Transcript HERE

Basic procedures in healthcare 1
(SOL / VCA81)
TOPICS:
6a) Preparation and application s. c. inj.
6b) Preparation and application i. m. inj.
6c) Dilution of drugs
6a) Preparation and application
s. c. inj.
 explanation of the terms
 way of application
 choosing an injection site, the most common application site
 tools
 general procedure
 technique when applying with conventional syringe
 technique when applying with insulin syringe
 technique when applying with insulin pen
 technique when applying with originally packaged syringe
 complications of applications
6a) Preparation and application
s. c. inj.
Definition:
- it is application of a small amount of medical solution into the
dermis,
- administered mainly for therapeutic reasons, exceptionally
for diagnostic reasons,
- onset of action is slow, it comes in 10 - 20 min.
Way of application
- usually is applied 1-2 ml of medicament,
- the application is performed either 1 or 2 ml syringe, original
syringe with medication or insulin pen.
6a) Preparation and application
s. c. inj.
Choosing the injection site:
 it is important to choose a suitable application site, because it can
influence the effectiveness of the medicine,
 the rate of absorption is also affected by the depth of injection
and the fat layer,
 when long-term application in the same site lipodystrophy can occur
(i.e.. fat loss in the application site),
 w.g. insulin is faster absorbed from the stomach area than from the
thighs,
 the most frequently applied medicines s. c. - insulin, anticoagulants.
6a) Preparation and application
s. c. inj.
The most common application site:
 the outer side of the arm (in m. biceps brachii),
 outer thighs (m. quadriceps femoris),
 abdomen (in m. rectus abdominis),
 dorsogluteal area (around m. gluteus medius),
 application site must be changed!
*
6a) Preparation and application
s. c. inj.
The most
common
application
site:
application site s. c. injections
6a) Preparation and application
s. c. inj.
Tools
 syringe, insulin syringe, original syringe with drug…
(individual depending on the type of drug to be administered),
 subcutaneous injection needle (25-30 mm), chosen according
to the physical constitution of the patient,
 disinfection,
 kidney / vomit bowl and container for used needles,
 cellulose,
 adhesive plaster.
*
6a) Preparation and application
s. c. inj.
General procedure:
 preparation of the drug on the basis of written prescription (checking
of name, concentration, quantity, expiration date, appearance
of the drug and whether the drug is prescribed for that application),
 tools preparation,
 checking of the identity of the patient, explanation of the procedure,
allergies control (drug, disinfection, adhesive plaster),
 hands disinfection,
 appropriate patient positioning and choice of application site (we
never apply in the places of edema, scarring, hematoma,
inflammation),
 disinfecting the injection site.
6a) Preparation and application
s. c. inj.
Technique when applying with conventional syringe:
 see general procedure (slide no. 7),
 create a skin fold and administer the injection under the angle
of 45°,
 loose the skin fold, aspirate (If you see blood in the syringe,
it is necessary to exchange the syringe),
 apply the drug,
 pull out the needle (while holding the
cellulose square on the application site),
 check the injection site after administration.
*
6a) Preparation and application
s. c. inj.
Technique when applying with insulin syringe:
 see general procedure (slide no. 7),
 technique of the application of the injection depends on the length
of a needle, on the physical constitution of the patient and on
application site, it is usually recommended to apply it under the angle
of 90° without the skin fold, if the length of the needle is 4 mm when
applied to the abdomen,
 if the estimated distance from the surface of the skin to the muscle is
less than the length of the needle → create the skin fold,
 if the needle length is ↑ 6 mm, it is always recommended to create
the skin fold (except obese patients),
 in cachectic patients, it is applied under the angle of 45 with the skin
fold,
 insulin is absorbed the fastest from the subcutaneous abdominal,
the slowest from the buttocks.
6a) Preparation and application
s. c. inj.
Technique when applying with insulin syringe:
 administer the injection under the angle of 90°(45°) with or without
the skin fold (according to the needle length, physical constitution
of the patient…),
 loose the skin fold (if it was created), aspirate (if you see blood
in the syringe, it is necessary to exchange the syringe),
 apply insulin,
 pull out the needle (while holding the cellulose square
on the application site).
*
6a) Preparation and application
s. c. inj.
ways of application of s. c. injections
Source: http://www.myclickfine.com/injection-technique.aspx, downloaded: 31. 5. 2015
6a) Preparation and application
s. c. inj.
Technique when applying with insulin pen:
 see general procedure (slide no. 7),
 on the basis of written prescription count number of units of insulin,
 administer the injection under the angle of 90°with or without
the skin folds (according to the needle length, physical constitution
of the patient …),
 it is not possible to aspirate,
 press the plunger, and wait approximately 10 seconds,
 if the skin fold was created, loose it before pulling out the needle,
 pull out the needle (while holding the cellulose square
on the application site).
insulin pen
needles to insulin pen
insulin pen
6a) Preparation and application
s. c. inj.
Technique when applying with originally packaged syringe:
- mostly low molecular weight heparins,




