Parenteral Injections Flashcards
Parenteral Injection Equipment (minimum)
-Exam Gloves(Not sterile)
-Medication (vials/ampules/pre-packaged others)
-Alcohol Swabs (a lot)
-Appropriate Syringe(s) and Needle(s)
~ Needle to withdraw (blunt/filter)
~ Needle to inject (sharp gauges)
-Medication Labels
-Clean Medication Drawer
If a vial is dark, what can you conclude from the vial?
sensitive to light and needs to be given quickly after drawn
With a liquid or powder med that is given through injections, what do you do exclusively for this med?
reconstitute with diluent (water or sterile water)
What should you always remember to do when preparing medication from a vial? (5)
-Ensure Sealed top
-A secure rubber injection port
-Clean the top before use
-CHECK EXPIRATION!
-Time, Date and Initial Multi-dose vial upon opening
Medication Vials variations
-Single or multi-dose
-Plastic or glass (clear or dark)
-Liquid or powder med (reconstituted with diluent)
What is a gauge?
“diameter”
What type of a relationship does the needle size and the gauge number?
inverted
When the needles are bigger, the number/gauge is
smaller
When the number/gauge is bigger, the needle and bevel are
smaller
Viscosity means
thickness
How to choose parenteral needles?
- Long enough to reach _targeted tissue__ of patients respective to age, weight, and muscle/tissue mass ( to deposit the medicine correctly
- The gauge (diameter) of the needle should be large enough to deliver the viscosity of the medication
Intradermis (ID) needle length
1/2 to 5/8”
Anticoagulants
thin the blood
does not dilute the blood
Subcutaneous anticoagulant (SQ) needle length
3/8 to 5/8”
Subcutaneous insulin (SQ) needle length
1/2 to 5/16”
Muscle (IM) needle length
1 to 1 1/2”
What needle length is most common in adults?
1 to 1 1/2”
Smaller gauge needles are used for __________ solutions.
- What gauge is used?
thinner
- 20-27 g
Larger gauge needles are used for __________ solutions.
- What gauge is used?
thicker
- 18-21 g
Non-Parenteral Needles are used for ____________ meds.
Withdrawing
Non = not for patient
What are the types of non-parenteral needles?
Filter needle
Blunt fill needle
Filter needles
small filter in hub catches debris
What needle do you always use with ampules?
= If not available, use what?
Filter needle (for preventing glass particles from being aspirated)
= use the smallest needle (29g)
What needle do you always use with vials (rubber stopper)?
= If not available, use what?
Blunt fill needle
= use smallest gauge available, or filter needle
After obtaining the necessary medication, what do you do?
Remove the non-parenteral needle
Replace with sterile needle for administration
Why do you never use a non-parenteral needle for injection?
they have a blunt edge and will harm the patient
What technique do you use when ALWAYS recapping a needle?
one-handed recap technique
After recapping the needle, what do you do?
Label the needles before leaving the med room
Before placing a needle in a sharps box, what do you do?
a) recapped
b) placed with needle out
c) all of the above - your choice
all of the above - your choice
What needles are used to prepare a parenteral medication before placing it in the sharps box?
Blunt/filter
T/F: Blunt/Filter needles are allowed in a pt’s room when used for Med Admin.
False - blunt/filter needles are only in the med room to prepare meds
Blunt or Filter Needles are never allowed in the room EXCEPT when
using a blood withdrawal
What are the different types of one-handed recap techniques?
Holding the syringe with one hand
- closing cap against a table, skin
Syringes are calibrated in
mL
Where is the 1st calibrated line of a syringe?
the first line on the barrel near the hub
The volume ordered stops at the
rubber stopper
(read from zero to volume ordered - leading ring)
Volume Ordered stops at what point in the syringe?
leading ring of a rubber stopper
Which type of syringe would you use when giving medications?
smallest syringe needed to correctly deliver the prescription volume
Most Commonly Used Syringes
3 mL
5 mL
10 mL
What parts of the syringe do you maintain asepsis?
