Injections Flashcards
1
Q
Syringe Parts
A
- Tip; where needle is connected
- Barrel; where the medication goes
- Plunger; pressed to administer medication
- Key parts; the tip, the inside of the barrel
- Keep hands off plunger because it goes into the barrel
- Can touch the outside of the syringe and won’t get contaminated
2
Q
Types of Syringes
A
1) Luer-lock
- Brand name for a needle-less system
- Can screw the needle directly onto the tip of the syringe
2) Tuberculin
- Hold 1mL and have markings of 0.01mL
- Used for accurate dosing
3) Insulin
- Typically come with needle already attached to them
Measured in units (not mL)
3
Q
Determining volume in a syringe
A
- Two rings; bottom and top
- Want to read it from the top ring
4
Q
Types of Needles
A
- A lot of syringes don’t come with needles attached; need to add them
1) Hypodermic needle - Creates puncture in the skin
- Slanted hole not round
2) Blunt needle - For drawing up medication from vile and ampules
- Sometimes comes with a filter to ensure glass doesn’t get into it
5
Q
Needle Parts
A
- Bevel at tip; creates the slit in the skin as opposed to a hole
- Hub; comes in colours, usually associated with the gage of the needle (the diameter of the needle)
6
Q
Safety Shields
A
- Once you’ve used the needle, you flip up the safety shield to prevent accidental injuries
- Some automatically retract
7
Q
Sizes and Types of Needles
A
1) IM Adult - 5/8"-1" if <130lbs - 1"-1 1/2" depending on weight - 22-25G Infant and Children - 7/8"-1" - 22-25G
2) SC
- 5/8”
- 25G
3) ID
- 1cm
- 26-27G
8
Q
Considerations for selecting a needle for injection
A
1) Size of patient
2) Location of injection
3) Medication you’re giving
9
Q
Preparing Ampule Injections
A
- Tap the neck; give it a quick flick to try and get any extra medication out of the lid
- Cover top with alcohol swab; minimize exposure to cutting yourself
- Open away from you; glass shards away
- Use filtered needle
- Dispose in sharps container
- Can aspirate medication with either ampule inverted or on a flat surface; won’t leak due to surface tension
10
Q
Preparing Vial Injections
A
- Most vials are single use
- Take alcohol swab, swab the top and let it dry
- Draw air into syringe equal to the amount you want to get out of medication
- Inject that directly into vial; creates a pressure inside and easier to draw out
- After drawing in medication remove any air bubbles by flicking or tapping
11
Q
Reconstitution
A
- Diluent or solvent is a liquid used to dissolve a powder (to reconstitute); cannot be stored in a stable liquid form
- Depending on how much diluent we add to a vial, we change the concentration of strength of that solution
- For a multi-dose vial, add date and time reconstituted, amount of diluent added and signature
12
Q
How to reconstitute
A
- Cleanse top of vial with alcohol swab
- Draw up the amount of air we need; inject it
- Invert the vial, get liquid back out into syringe
- Clean top of second vial
- Inject the solution (the diluent) into the powder
- Gently roll it around to ensure it is mixed (gently to prevent lots of air bubbles)
13
Q
What are compatible medications?
A
Compatible meds can be mixed into one syringe
- Check compatibility chart in drug book or wall chart in med room
- C= compatible
- I = incompatible
- Nothing means not enough information, so act as though incompatible
14
Q
Principles of Mixing Medications
A
1) Do not contaminate one med with another
2) Ensure the final dose is accurate
3) Maintain aseptic technique
15
Q
Mixing Insulin in one Syringe
A
Principles:
- Do not contaminate one type of insulin with the other
- Inject air in both vials and withdraw the clear insulin first
CLEAR BEFORE CLOUDY
- Clear is usually the fast acting insulin
- Cloudy is usually the slow acting insulin
- Don’t want to contaminate the clear insulin
Steps:
- Inject air into the cloudy
- Inject air into the clear
- Draw up the clear
- Draw up the cloudy
16
Q
Using Pre-filled Syringes
A
- Come filled with the medication so you don’t need to draw it up
- Some come with needle, some don’t
- All are a bit different, need to read manufactures instructions
- 10 rights of medication administration
17
Q
Using Auto-injectors
A
- Follow manufactures instructions
- May provide practice kits for teaching purposes
- Usually for patient who are anaphylaxis
- “Orange to the thigh, blue to the sky”
18
Q
Routine Practices of Injections
A
- Used all the time with all clients regardless of diagnosis
- Apply to most body substances
- HCPs make a judgement about what routine practices to implement (i.e. gowns, masks, eye protection, shields, gloves)
- Safe disposal of sharps in the sharps bin
19
Q
Types of Injections
A
1) Intradermal (ID); into the dermis or just below the epidermis - 10-15 degrees
2) Subcutaneous (subcut/SC); into the issues below the dermis, often adipose tissue - 45-90 degrees
3) Intramuscular (IM); into the muscles - 90 degrees
4) Intravenous (IV) - 25 degrees
20
Q
Intradermal Injections (ID)
A
- For allergy testing, Mantoux (TB) skin test
- Into the dermis
- Sites: inner arm, upper back
- Use 1mL tuberculin syringe with pre-attached 26-27G needle (~1cm length)
- Angle 5-15 degrees, bevel up
- Small bleb appears during injection
- NO ASPIRATION
- Do not massage
- Maximum volume: 0.01-0.1mL
21
Q
Subcutaneous Injections (SC)
A
- For insulin, LMWH, some immunizations
- Into loose connective tissue under the dermis
- Slow absorption than IM
- 5/8” (1.6cm) needle length
- 25-30G
- Angle 45 degrees (slim limbs or abdomen with little subcutaneous tissue) or 90 degrees (not within 5cm of umbilicus)
- Sites: Abdomen, back of the arms
- NO ASPIRATION
- Maximum volume: 0.5-1mL
22
Q
SC Injection Technique
A
- Important not to use the same injection site over and over; prevent infection, bruising, soreness, etc.