follow the information on an instruction leaflet,
the best place for the application of the abdomen,
do not remove the air from the original syringe,
administer the injection under the angle of 90° in the skin fold
and hold it for the whole time of the drug application,
 do not aspirate, apply medication straight,
 pull out the needle and slowly loose the skin fold,
 after application do not massage
the injection site (hematoma inception)!
6a) Preparation and application
s. c. inj.
Complications of applications:
 application to the vein,
 application to the muscle,
 superficial applications,
 hypertrophy of subcutaneous binder
(injection site is not changed),
 lipodystrophy,
 skin atrophy,
 infecting the injection site.
*
6b) Preparation and application
i. m. inj.
 explanation of terms
 the most common application site
 tools
 choosing a needle
 procedure to locate the injection site in m. gluteus medius
 procedure to locate the injection site in m. quadriceps femoris
 application technique
 application using „Z-track“
 complications during and after application
6b) Preparation and application
i. m. inj.
Definition
- administration of effective drug into the muscle in a volume
of 1-20 ml, for therapeutic or prophylactic purposes,
- effect starts after 5 - 10 minutes,
- administered drugs forms: solutions, emulsions, suspensions.
*
6b) Preparation and application
i. m. inj.
The most common application site:
passing of the sciatic nerve through gluteal muscles
• m. gluteus medius,
• m. gluteus maximus,
• m. quadriceps femoris,
• m. vastus lateralis,
• m. deltoideus.
6b) Preparation and application
i. m. inj.
The most common application site:
Source: http://what-when-how.com/nursing/administration-of-injectable-medications-pharmacology-and-administration-of-medications-nursing-part-2/, downloaded: 31. 5. 2015
6b) Preparation and application
i. m. inj.
Tools:
 prescribed drugs,
 syringe 1-20 ml,
 intramuscular injection needle 38-76 mm,
 kidney / vomit bowl and container for used needles,
 disinfectant solution,
 cellulose,
 adhesive plaster.
*
6b) Preparation and application
i. m. inj.
Choosing a needle:
 we choose a shorter needle (4 - 5 cm) in cachectic patients,
 we choose a longer needle (5 - 7 cm) with a wider lumen
in patients with well-developed muscles or obese,
 we choose a needle with a wider lumen at oily substances
or ATB suspensions.
*
different types of needles
6b) Preparation and application
i. m. inj.
Procedure to locate the injection site in m. gluteus medius:
 put the wrist on the greater trochanter, toes are pointing up
to the head,
 we use for the left side the right hand and for the right side
the left hand,
 put a forefinger on the front upper iliac spine, outstretched
middle finger put off towards the back and feel the iliac crest
and press under it,
 the triangle that creates the forefinger, the iliac crest and middle
finger is the site for injection.
6b) Preparation and application
i. m. inj.
Procedure to locate the injection site in m. gluteus medius
Source:
http://eamos.pf.jcu.cz/amos/kos/modules/low/kurz_text.php?identifik=kos_392_t&id_kurz=&id_kap=13&id_teach=&kod_kurzu=kos_392&id_
kap=13&id_set_test=&search=&kat=&startpos=2, downloaded: 18. 6. 2015
feeling the injection site for i. m. application to gluteal muscles
6b) Preparation and application
i. m. inj.
Procedure to locate the injection site in m. quadriceps femoris:
 the injection site
is the middle third
of the muscle –
the area between
the iliac spine
and the patella.
Source: http://ose.zshk.cz/vyuka/osetrovatelske-postupy.aspx?id=30, downloaded: 18. 6. 2015
6b) Preparation and application
i. m. inj.
Application technique:
 see general procedure (slide no. 7),
 feel the appropriate injection site,
 stretch the skin with the thumb and the forefinger of the second hand,
 make a quick and vigorous needle mark under the angle of 90°,
the needle introduce 3-5 cm deep (in cachectic patients under
the angle of 45°- 60°),
 aspirate (If you see blood in the syringe, it is necessary to exchange
the syringe),
 apply the drug slowly (throughout the application hold the needle
conus),
 pull out the needle after the application (always hold the needle conus,
not only the syringe),
 the injection site cover with adhesive plaster.
6b) Preparation and application
i. m. inj.
Application using „Z-track“:
 suitable for application of drugs strongly irritating subcutaneous prevents the escape of the drug from the muscles to
the hypodermis,
 with the hand shift the skin and hypodermis of about 3 cm from
the injection site,
 apply the injection and still hold
the skin stretched out to pull the needle,
 after withdrawing the needle return
the skin to its normal position.
*
6b) Preparation and application
i. m. inj.
application using „Z-track“
Source: http://nursingcrib.com/wp-content/uploads/ztrack1.jpg, downloaded: 1. 6. 2015
6b) Preparation and application
i. m. inj.
I. m. injection complications:
• stabbing of nerve (inappropriately chosen injection site)
– feeling like tingling, pain shooting to the legs, slight paralysis,
• stabbing of blood vessel (inappropriate injection site) – during aspiration
blood appears in the syringe,
• drug encapsulation and abscess formation – in particular when
applying on oily solution, when applying badly in adipose tissue or fascia,
the cause may be a short needle and inappropriate injection site (the site
is reddish, swollen, stiff),
• inflammatory process- resulting from the introduction of infection
into the injection site during non-sterile procedure (site is reddish, warm,
painful, fever can increase),
• stabbing of bone – especially in cachectic patients:
→ a hook can be created in case of an impact of the top of the needle
to the bone. This can damage tissue when pulling the needle out,
→ or the needle can be broken because of the sharp impact.
6b) Preparation and application
i. m. inj.
Stabbing of bone in i. m. inj.
- solution:
 if you feel the impact of the needle into the bone, never start
with application of a solution in the syringe,
 the main principle – do not panic and keep the needle in place
and in the same position!!!
 gently try to pull up the needle, max. 1-2 mm – if it is possible to
pull it out and we do not feel any resistance, pull out the needle,
 if we feel it is not possible to pull out the needle – we hold it still
in place and we call a physician who should solve this situation
surgically (application of anaesthetics, incising of tissue and
withdrawing the needle).
6c) Dilution of drugs
 explanation of the terms
 drug preparation from the ampoule
 drug preparation from the vial
 dilution of drugs process
 examples how to calculate the concentrations of drugs
6c) Dilution of drugs
Definition:
- number of drugs are supplied in vials as a powder which is
necessary to dilute,
- dilution is done in sterile conditions right before its administration,
drugs are diluted according to an instruction leaflet.
For dilution is used:
 aqua for injectione,
 saline (NaCl 0,9%),
 5% glucose,
 diluent, which is part
of the package.
6c) Dilution of drugs
Drug preparation from the ampoule:
 check the drug in the ampoule (name, concentration, quantity,
expiration date, appearance of the drug and whether the drug is
prescribed for that application),
 remove sterile syringe and needle,
 shake the drug in the ampoule so there is non in a neck,
 disinfect the neck of the ampoule before opening,
 suck the volume of the ampoule through needle into the syringe
(for sucking use the needle which we will not use for the drug
application, do not suck only with the conus of the syringe – it is not
sucked the whole amount of drug),
 mark syringe barrel (room number / bed number, patient´s name, year
of birth, the name and quantity of the drug),
 apply as soon as possible after the sucking.
6c) Dilution of drugs
Srug preparation from the vial:
 check the drug in the ampoule (name, concentration, quantity, expiration
date, appearance of the drug and whether the drug is prescribed for that
application),
 remove sterile syringe and needle,
 disinfect the access point of the vial,
 stab the vial with the suction needle and to suck the drug into the syringe,
 leave the suction needle with the syringe in the vial with the drug till
the time of application,
 mark syringe barrel (room number / bed number, patient´s name, year
of birth, the name and quantity of the drug – if we leave needle with
the syringe in the vial with the drug it is not necessary to write name
and amount of the drug),
 apply as soon as possible after the sucking, when applying with the
needle always replace aspiration needle for application!
ampicillin for injection administration
6c) Dilution of drugs
Dilution of drugs process:





prepare a vial with the drug,
remove the metal cover,
disinfect the rubber stopper,
prepare the diluent,
*
inject diluent into the vial, ensure proper dissolution of the drug
(mix it gently, do not shake),
 suck the required amount of drug into the syringe,
 tap the syringe to make bubbles collect at the top of the syringe,
 replace the needle with an application according to the method
of application (bolus i. v. injection, bolus through a peripheral
venous catheter, i. m.), or prepare an infusion with diluted drug.
6c) Dilution of drugs
Examples of dilution #1
Prokain Penicilin G
• it supplied in bottles in powder form of volume: 1 500 000 u.,
3 000 000 u., 5 000 000 u.
• diluting of vial with volume of 1 500 000 u. 7,5 ml saline we get
a solution having in 1 ml 200 000 u.
• diluting of vial with volume of 1 500 000 u. 15 ml saline we get
a solution having in 1 ml 100 000 u.
– How many do I apply, if I administer 350 000 u.?
– How many ml a units will be left in the vial?
6c) Dilution of drugs
Examples of dilution #2
Streptomycin
• the vials with volume of 1g Streptomycin are diluted 5 ml
saline, then we get a solution having in 1 ml 200 mg (0,1 ml
of saline contains 20 mg STM)
- How many do I apply, if I administer 280 mg STM to a child?
- How many do I apply, if I administer 500 mg STM to a child?
6c) Dilution of drugs
Examples of dilution #3
• The vial PNC-G containing in powder form 600 000 u., we
should administer 100 000 u. With how many ml of saline we
dilute the vial, how many we apply and how many we will have
left - in the vial in ml and number of units.
6c) Dilution of drugs
Solution – example #3
• 600 000 u. we dilute with 6 ml of saline, then we will have in 1 ml
of solution 100 000 u.
• if I should apply 100 000 u., I administer 1 ml of solution
• 5 ml solution will be left in the vial. It will contain 500 000 u.
6c) Dilution of drugs
 Examples of dilution #4
In the vial there is 1 500 000 IU PNC. You have to apply 1 200 000 IU.
How many ml of PNC you will suck in the injection, if you dilute the
amount of the vial:
a) 10 ml NaCl
b) 5 ml NaCl
---------------------------------------------------------------------------------------a)
b)
6c) Dilution of drugs
Solution – example #4
In the vial there is 1 500 000 UI PNC. You have to apply 1 200 000 UI.
How many ml of PNC you will suck in the injection, if you dilute the
amount of the vial:
a) 10 ml NaCl
b) 5 ml NaCl
---------------------------------------------------------------------------------------a) 1 ml = 1 500 000 PNC : 10 NaCl = 150 000
1 200 000 : 150 000 = 8 ml PNC when diluting 10 ml NaCl
b) 1 ml = 1 500 000 PNC : 5 NaCl = 300 000
1 200 000 : 300 000 = 4 ml PNC when diluting 5 ml NaCl
6c) Dilution of drugs
 Examples of dilution #5
The vial of Streptomycin (STM) contains 1 g of an active substance.
You have to apply 280 mg of STM. How many ml you will apply if you
dilute:
a) 10 ml
b) 5 ml
-----------------------------------------------------------------------------------------a)
b)
6c) Dilution of drugs
Solution – example #5
The vial of Streptomycin (STM) contains 1 g of an active substance.
You have to apply 280 mg of STM. How many ml you will apply if you
dilute:
a) 10 ml
b) 5 ml
-----------------------------------------------------------------------------------------a) 1 000 mg STM : 10 NaCl = 100 mg STM (1 ml STM)
280 mg STM : 100 mg STM = 2,8 ml STM when diluting 10 ml NaCl
b) 1 000 mg STM : 5 NaCl = 1 ml STM = 200 mg STM
280 mg STM : 200 mg STM = 1,4 ml STM when diluting 5 ml NaCl
6c) Dilution of drugs
 Examples of dilution #6
The vial of Ampicillin contains 2 g of an active substance. You have to
apply 1,5 g. How many ml you will suck in the injection if you dilute:
a) 20 ml
b) 10 ml
c) 5 ml
-----------------------------------------------------------------------------------------a)
b)
c)
6c) Dilution of drugs
 Solution – example #6
The vial of Ampicillin contains 2 g of an active substance. You have to
apply 1,5 g. How many ml you will suck in the injection if you dilute:
a) 20 ml
b) 10 ml
c) 5 ml
-----------------------------------------------------------------------------------------a) 2 000 mg AMP : 20 ml NaCl = 100 mg active substance in1 ml AMP
1 500 mg AMP : 100 mg AMP = 15 ml AMP when diluting 20 ml NaCl
b) 2 000 mg AMP : 10 ml NaCl = 200 mg active substance in 1 ml AMP
1 500 mg AMP : 200 mg AMP = 7,5 ml AMP when diluting 10 ml NaCl
c) 2 000 mg AMP : 5 ml NaCl = 400 mg active substance in 1 ml AMP
1 500 mg AMP : 400 mg AMP = 3,75 ml AMP when diluting 5 ml NaCl
Revision
 For how long does the effect of s. c. injection start?
 What are the most common sites for s. c. injection?
 What is the procedure when the blood is sucked
into the syringe during aspiration?
 What will be the application technique of insulin in an obese patient?
 Do you remove the air from the syringe in the application of low molecular
weight heparin, if you apply it with syringe prepared in advance?
 Is it recommended to massage the injection site after the injection
application?
 Please list at least 3 complications of i.m. injection application?
 Why is it necessary to vary the sites when injecting?
 What solutions can be used to dilute drugs?
 f we dilute the drug, we aspire first drug or diluent? Explain why.
 The patient should receive premedication before surgery: Atropine 0.4 mg vial
containing 0.5 mg in 1 ml. Dolsin 30 mg vial contains 1 ml of 50 mg. How
much of which solution will you apply?
Reference:

HŮSKOVÁ, Jitka a Petra KAŠNÁ. Ošetřovatelství - ošetřovatelské postupy pro zdravotnické asistenty. 1. vyd.
Praha: Grada Publishing, 2009, 96 s. ISBN 9788024728537.

JIRKOVSKÝ, Daniel a Marie HLAVÁČOVÁ. Ošetřovatelské postupy a intervence: učebnice pro bakalářské a
magisterské studium. Vyd. 1. Praha: Fakultní nemocnice v Motole, 2012, 411 s. ISBN 978-80-87347-13-3.

KELNAROVÁ, Jarmila. Ošetřovatelství pro střední zdravotnické školy - 2. ročník. 1. vyd. Praha: Grada
Publishing, 2009, 228 s. ISBN 9788024731063.

POKORNÁ, Andrea, Alena KOMÍNKOVÁ a Nikola SIKOROVÁ. Ošetřovatelské postupy založené na důkazech.
1. vyd. Brno: Masarykova univerzita, 2013-2014, 2 sv. (124; 171 s.). ISBN 978-80-210-6331-0.

TONDROVÁ, Bc. Irena. Aplikace intramusculárních injekcí [online]. [cit. 2015-06-01]. Dostupné z:
http://www.szsmb.cz/admin/upload/sekce_materialy/Aplikace_intramuscul%C3%A1rn%C3%ADch_injekc%C3
%AD.pdf

VYTEJČKOVÁ, Renata, Petra SEDLÁŘOVÁ, Vlasta WIRTHOVÁ, Iva OTRADOVCOVÁ a Lucie KUBÁTOVÁ.
Ošetřovatelské postupy v péči o nemocné III: speciální část. 1. vydání. 303 strany, iv strany obrazových příloh.
Sestra (Grada). ISBN 978-80-247-3421-7.

IMAGES (unless otherwise stated) pinterest.com, google.com (key words: „ok“, „not ok“, „injection“,
„guestion mark“, … )
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