Holy and Sacred Parts
Hub (tip)
Needles
Where are the med checks? (3)
Acknowledge HCP Orders
Remove meds from Pyxis and verify with eMAR screen
Take original med val/ampule with syringe to verify at the bedside
How many patients’ medication do you pull at one time?
only one
What is the minimum information included on the prescriber’s orders?
name of medication
dosage/amount
route
frequency
if PRN, the reason for giving
Why do you always examine expiration dates and package integrity?
ensure nothing has been tampered with
When preparing a medication
-Acknowledge HCP Orders – check #1
-Focus and prepare only one patient’s meds at a time
-Clean medication drawer and place cloth
-Remove meds from Pyxis & verify against eMAR on computer screen – check 2
-Check Exp. Date and Pkg Integrity - why?
What do use when selecting the appropriate syringe and needle?
Medication
Volume
Injection site
pt assessment
After obtaining the medication what are the steps while in the med room?
-Perform Hand Hygiene & don Gloves
~Gloves – required for all preparing all parenteral routes
-Prepare parenteral medication(s)–
-Select Appropriate Syringe and Needle – med, vol., injection site, pt assessment
~Maintain an aseptic state of critical components of equipment during preparation and administration – no exceptions!
~Labelthe syringe with a “Blue Label” - med, dose, time, and initial
-Take the original med vial/ampule with a syringe to verify at the bedside (exception is insulin) - 3rd check
What is included on a “blue label”?
drug
strength
date
time
initials
What is charging?
inject air equal to amount of medication for withdrawn
Withdrawing a medication Single Dose Vial
- Cleaning top
- Charge: inject air equal to the amount of medication to be withdrawn (15 secs)
- Withdraw the entire amount from the vial – why? so no one uses the extra
- Discard any extra medication to deliver the exact amount of the medication ordered
- Remove the Blunt Fill needle & attach the sterileneedle
Combining 2 Medications of Vials
Vial A and Vial B or Vial/Ampule
Meds must be compatible!
Cannot exceed acceptable volume for intended site/syringe
Select the appropriate syringe and use a BF needle
Select the appropriate needle to administer
What are the 2 exceptions of Combining 2 Medications from Vial and Ampule?
- Need a blunt fill and a filter needle or FN
- vial 1st, ampule 2nd (charge vial)
Troubleshooting with air and bubbles
~ needle - below fluid level
~ Withdraw slowly
Single Dose Vials:
- Withdraw entire volume from the vial - expect air to follow
- Expel the air and medication, if more than required in the syringe, to ensure the exact dose
Multi-Dose Vials:
- Withdraw more med than you need, leaving the needle in vial, then push the med back into the vial for the exact dose
- If still having issues, tap or thump the syringe gently to move air to the top of the syringe then purge air back into the vial
When using an ampule, why do you use a filter needle ONLY?
possible glass particles
Ampules
Single Dose made of glass (clear/dark)
“sharps” hazard
Scored neck (colored)
Always wear gloves
Need syringe and Filter Needle
Withdrawing from an ampule
- Apply gloves, prepare syringe & attach filter needle
- Hold the Ampule upright and tap the top to dislodge medication from the neck
- Place a barrier (gauze pad) around the neck and break away from you
- Withdraw medication – dispose of excess according to P&P
- Place glass ampule and syringe/needle in sharps box when finished in pt’s room
How do you open an ampule?
Tap at top
Gauze around neck
Break away: bottom away and top to you
Reconstitution
is the process of adding a liquid diluent to a dry or liquid-concentrated ingredient (solute) to make a specific concentration of liquid.
Drugs in powder form retain _______ only for a short period of time once reconstituted - _____ _______ ____.
potency;
short shelf life
T/F: Reconstituted volumes do not always equal the amount of diluent because the medication itself has volume.
True
What dictates which diluent to use?
What diluent is typically used?
label or package insert
- NS or sterile water
If IV or IM is a choice, the diluent is
different
What technique should you use when adding diluent to solute medication?
What needle do you use?
sterile
- Blunt fill
Medication Reconstitution is used for medications in?
What needs to happen before injection?
dry forms, such as powders or crystals
-reconstituted with fluid before they are administered.
Mix well then withdraw medication.
Remove BF needle then attach appropriate needle for injection
T/F:NEVER RECAP used needles
True - contaminated
When you enter the pt’s room, what are the steps?
