• Cushioning of the body
• Temperature regulation
• (Van De Graff Fox, 1986)

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SUBCUTANEOUS INJECTIONS

• Medication injected beneath the skin into
  connective tissue or fat under dermal layer
• Medication should not be irritating to the tissue
  can cause
• Severe pain
• Tissue necrosis
• Tissue sloughing
• Slow absorption and can provide sustained effect
• Unusual to use syringe greater than 5ml for a sc
  or im
• Larger volumes create discomfort

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HYPODERMIS OR SUBCUTANEOUS LAYER

• This is the deepest skin layer. Connects or binds
  the dermis above it to the underlying organs
• Mainly composed of loose fibrous connective
  tissue and fat (adipose) cells
• Interlaced with blood vessels
• Hypodermis in females usually 8 thicker than in
  males
• Absorption is slower as subcutaneous tissue is
  not richly supplied with blood

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Subcutaneous (SubQ) Tissue
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SUBCUTANEOUS INJECTION SITES

• Deltoid
• Abdomen
• Thighs

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Subcutaneous injections

• Inspect skin for masses or tenderness
• Site should be free from infection scars and bony
  prominences
• Long term therapy rotate injection site
• Only small doses of water soluble medications
  should be given

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Subcutaneous Sites
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Sites recommended for Subcutaneous Injections
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Subcutaneous injections

• Best sc injections site are the outer posterior
  aspect of the upper arms, the abdomen from below
  the costal margins to the iliac crests and the
  anterior aspects of the thigh
• Site most recommended for heparin is the abdomen

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Subcutaneous injections

• The injection site should be free from lesions
• Bony prominences
• Large underlying muscles
• Nerves
• Should be given at least 2.5cm away from last
  injection

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Subcutaneous injections

• Thin patients may have insufficient tissue
• Upper abdomen is the best site with this type of
  patient
• If 5cm of tissue can be grasped needle should be
  inserted at 90 degrees
• If 2.5cm of tissue can be grasped the needle
  should be inserted at 45 degrees

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• Pucker or slightly stretch skin
• Swab ( not necessary for insulin as it may assist
  with the formation of necrotic tissue)
• Insert needle with a firm quick approach
• Remove needle quickly
• Re-swab site Do not rub particularly after
  insulin administration
• Check patient

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Giving Subcutaneous injections in the abdomen
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Subcutaneous Needle

• Gauge 25
• Length 5/8 inch

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• Prepare equipment
• Check medication (follow principles )
• Draw up medication
• Prepare site
• Inject needle
• 45º angle for most SC injections
• 90º (straight in ) for insulin

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Infection Control

• Hand hygiene
• recommended between patients
• alcohol-based waterless antiseptic can be used
• Gloves
• not mandatory unless
• potential for exposure to blood or body fluids,
• open lesions on the hands, or
• agency policy

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Infection Control

• Equipment disposal
• never detach, recap or cut a used needle
• place in puncture-proof container
• dispose as infectious medical waste
• use safety needles or needle-free devices
  whenever available to reduce risk of injury

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Intramuscular (IM) Tissue
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Intramuscular Sites
Deltoid
Injection Site
Vastus Lateralis
Injection Site
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Characteristics of Intramuscular sites

• Vastus lateralis
• Lacks major nerves and blood vessels
• Rapid drug absorption
• Used for volumes up to 5mls
• Ventrogluteal
• A deep site situated away from major nerves and
  blood vessels
• Less chance of contamination incontinent clients
  or infants.
• Safe site for injections up to 4mls
• Deltoid
• Easily accessible but muscle not well developed
  in most clients. Used for small amounts of
  medications.
• Not used in infants or children with
  underdeveloped muscles.
• Potential for injury to radial and ulnar nerves
  or brachial artery.
• Not recommended for amounts more than 2mls

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Landmark for ventrogluteal siteB. Locating IM
injection for ventrogluteal site.
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Landmarks for vastus lateralis siteB. Giving IM
injection in vastus lateralis
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Landmarks for Deltoid siteB. Giving IM
injection in deltoid muscle
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Intramuscular injections

