Injections

Question 1

What are the indications for injections?

Answer 1

1. Illness or injury that requires parenteral medication

2. Administration of various vaccines

Question 2

What are the contraindications for injections?

Answer 2

1. Allergy to specific medication or any of injections components (i.e. vaccines- egg or gelatin allergy)
2. Lack of suitable injection site
3. Coagulopathy (IM)
4. Occlusive peripheral vascular disease
5. Shock
6. Impairment of peripheral absorption
7. Pregnancy (i.e. MMR)

Question 3

What are the potential complications of injections?

Answer 3

1. Pain, burning, erythema @ injection site
   A. Use techniques to reduce pain
2. Vasovagal Syncope
3. Allergic rxn (including anaphylaxis)
4. Medical error (Patient, dose, route, time)
5. Infection or abscess
6. Lipodystrophy

Question 4

Define intradermal injections

Answer 4

1. Ventral surface of forearm most commonly used into dermal layer of skin
   A. Skin testing, PPD test

Question 5

Define subcutaneous injections

Answer 5

1. Common sites- outer aspect of upper arm, anterior thigh, loose tissue of lower abdomen, upper buttocks, upper back into subcutaneous layer
   A. Useful for low volume of medication (i.e. insulin or enoxaparin) and some vaccinations

Question 6

Define intramuscular injections

Answer 6

1. Common sites- deltoid, gluteus medius, gluteus minimus, vastus lateralis into muscular layer
   A. Some vaccinations, useful for higher volume of medication delivery

Question 7

How do you perform an IM injection into the deltoid?

Answer 7

1. Place four fingers across deltoid muscle, with top finger across acromion process
2. Injection site is 2 to 3 fingerbreadths below acromion process
3. Injecting lower or more posterior in muscle can result in NV injury:
   A. Radial and ulnar nerve or brachial artery

Question 8

How do you perform an IM injection into the vastus lateralis?

Answer 8

1. Located at anterolateral aspect of thigh
2. Middle third of muscle is best for injection
3. Lacks major vessels & nerves
4. PREFERRED injection site for infants, children, adults

Question 9

How do you perform an IM injection into the gluteus medius and minimus?

Answer 9

1. Place your hand over greater trochanter
2. Point thumb towards
   groin & fingers toward head
3. Place index finger over ant
   sup iliac spine & middle finger
   along iliac crest with Index &
   middle finger should form “V”
4. Inject in the center of the “V”

Question 10

How do you perform an IM injection into the gluteus medius (dorsogluteal)?

Answer 10

1. Draw an imaginery line between posterior superior iliac spine and greater trochanter
2. Injection site is superior and lateral to this line, approx 2-3 inches below iliac crest
3. Be cognizant of sciatic nerve
4. Injury to sciatic nerve can cause paresthesias & muscle weakness in affected leg
   * *NOT IN CHILDREN**

Question 11

What are the rates of absorption for injections?

Answer 11

IV>IM>SQ

Question 12

What type of syringes are used for injections?

Answer 12

1. 2 or 3 ml – most subcutaneous (SQ) & intramuscular (IM) injections
2. 1 ml – insulin & tuberculin injections

Question 13

What type of needles are used for injections?

Answer 13

1. SQ – 25 to 29 gauge 0.5 to 5/8 inches
2. IM – 18-22 gauge, 5/8–1.5 inch
3. Intradermal – 26 or 27 gauge or 31 g, 0.5 to 5/8 inches

Question 14

What is the length of a needle determined by?

Answer 14

1. Size & weight of patient
2. Type of injection
   A. IM vs SQ

Question 15

What is the gauge of the needle determined by?

Answer 15

1. Gauge of needle is dependent on viscosity of injected material
   A. 25 or 26 gauge needle – thin, watery, non-sticky solution
   B. 20 to 22 gauge needle – thicker, sticky solution

Question 16

What equipment is needed for injections?

Answer 16

1. Medication
2. Syringe & needle
3. Alcohol wipe
4. Gloves
5. Needle disposal box (Sharps Container)
6. Band-Aid

Question 17

Define ampule

Answer 17

Contains single dose of drug

Question 18

Define vial

Answer 18

1. Contains single or multiple drug doses

2. Contains powder to which sterile dilutant is added

Question 19

How do you aspirate from an ampule?

Answer 19

1. Identify patient
2. Wash your hands and put on gloves
3. Assemble needle & syringe
4. Remove liquid in neck of ampule by tapping neck of ampule
5. If ampule is glass
6. Aspirate fluid
7. Remove any aspirated air
8. Dispose of needle in needle box and empty ampule in sharps container

Question 20

How do you aspirate from a vial?