- Knock … AIDET, assess patient readiness
- Open the patient’s profile and eMAR - scan the armband and confirm “Scanned” on the screen
- ID the patient: name, dob, allergies
- ALWAYS acknowledge/verify information on the screen
- Compare every medication toeMAR(drug, dose,time, volume,reason,etc) – check 3
- Patient teaching –The “What and Why” foreach med
- Scan Medication Barcode -
- always look at the screen to acknowledge and address all pop-ups! This occurs with almost every injection
- Prior to Administration, select appropriate site for medication
- Once the site has been carefully selected
Hand hygiene, don clean gloves, aseptically clean site in circular motion in and around the site selected -
Verify integrity of needle and volume
Inject into a correct landmark, angle, and rate - Withdraw Needle at Same Angle Injected
- Discharge safety mechanism IMMEDIATELY after injection
- Away from You and the Patient!
- Dispose of in Sharps – one needle, one time
NEVER RECAP used needles - Saving documentation …..
- Once a med has been scanned, the screen automatically will say “Given” which means your documentation has been saved
Monitor effects and re-assesspatient, as indicated
“Don’ts” at the bedside
Don’t place trash or items in pt bed
-Don’t leave equipment or meds administration in a room alone
~ place in a tray and dispose of properly when finished
IM Injections sites
deltoid, ventrogluteal, or vastus lateralis
Inject at a rate of ________________ before removing needle - Why?
1 mL/10 sec –wait 3-5 sec
IM Injections Guidelines
- Select Appropriate Syringe and Needle Based on Medication, Volume, Injection Site & the patient
- Position Pt. and landmarks
- Select muscle to accommodate medication
deltoid, ventrogluteal, vastuslateralis - Visualize and palpate for the “belly” of well-developed, relaxed muscle (densest)
- Avoid scars, irritations, bruises, lesions in muscle, etc.
- Post injection, do not rub or massage – Why?
Angle for IM Injections
90 degree
Deltoid Max Volume Recommended
1 mL
Deltoid Recommended Needle length
1”
Deltoid Recommended syringe?
1-3 mL
Deltoid is used for
For Smaller Volumes, Less Irritating Medications (ie: Vaccines, B-12, etc.)
How do you landmark a site?
Position and secure the arm –
Cleanse the site with alcohol & allow it to dry
Assess syringe integrity
Quickly insert a needle into a selected site - 90 angles to the hub
Injectand remove the needle using recommended guidelines
For Deep IM Injections, what are the 1st and 2nd choices?
Ventrogluteal
Vastus Lateralis
Deep IM Injections
Maximum Vol Recommended
3 mL
Z Track Method
Helps deposit the medication and help minimize the risk of medicine going into other tissues
Ventrogluteal and Vastus Lateralis is used for
thicker,painful, or irritating meds (Deep IM)
Deep IM Injection
Recommended syringe?
3 - 5 mL
For a Deep IM injection Inject at rate of _______________, withdraw needle then release Z-track
1 mL ±10 sec, wait 3-5 sec
After injecting the medication, what should you do?
withdraw needle at the same angle injected then release Z-track
Deep IM Injections
Recommended Needle Length
1” to 1 ½”
If blood returns with aspiration on an IM injection,
DO NOT INJECT – Start Over!
Deep IM Technique
- Position patient – lean over table, SIMS
- Select VG or VL site – Always Rotate Sites
- Landmark – flex the leg
- Clean site with alcohol pad– turn over & leave the tip of alcohol pad pointed towards injection site
- Assess syringe for correct vol. and straight needle
- Place heel of hand next to the injection site and z-track
Insert needle quickly 90 degree to hub, 3-5 seconds
If blood returns with aspiration, DO NOT INJECT – Start Over!
How do you correctly landmark ventrogluteal muscle?
- Place your palm on the greater trochanter
- Thumb to groin
- Middle finger to iliac crest
- Pinter finger to iliac spine
*Between the middle and pointer
Avoid what type of muscle? Why?
dorsogluteal
- close to major veins, arteries, and nerves
Vastus Lateralis is located where?