- Lypohypotrophy; small bubbles of fat accumulate under the skin and don’t want to inject into them if they exist
- Abdomen offers the fastest absorption for any SC injection sites; good for diabetics
- Insulin pens; are SINGLE USE (change the little tip), and dedicated to ONE CLIENT
23
Q
Intramuscular Injections (IM)
A
- Fast medication absorption due to vascularity (10-30mins)
- Less risk of causing tissue damage in deep muscle
- Good for irritating medication as there are fewer nerve endings in deep muscle
- For influenza, pneumonia, HPV vaccines
- Sites: ventroglutal, vastus lateralis, deltoid
- Needle lengths; long enough to reach muscles
- 5/8”-1” for infants, toddlers, and older children
- 1”-1 1/2” for adolscents and adults
- 22-25G
- Angle of 90 degrees
- Maximum volumes: 1mL for infants and small children, 2mL for children, older adults and thin people, 3mL for well developed adults
- Deltoid maximum of 1mL
24
Q
IM Injection Sites
A
- Ventrogluteal
- Vastus lateralis
- Deltoid (site of choice for immunizations for adolescents and adults)
- Dorsogluteal
25
Reminders before IM injections
- Assess site first to ensure its free from infection, abrasions, bruising, etc.
- Looking at the muscles; use well developed side as opposed to atrophied side
26
Ventrogluteal Injections
- Preferred site for IM injections in general for adults and children older than 1 year
- Adults can tolerate up to volumes up to 3mLs
- Exception; deltoid is site of choice for all immunizations for adolescents and adults
Recommended safest site
- Underlying muscles (gluteus medius) is well developed and thick
- Free of nerves and blood vessels
- Easily palpable bony landmarks
- Subcutaneous fat is thinner than dorsogluteal site; less likelihood of injection into subcutaneous tissue
27
Land Marking for Ventrogluteal Injection
- Positioning; client lies on side of back, flexing knee and hip helps relax muscle
- Place heel of hand over GREATER TROCHANTER of client's hip, with wrist perpendicular to the femur (Rt hand for Lt hip, Lt hand for Rt hip)
- Point thumb toward client's groin and fingers toward client't head; point index finger to the ANTERIOR SUPERIOR ILIAC SPINE (ASIS), and extend middle finger back along iliac crest toward buttock
- The index finger, middle finger, and the iliac crest form the triangle (injection site centre of triangle)
28
Vastus Lateralis Injections
- Site of choice for infants
- Thick and well developed
- Free of major nerves and blood vessels
- Very easy to access
- Adults can tolerate volumes up to 3mLs
- Can be used by patients who administer their own injections
29
Land Marking for Vastus Lateralis Injections
- Positioning; supine or sitting
- Site: anterior lateral aspect of the thigh
- Handbreadth above the knee to and handbreadth below the greater trochanter of the femur in the adult
- Lateral aspect of the middle third of the thigh muscle
30
Deltoid Injections
- Predominantly for immunizations and emergencies (i.e. adrenaline)
- Used for immunizations in some children, adolescents and adults
- Used for small volumes only (for adults <1mL is best)
- Axillary, radial, brachial, and ulnar nerves as well as brachial artery lie in the upper arm along the humerus
31
Land Marking for Deltoid Injections
- Expose full upper arm and shoulder; client may need to remove arm from garment
- Ask client to relax arm and flex elbow
- Palpate the lower edge of the ACROMION PROCESS
- The injection site is in the middle of the deltoid muscle, about 3-5cm below the acromion process (~3 finger widths)
- Injection should never be given below the level of the axilla
32
Dorsogluteal Injections
- DO NOT USE
Why is it NOT recommended
- Slowest absorption of all four sites
- Greatest risk of complications
- Thicker subcutaneous tissue; more risk of injections into subcutaneous tissue and this poor absorption
- Puncture injury to superior gluteal artery
- Injury to sciatic nerves causing problems ranging from foot drop to paralysis of lower limb
33
Z-Track Method (Zig Zag)
- For highly irritating substances (e.g. Imferon, depot injections)
- Seals medication into muscle tissue, reduces pain
- Some authors advocate giving all injection by Z-track; practice guidelines catching up
Procedure
- Pull skin and underlying tissue to side ~2.5-3.5cm
