Transcript Injection Sites

Chapter 34
Parenteral Medications
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
1
Parenteral Administration Equipment
 The parenteral route means a route of
drug administration other than oral or
through the gastrointestinal tract.
Second semester 15 - 16
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BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
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Parenteral Administration Equipment
 Syringes: all syringes contain a
barrel, a plunger, and a tip or hub
 Calibrated in milliliters (mL), cubic
centimeters (cc), units (U), and in some
cases minims (m)
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
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Parenteral Administration Equipment (cont’d)
• Needles are supplied in various lengths and
gauges
– Shaft: length of the needle
– Gauge: diameter of the needle
• Lengths vary from approximately 0.5 to 2.5
inches
• Needle gauge refers to width
– For most injections, 18- to 27-gauge needles are
used; the smaller the number, the larger the diameter
• For example, an 18-gauge needle is wider than a
27-gauge needle.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
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Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
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Factors considered when selecting
syringes and needles
 The type of medications
 The depth of tissues
 The volume of prescribed drugs
 The viscosity of the drugs
 The size of the client
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
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common sizes of syringes and needles
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
7
Parenteral Administration Equipment (cont’d)
Modified safety injection equipment
• Avoids needlestick injuries to reduce the risk for
acquiring a blood-borne viral disease such as
hepatitis or AIDS
• Techniques with standard equipment to prevent
needlestick injuries:
1. Before administering an injection, the protective cap
covering a needle is replaced by using the scoop
method
2. After administering an injection, the needle is left
uncapped and deposited in the nearest biohazard
container
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
8
Safety Injection Devices
A.
B.
A syringe with a circular sleeve that cover the needle
A syringes with an articulated levered shield that glides over the needle
after it is used
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
9
Drug Preparation
 Ampule: sealed glass drug container
 Vial: glass or plastic container of parenteral
medication with a self-sealing rubber stopper
 Reconstitution: process of adding liquid,
known as diluent, to a powdered substance
 Prefilled cartridges
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
10
Ampule, Vial, and Prefilled Cartridge
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
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Injection Routes
 There are four injection routes for parenteral
administration:
1. Intradermal injections (between the layers of the
skin),
2. Subcutaneous injections (beneath the skin but above
the muscle),
3. Intramuscular injections (in muscle tissue), and
4. Intravenous injections (instilled into veins; Fig. 34-8).
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
12
Injection routes:
A. : intradermal
B. : subcutaneous
C. : intramuscular and subcutaneous in other than thin
persons and
D. : intravenous
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
13
Intradermal Injections
 Intradermal injections are commonly used for
diagnostic purposes.
 Examples include tuberculin tests and allergy testing.
 Small volumes, usually 0.01 to 0.05 mL, are injected
because of the small tissue space.
 Injection Sites
 A common site for an intradermal injection is the inner
aspect of the forearm. Other areas that may be used
are the back and upper chest
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
14
Injection Equipment
 A tuberculin syringe holds 1 mL of fluid and
is calibrated in 0.01-mL increments (Fig. 34-9).
 It is used to administer intradermal injections.
 A 25- to 27-gauge needle measuring a halfinch in length commonly is used when
administering an intradermal injection.
Injection Technique
 When giving an intradermal injection, the
nurse instills the medication shallowly at a 10to 15-degree angle of entry
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
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Subcutaneous Injections
 A subcutaneous injection is administered more
deeply than an intradermal injection.
 Medication is instilled between the skin and
muscle and absorbed fairly rapidly
 The medication usually begins acting within 15 to
30 minutes of administration.
 The volume of a subcutaneous injection is
usually up to 1 ml.
 The subcutaneous route commonly is used to
administer insulin and heparin.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
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Injection Sites
 The preferred site for giving a subcutaneous
injection of insulin and heparin is the abdomen.
 Additional or alternative injection sites for insulin
are the outer back area of the upper arm, where it
is fleshier, and outer areas of the thigh and upper
buttocks.
 Rotating within one injection site, preferably the
abdomen, is recommended rather than rotating to
a different area with each injection
 The rate of drug absorption at various
subcutaneous sites from fastest to slowest is
abdomen, arms, thighs, and buttocks.
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Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
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Injection Equipment
 Insulin is prepared in an insulin syringe A 25gauge needle is used most often
Injection Technique
 To reach subcutaneous tissue in a normalsized or obese person who has a 2-inch tissue
fold when it is bunched, the nurse inserts the
needle at a 90-degree angle.
 The tissue usually is bunched between the
thumb and fingers before administering the
injection to avoid instilling insulin within the
muscle.
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Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
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Subcutaneous injection sites
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BSN , MSc
Figure 34-11 • Angles
and needle lengths for
subcutaneous injections.
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Intramuscular Injections
 An intramuscular injection is the administration of
up to 3 ml. of medication into one muscle or
muscle group.
 Because deep muscles have few nerve endings,
irritating medications commonly are given
intramuscularly.
 Injection Sites
 The five common intramuscular injection sites are
named for the muscles into which the medications
are injected: dorsogluteal, ventrogluteal, vastus
lateralis, rectus femoris, and deltoid.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
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Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
21
Dorsogluteal Site
 The dorsogluteal site is the upper outer quadrant of
the buttocks and is a common location for
intramuscular injections.
 The primary muscle in this site is the gluteus
maximus, which is large and therefore can hold a fair
amount of injected medication with minimal
postinjection discomfort.