Outer, middle 3rd of the side of thigh
Insulin needles are unique in being
very fragile and permanently attached to syringe
SubQ needle length
3/8-5/8”
Subcutaneous Injections are used for
Insulin
Anticoagulants
SQ Injection Rule of Thumb:
Injectat a 90°angleif you can “bunch” the skin more than 2”; otherwise, inject ata 45°angle
Insulins Types and Needs to Know from Med Sheets
Multi-Dose Vials
Short Acting
Intermediate Acting
Long Acting
Know purpose (why and when)
Teaching
Side Effects/Adverse Reactions
Post Injection Responsibilities
Insulin Rules of Administration
= Before administering, Know/Verify BLOOD GLUCOSE Level or trends and next meal
= Administered in units – never mL!
= Administer all insulins within minutes of preparation
**DO NOT SHAKE - roll in palms to mix evenly **
Which medication is last to be withdrawn and first to be given due to fast-acting proteins?
Insulin
Where is insulin administered?
adipose “fatty” tissue of arms, abdomen, back, or thighs
Lipodystrophy
knots under the skin
Do Not aspirate, rub or massage any SQ injections- why?
displace the dermis and cause hematoma
SQ Insulin injection sites
- What do you avoid?
Alternate/Separate injection Sites by at least 1”
Avoid Areas of Bruising or Lipodystrophy –
Avoid linea alba and umbilicus by at least ” away -
Do Not aspirate, rub or massage any SQ injections- why?
SQ Insulin Administration
- Obtain correct insulin & corresponding label from Pyxis
- Draw dose based on verified BS or standing order and attach insulin label to syringe
– leave insulin vial in pyxis - TPCNoftentimeswill ask another nurse toverify med, amount
Insulin Administration
Select Site, Assess, Cleanse with Alcohol & Allow to Dry
Assess needle and syringe – needle is not bent and fluid in syringe recap
- Bunch the Selected Site
- Typically inject at a 90 angle due to needle size – (to the hub)
– release bunch –
- Wait 3-5 sec & withdraw needle at the same angle
- Do not Aspirate, Rub or Massage –
- Engage safety device and place in Sharps box
SQ - Enoxaparin Injection Do’s
Always:ABDOMINAL Administration –
Properly position pt first – reclining/supine is always best
Assess abdominal “Love Handle” region
– greater than or equal to 4” from the umbilicus
- Avoid Bruised Inj Sites – Must Rotate Sites!
- Administer DEEP – SQ angle is recommended
SQ - Enoxaparin Injection NEVER
Aspirate
Administer IM
Do not Aspirate orExpel Nitrogen Bubbles in which injection medication
Enoxaparin SQ
SQ - Enoxaparin Injection
- Select Site, Cleanse with Alcohol & Allow to Dry
- Bunch During Entire Injection
- Inject90°angle/Deep SQinto”Love Handle” area – to hub
- Wait 3-5 sec & withdraw needle at same angle
- Engage safety device and place in Sharps box
- Safety Device is Very Different
What lab value is important for Enoxaparin and what lab value should you not give it?
Platelet count
less than 80,000
Enoxaparin SubQ anticoagulant
Pre-filled by manufacturer
Cannot change needle
Unique built-in safety mechanism
Strict guidelines for administration
Refer to Med Sheets:
Know why, teaching, side/adverse effects, what labs are important?
ID Injection is used for
allergy testing and TB testing
ID Injections steps
- Select site (free of tattoos (if possible), blemishes, hair, scarring, bruises, etc.)
- Clean area with Alcohol & Allow to Dry
- Stretch middle 1/3 of forearm relatively taut
- Inject at almost parallel angle ( 5-15 degrees)
- Bevel faces up barely under the skin
- Inject – must form a “ bleb or wheal”
- Withdraw and release skin
Do Not Aspirate, Rub, or Massage! –
ID “Bleb or Wheal”
Indicates medication has been deposited into the targeted tissue site correctly
CDC One and Only Campaign
Check Your Steps! Make Every Injection Safe
ManagingPatient Safety, One Injection at a Time
Safe Injection Practices – How to Do It Right
Safe Injection Practices for Healthcare Providers
YouTube CDC Videos: https://www.youtube.com/watch?v=Xsxc2LvMoWs
What is the rate of absorption from quickest to slowest?