• Provides faster medication absorption, because of
  greater vascularity of muscle
• Less danger of tissue damage when medications
  enter deep into the muscle
• Risk of injecting into directly into blood vessels

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Intramuscular Sites

• Site selection depends on
• persons age
• muscle development
• Use deltoid muscle for older children, adults
  (toddlers only if adequate muscle mass)
• Use anatomical landmarks to locate site
• Well developed person can tolerate 3mls without
  severe discomfort

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• Never administer vaccines into the buttock
• May administer large doses of immune globulin
  into buttock of older children or adults

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Intramuscular Needle

• Gauge 23 or sometimes 25 in very thin patients

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Intramuscular Injection Technique
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Z Track

• For irritating preparations such as iron
• Minimises irritation and staining by sealing the
  medication in muscle tissue
• Preference site ventogluteal

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Z Track

• New needle should be applied after preparation of
  injection
• Swab site
• Pull overlying skin and subcutaneous tissue
  approx 2.5-3.5 cm to the side
• Holding skin taut inject deep into the muscle
• The needle remains inserted for 10 seconds to
  allow medications to disperse evenly
• Withdraw needle and release the skin

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Needle Recapping

• Never Recap needles
• Normally against hospital policy
• Risk of needle stick injury
• Take sharps or kidney dish with you
• Empty sharps containers when three quarters full

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Infection Control

• Equipment disposal
• never detach, recap or cut a used needle
• place in puncture-proof container
• dispose as infectious medical waste
• use safety needles or needle-free devices
  whenever available to reduce risk of injury

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Injection Pain

• Pain is subjective and influenced by
• persons age
• anxiety level
• previous healthcare experiences
• culture
• Pain management
• medical (e.g., anesthetics)
• non-medical (e.g., diversionary techniques)

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INSULIN ADMINISTRATION

• Choose correct syringe size
• Check dose of insulin (s) to be administered
• Follow drug administration protocols
• Draw up correct dose of insulin
• Administer to patient in appropriate site

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INSULIN ADMINISTRATION

• Types of insulin
• Rapid acting
• Short acting
• Intermediate acting
• Premixed insulin
• Premixed insulin Lispro
• Refer to accompanying chart from Lilly

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INSULIN ADMINISTRATION

• Mixing insulins
• Clear - regular
• Cloudy - isophane
• Withdraw amount of clear from clear vial
• If you make a mistake discard and start again

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INSULIN ADMINISTRATION

• Mixing insulins
• Keep control of plunger and withdraw amount of
  cloudy from cloudy vial
• Always draw clear insulin up first

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INSULIN ADMINISTRATION

• Prepare patient
• Administer dose
• Unless there are facility protocol reasons it is
  not necessary to swab skin before or after
  administration
• Do not rub site after administration
• You may press firmly on skin with a dry swab if
  fluid appears on skin

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INSULIN PUMPS

• Found to be successful in
• Brittle , labile or hard to control diabetes
• Frequent or severe hypoglycaemia
• Pregnancy

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INSULIN PUMPS

• Found to be successful in
• Elevated HbA1C
• Gastroparesis
• Early nephropathy, neuropathy retinopathy
• Post renal transplant

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INSULIN PUMPS

• How they work
• Basal management
• Pump continuously delivers a basal rate of
  insulin
• Patient can store three basal patterns

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INSULIN PUMPS

• How they work
• These patterns each have up to 48 rates in order
  to match daily, weekly and monthly activities
• Smallest dose is 0.05 units

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INSULIN PUMPS

• Temporary basal rate
• Allows person to change basal rate in response to
  stress , illnesses or changes in activity ie
  attending the gym
• Bolus management
• Allows person to administer a bolus dose relating
  to a blood glucose reading which is calculated by
  the machine