Answer 20

1. Identify the patient
   2 Wash hands and put on gloves
2. Disinfect top of vial with alcohol wipe
3. Select a syringe with twice the required amount of drug or solution
4. Attach needle to syringe
5. Draw up as much air as the amount of solution to be aspirated
6. Insert needle into top of vial and turn vial upside-down
7. Push air out of syringe into vial
8. Aspirate the required amt of sol’n
9. Pull the needle out of the vial
10. Remove air from syringe
11. Dispose of needle; attach new
    needle to syringe
12. Filled syringe is now ready
    for injection

Question 21

What is the procedure for administering an intradermal injection?

Answer 21

1. Identify the patient
2. Wash your hands and put on gloves
3. Select a tuberculin syringe with a 26 or 27 gauge needle, 0.5 to 5/8 inches long
4. Using aseptic technique, withdraw the appropriate amount of medication from vial or ampule
5. With patient sitting up, have him extend forearm with ventral surface exposed
6. Cleanse surface of ventral forearm approx 2 to 3 fingerbreadths distal to antecubital space
7. Allow skin to dry completely before administering the injection
8. Stretch skin taut ; hold needle at a 15 degree angle to patient’s arm, bevel side up
9. Insert needle approx one-eigth inch below epidermis; stop when needle bevel is just under skin
10. Inject antigen SLOWLY; a wheal should form
11. If no wheal noted, withdraw needle & start again at least 2 in from original site
12. Withdraw needle at same angle as it was inserted
13. Do not rub the site
14. Dispose of syringe and needle
15. Document what agent was given, lot #, exp date, where, how much, date, person administering medication

Question 22

What is the procedure for administering an SQ injection?

Answer 22

1. Identify the patient
2. Wash your hands and put on gloves
3. Select a 2-3 ml syringe with a 24-26 gauge needle that has the appropriate length for your patient (3/8 to 1 inches)
4. Using aseptic technique, withdraw medication from vial/ampule
5. Select injection site
6. Cleanse injection site moving outward in circular manner
7. Allow skin to dry
8. With nondominant hand, pinch skin around injection site
9. Inject needle with bevel up at 45 degree angle
10. If fat fold is greater than 1 inch, the needle may be injected at 90 degree angle
11. Release patient’s skin to avoid injecting in compressed tissue
12. Remove needle at same angle as used for insertion
13. Cover site with alcohol wipe and massage area to distribute drug
14. Document the med given, lot #, exp date, site of injection, date, and by whom it was given

Question 23

What is the procedure for administering an IM injection?

Answer 23

1. Identify the patient
2. Wash hands and put on gloves
3. Select a 2-5 ml syringe with an 18-22 gauge needle that is 5/8 to 1.5 inches long
4. Using aseptic technique, withdraw appropriate amount medication from vial/ampule. Then draw approx 0.2 ml of air into the syringe
5. Select the appropriate IM site
6. Cleanse injection site
7. With your thumb & index finger of your non-dominant hand, press down and stretch the skin of injection site
8. Position the syringe at a 90 degree angle to skin surface
9. Quickly and firmly thrust the needle through the skin and SQ tissue into the muscle
10. Pull back slightly on syringe and check for aspirated blood
11. If blood is aspirated, remove needle & syringe and begin again with new equipment
12. After the injection, remove needle at a 90 degree angle
13. Cover injection site with an alcohol wipe, apply gentle pressure, and gently massage the muscle to help with distribution & absorption
14. Remove alcohol wipe and apply Band-Aid
15. Dispose of needle/syringe in needle box
16. Document the medication given, lot #, exp date, date, site, and by whom injection was given

Question 24

What are the special considerations for administering insulin?

Answer 24

1. Rotate insulin injection sites within anatomic regions
2. Absorption varies from one region to another
   A. To help avoid lipodystrophy
3. When combining insulin types in a syringe, be sure they are compatible
4. Regular insulin can be mixed with all types
5. Before administration, gently roll and invert insulin bottle
6. DO NOT shake the bottle as this can change potency with presence of foam or bubbles

Question 25

What are the preferred SQ insulin injection sites?

Answer 25

Arms
Abdomen
Thighs
Buttocks

Question 26

What are the special considerations for administering heparin?

Answer 26

1. Preferred site for SQ heparin injection is lower abdominal fat pad, approx 2 inches below umbilicus, between iliac crests
   A. Always rotate sites from one side to the other
2. DO NOT inject heparin within 2 inches of scar, bruise, or umbilicus
3. DO NOT aspirate to check for blood return
   A. Can cause bleeding into tissues at site
4. DO NOT rub or massage area after injection
5. If patient bruises easily, apply ice to site for first 5 min after injection

Question 27

Where are pediatric SQ injections usually administered?

Answer 27

1. Fatty tissue over anterolateral thigh of infants

2. Fatty tissue outer upper arm of >12 mos

Question 28

Where are pediatric IM injections usually administered?

Answer 28

1. Anterolateral aspect of upper thigh (vastus lateralis)
   A. Recommended site for neonates/infants
2. Upper deltoid (>36 mos)
3. NEVER use gluteal muscles in children