Vascularity
Intravenous
Intramuscular
- Ventrogluteal
- Vastus lateralis
SubCutaneous
Intradermal
Parenteral Administration definition
any route od administration that does not involve frug absorption through the GI Tract
Intradermal Injection angle
10-15 degrees (form a “bleb”)
Intradermal Injection uses
- TB testing and allergies sensitivity
Intradermal Injection needle size
25-27 gauge
Intradermal Injection usual site
inner forearm
What type of injection should form a “bleb” when injected?
Intradermal
Subcutaneous Injection angle
Normal to overweight clients
90 degrees
Subcutaneous Injection angle
Thin clients
45 degrees
Subcutaneous Injection uses
non-irritating, water-soluble medication
– Insulin and heparin
Subcutaneous Injection needle size
23-25 gauge
Subcutaneous Injection usual site
abdomen
posterior upper arm
thigh
Intramuscular Injection angle
90 degrees
Intramuscular Injection uses
Irritating, solutions in oils, and aqueous suspensions
Intramuscular Injection needle sizes
22-25 gauge
Intramuscular Injection usual site
deltoid
vastus lateralis
ventrogluteal
Z track method
Do not inject more than ____ mL in vastus lateralis and ventrogluteal.
3
Do not inject more than ____ mL into the deltoid.
2
If the intramuscular injection contains a large volume, what should happen?
divide the larger volume into two syringes and use 2 different sites
Intravenous Injections uses
administering medications, fluids, and blood products
Intravenous Injections angle
25 degrees used when starting an IV
Intravenous Injections needle sizes
16 gauge: trauma
18 gauge: surgery and blood administration
22-24 gauge: children, older adults, and patients with medical issues or stable post-op
Intravenous Injections usual site
medial AC
cephalic
basilic
(hand, wrist, foot, scalp)
The 16 gauge needle is used for
trauma, surgery, rapid fluid administration (bolus)
The 18 gauge needle is used for
administering blood, rapid infusions (bolus), CT scans with IV dye
The 20 gauge needle is used for
medications, routine therapies, IV fluids
The 22 gauge needle is used for
IV fluids, medications
The 24 gauge needle is used for
pediatric pts, elderly pts, very fragile and small veins
Rapid Insulin Names
Generic: Lispro, Aspart, Gluslisine
Brand: Humalog, Novolog, Apidra
Rapid Insulin
Onset:
Peak:
Duration:
~ 5-30 mins
~ 30-90 mins
~ 3-5 hrs
Which insulin is at the highest risk for hypoglycemia?
Rapid Insulin
Short Reaction Insulin Names
Regular
Humulian R, Novolin R
Regular Insulin
Onset:
Peak:
Duration:
~ 30-60 mins
~ 2-4 hrs
~ 5-7 hrs
Regular Insulin is only given through what method
IV
Regular goes Right into the vein
Intermediate Reaction Insulin Names
NPH
Humulin N, Novolin N
Intermediate Insulin
Onset:
Peak:
Duration:
~ 1-2 hrs
~ 4-12 hrs
~ 18-24 hrs
Long Reaction Insulin Names
Glargine, Detemir
Lantus, Levemir
Long-Acting Insulin
Onset:
Peak:
Duration:
~ 1-2 hrs
~ None (lowest risk for hypoglycemia)
~ 24+ hrs
Which insulin do you not mix with any other insulin?
Long-acting
Why is insulin only given SubQ or IV?
GI Tract will destroy insulin if given PO
If the mixture is cloudy, what type of insulin is it?
Intermediate
If the mixture is clear, what type of insulin is it?
Short
What insulin is not given IV?
Intermediate
Mixing Regular and NPH insulin
** You are Not Retired, you are an RN.**
NPH - inject air
Regular - inject air
Regular - withdraw insulin
NPH - withdraw insulin
Lipoatrophy
loss of subcut fat
Insulin is what type of hormone
growth
What is a gauge?
“diameter”
Volume Ordered stops at what point in the syringe?
leading ring of a rubber stopper
What do use when selecting the appropriate syringe and needle?
Medication
Volume
Injection site
pt assessment
CDC’s Campaign says
One Needle
One Stick
One Time