 This site is avoided in clients younger than 3 years
because their muscle is not sufficiently developed.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
22
 If the dorsogluteal site is not identified correctly,
damage to the sciatic nerve with subsequent
paralysis of the leg can result, To locate the
appropriate landmarks :
 Divide the buttock into four imaginary quadrants.
 Palpate the posterior iliac spine and the greater trochanter.
 Draw an imaginary diagonal line between the two
landmarks.
 insert the needle superiorly and laterally to the midpoint of
the diagonal line.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
23
Ventrogluteal Site
 The ventrogluteal site uses the gluteus medius and
gluteus minimus muscles in the hip for injection.
 This site has several advantages over the
dorsogluteal site:
 it has no large nerves or blood vessels, and
 it is usually less fatty and cleaner because fecal
contamination is rare at this site.
 The ventrogluteal site is also safe for use in children.
 To locate the ventrogluteal site:
 Place the palm of the hand on the greater trochanter and the
index finger on the anterior-superior iliac spine (Fig. 34-15).
 Move the middle finger away from the index finger as far as
possible along the iliac crest.
 Inject into the center of the triangle formed by the index finger,
middle finger, and iliac crest.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
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Ventrogluteal Site
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
25
Vastus Lateralis Site
 The vastus lateralis site uses the
vastus lateralis muscle, one of the
muscles in the quadriceps group of
the outer thigh. Large nerves and
blood vessels usually are absent in
this area,
 The nurse locates the vastus lateralis
site by placing one hand above the
knee and one hand just below the
greater trochanter at the top of the
thigh (Fig. 34-16).
 He or she then inserts the needle into
the lateral area of the thigh (Fig. 34-17).
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Figure 34-16 • Locating the
vastus lateralis muscle .
Figure 34-17 • Spreading the skin
at the vastus lateralis site and
darting the tissue
Fundamental of Nursing – B
Parenteral Medications
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Rectus Femoris Site
 The rectus femoris
site is in the anterior
aspect of the thigh.
 This site may be used
for infants.
 The nurse places an
injection in this site in
the middle third of the
thigh, with the client
sitting or supine (Fig. 34-18).
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Figure 34-18 • Location of rectus
femoris injection site .
Fundamental of Nursing – B
Parenteral Medications
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Deltoid Site
 The deltoid site in the lateral aspect of the upper arm
(Fig. 34-19) is the least-used intramuscular
 Injection site because it is a smaller muscle than the
others.
 It is used only for adults because the muscle is not
sufficiently developed in infants and children. Because
of its small capacity, intramuscular injections into this
site are limited to 1 mL of solution.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
28
 There is a risk for damaging the radial nerve and
artery if the deltoid site is not well identified. To
use this site safely:
 Have the client lie down, sit, or stand with the
shoulder well exposed.
 Palpate the lower edge of the acromion process.
 Draw an imaginary line at the axilla.
 Inject in the area between these two landmarks.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
29
Reducing Injection Discomfort
 Use the smallest-gauge needle that is appropriate.
 Change the needle before administering a drug that is
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irritating to tissue.
Select a site that is free of irritation.
Rotate injection sites.
Numb the skin with an ice pack before the injection.
Insert and withdraw the needle without hesitation.
Instill the medication slowly and steadily.
Use the Z-track method for intramuscular injections.
Apply pressure to the site during needle withdrawal.
Massage the site afterward, if appropriate.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
30
The Z-track technique.
 Performing the Z-track method
 Place gloved fingers on the skin surface and pull the overlying skin and subcutaneous
tissue approximately 2.5-3.5 cm (1 to 1 ½ inches) laterally to the side. (See Figure A)
 Holding the skin taut with the non dominant hand, insert the needle at a 90 degree angle at
the spot where the finger was initially placed before displacing the skin laterally. (See Figure B)
 Aspirate for blood return with the dominant hand only (practice of nurse makes this step
easy). If there is no blood return on aspiration, inject the drug slowly, followed by the air. Air
clears the clears the needle of the medication and prevents tracking of the medication
through the subcutaneous layers upon needle withdrawal. (Air-lock technique)
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Wait for 10 seconds before withdrawing the needle to allow the medication to disperse evenly.
 Slowly remove the needle.
 Release the skin taut. A zigzag needle track is created (by sliding of the tissue planes
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across each other) preventing the escape of medication from the muscle tissue. (See Figure C)
Instruct the patient never to wear tight or constricting clothing because it can force out the
injected medication to the subcutaneous layers. Do not massage the site.
Encourage the patient to mobilize (walk or move in bed) to facilitate the absorption of
medication.
Discard the needles and syringe in an appropriate sharps container. Always remember,
never to recap the syringe to avoid needle-stick accidents.
Remove gloves.
Document medication, dosage, date, time and site of
injection on the patient’s chart.
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Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
31
Nursing Implications
 Acute Pain
 Anxiety
 Fear
 Risk for Trauma
 Deficient Knowledge
 Ineffective Therapeutic Regimen Management
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Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
32
Sample Documentation
Time and date ( 11/21/2015 5:42:58 PM)
Tuberculin skin test administered
intradermal in left forearm with no immediate
unexpected effects. Instructed to return in 48 hours for
inspection of site
Signature/ Title
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing – B
Parenteral Medications
33