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INFECTION CONTROL

• Hand hygiene
• recommended between patients
• alcohol-based waterless antiseptic can be used
• Gloves
• not mandatory unless
• potential for exposure to blood or body fluids,
• open lesions on the hands, or
• agency policy

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INFECTION CONTROL

• Follow facility protocols if you experience a
  needle stick injury
• All facilities have a formal reporting system
• Risk factors
• Contracting infectious diseases ie HIV Hep B C
• Blood infections ie septicaemia

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Infection Control

• Equipment disposal
• never detach, recap or cut a used needle
• place in puncture-proof container
• dispose as infectious medical waste
• use safety needles or needle-free devices
  whenever available to reduce risk of injury

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Injection Pain

• Pain is subjective and influenced by
• persons age
• anxiety level
• previous healthcare experiences
• culture
• Pain management
• medical (e.g., anesthetics)
• non-medical (e.g., diversionary techniques)

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12 steps towards a painless injection

• 1. Prepare patient with adequate information
  before procedure
• Allows patient to understand and comply

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12 steps towards a painless injection

• 2. Change needle after preparation of the drug
  and before administration
• Ensures needle is clean, sharp dry and the right
  length

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12 steps towards a painless injection

• 3 Make the ventro-gluteal site your first choice
  to ensure medication reaches muscle layer
• Used in adults and children over 7 months of age
• 4 Position your patient so the designated muscle
  group is flexed and therefore relaxed

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12 steps towards a painless injection

• 5. If cleaning skin before needle entry make sure
  skin is dry before injecting
• 6. Consider using ice or freezing spray to numb
  the pain, particularly with children or
  needle-phobic patients

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12 steps towards a painless injection

• 7.Use the Z track technique if appropriate
• 8. Rotate sites from one side to other or follow
  around sites
• 9. enter skin firmly with controlled thrust,
  holding needle at 90º angle
• (IM injection)

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12 steps towards a painless injection

• 10. Inject fluid steadily and slowly about 1ml
  per 10 second to allow muscle to accommodate
  fluid
• 11. Allow 10 seconds after completion of
  injection to allow medication to diffuse and
  withdraw needle at same angle as it entered

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12 steps towards a painless injection

• 12.Do not massage area but be prepared to apply
  gentle pressure with a gauze swab.

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RESPONSIBILITIES

• Once given, a parenteral drug cannot be
  retrieved
• All drugs should be prepared according to
  manufacturers instructions

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RESPONSIBILITIES

• Ensure that policy and safety processes have been
  followed
• Right
• Patient
• Drug
• Dose
• Route
• Time
• Document correctly and promptly

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RESPONSIBILITIES

• Know common side effects of the drugs
• Understand that other side effects may occur
• Know if a drug has an antidote
• Use professional judgement and ask if unsure

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DANGEROUS DRUGS

• Kept in locked DD cupboard
• D2, D1, D3 RNs must check drugs
• Patient orders checked
• Drug, dose, route, frequency, time, date due and
  last given
• Check Drs signature on order

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DANGEROUS DRUGS

• Check pts details are correct
• Check DD against medication order
• Check expiry date
• Check drug order (calculation)
• Check pts ID carefully (same name duplicate)

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DANGEROUS DRUGS

• Give enteral topical medications to patient Do
  not leave on locker
• Document discrepancies
• Schedule 8 drugs ensure drug register correctly
  filled out
• Date, time, patient drug, nurses administering
  drug, balance of drugs remaining

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DANGEROUS DRUGS

• Observe patient and document in patients history
• Note beneficial effects
• Note, report and chart any advers effects
• Correctly dispose of equipment
• Needles in sharps containers follow facility
  policies

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COMPLICATIONS

• Infection if strict aseptic technique not
  followed
• Sterile abscesses
• Oedematous or paralysed tissues have limited
  ability to absorb drugs
• Needle too short for muscle depth

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COMPLICATIONS

• Nerve damage ie sciatic nerve if gluteal
  injection incorrectly sited
• Accidental intravenous injection resulting in a
  reaction
• Embolism from composition of drug
• Lipohypertrophy