- Hold skin taught and inject slowly
- Leave needle in place for 10 seconds
- Withdraw needle and release skin
34
Best Practices for IM Injections
1) Consider CHANGING NEEDLES after drawing up medication and prior to administration where possible
2) Use a needle of APPROPRIATE LENGTH to ensure medication is deposited into the muscle bed
3) Always use BONY LANDMARKS to landmark for IM injections
4) Use the VENTROGLUTEAL site unless contraindicated (exceptions: immunizations and injections for infants and children <1year)
5) Consider WEARING GLOVES for the injection
6) Swab the site with na alcohiol wipe pre-injection using MECHANICAL FRICTION and CIRCULAR MOTION, let sit dry before injection
7) Quickly and smoothly plunge needle into skin at 90 DEGREE angle
8) NO ASPIRATION
9) In adults, inject medication at a rate which does not exceed 1mL per 10 seconds. Use RAPID INJECTION TECHNIQUE (1-2secs) in children to reduce pain
10) Withdraw the needle RAPIDLY, apply pressure to the bleeding point if needed
35
Post Injection Safety
- Dispose of needles in sharps container
- Hang hygiene
- Observe client for 15 minutes following vaccination
- Educate client about side effects and follow up
- Document
36
Injection Comfort Considerations
Multiple Injections
- See if they can be mixed in one syringe
- Give stinging substances last
Special populations
- Older clients
- Clients taking anticoagulants
- Clients who are anxious or afraid
- Clients who faint
37
Injection comfort techniques for infants and children
- Breastfeeding
- Oral sucrose
- Topical anesthetics
- Oral anesthetics
- Seated position
- Rubbing or stroking the skin near the injection site
- Distraction
- Other vaccine administration methods where possible
38
Risk of Needle Stick Injuries
Depends on many factors:
- Type/depth of injury
- Type of instrument (hollow bore vs solid needle)
- Amount of blood
- Amount of virus/stage of illness
- Susceptibility ot HCP
39
Risk of becoming infected when pricked with a contaminated needle
Hepatitis B - 30% if unvaccinated
Hepatitis C - 1.8%
HIV - 0.3% (1 in 300) after percutaneous exposure and 0.09% after mucous membrane exposure
40
Causes of Needle Stick Injuries
1) Patient actions
- Combative patients
- Unexpected movements
2) Sharps disposal
- Overfilled containers
- Lack of access to containers
- Recapping
- Poorly designed safety devices (e.g. needle remains exposed, devices that must be disassembled)
3) Equipment
- Devices with tubes (e.g. butterfly needles)
4) Work conditions
- Crowded work environment
- Time constraints, rushing
- Breaks in concentration
41
Preventing needle stick injuries
Avoid exposure
- Take time with administration and disposal
- Wear gloves for administration
- Expect the unexpected
- Be careful during emergent situations
- NEVER recap
Sharps containers
- Horizontal drop
- Have container close to place where vaccine administered
- Don't overfull containers
- Safety Engineered Safety Devices/Safety Sharps/Safe Needles
- Report incidents and near misses
42
What to do if you have a needle stick
- First Aid
- Wash area with soap and water
- Allow to bleed gently for 30-60 seconds
- Do not pressure to stop bleeding but don't squeeze to promote bleeding either
- Report exposure immediately to supervisor
- Seek medical attention ASAP
- Follow individual agency policy
- Report to ER for bloodwork and possible post-exposure . prophylaxis (PEP)
- Serologic testing of the source client for HBV, HCV, and HIV is the most reliable method to assess risk of exposure
- PEP ideally within 24 hours
- Document the incident
- Follow up testing and counselling
43
Why is insulin given as an injection?
Because insulin is a protein, if it were taken orally, it would break down and be destroyed in the GI tract.
44
Techniques to minimize client discomfort associated with injections
1. Use a sharp-bevelled needle in the smallest suitable length and gauge
2. Position the patient as comfortably as possible, to reduce muscular tension
3. Select the proper injection site, by using anatomical landmarks
4. Divert the patient’s attention from the injection by asking open-ended questions
5. Insert the needle quickly and smoothly to minimize tissue pulling
6. Hold the syringe steady while the needle remains in the tissues
7. Inject the medication slowly and steadily
