Procedures - Injections

Question 1

What are 2 types of medications that you would inject using an intramuscular technique?

Answer 1

Antibiotics and Vaccines

Question 2

What 2 types of medications that you would inject using a subcutaneous technique?

Answer 2

Insulin & Anti-coagulants (Heparin and Dalteparin)

Question 3

What 2 sites that can be used to inject subcutaneous heparin?

Answer 3

Lower abdomen & Upper inner arm

Question 4

What is important to do when after the needle has been placed through the tissue layers and is still in the arm?

Answer 4

It is important to STABILISE the needle and syringe after the needle has been placed through the tissue layers.

Question 5

Are vaccines are always injected intramuscularly?

Answer 5

False - Dependent on any underlying conditions; a vaccine may be given deep subcutaneous if warranted.(see your Practical Procedure workbook or the “Green Book”)

Question 6

Prior to inserting a needle through the tissue layers for an intramuscular injection, the skin should be…

Answer 6

Stretched

Question 7

Why is the “skin fold” technique used?

Answer 7

Its used for subcutaneous injections to make sure that there is no muscle involvement.

Question 8

What site is often used to inject PPD Intradermally?

Answer 8

Lower anterior forearm.

Question 9

What must be done before inserting the needle into the skin?

Answer 9

According to the procedure demonstrated in your Injections Session, the intramuscular site is swabbed with a disinfectant swab prior to stretching the skin and inserting the needle through the tissue layers.

Question 10

True or false: After cleansing the skin, it is not necessary for the disinfectant to dry before inserting the needle into the site.

Answer 10

False

Question 11

True or false: A used needle should never be re-sheathed.

Answer 11

True

Question 12

According to Best Practice and Health & Safety considerations, when injecting a patient, a sharps container should be …

Answer 12

At point of use

Question 13

When drawing the medication from a vial then into a patient’s tissue layers what must you remember to do?

Answer 13

Needles should be changed after drawing up the drug and before the Intramuscular injection. This is obvious where one of the specially designed blunt needles has been used, but even where a sharp needle has been used it should be changed as the needle bevel will have been blunted by the insertion through the top of the vial and so will increase the patient discomfort if used.

Question 14

How many staff member(s) should simultaneously check insulin or anti-coagulants drawn up into a syringe and the prescription before it is injected into the patient (minimum number for safety)?

Answer 14

2

Question 15

If an Intradermal injection has been done correctly, what should the staff see at the injection site?

Answer 15

A wheal

Question 16

What should you wear when doing an Injection procedure.

Answer 16

Gloves

Question 17

True or false: You can inject insulin using a 1 mL syringe.

Answer 17

False

Question 18

True or false: It doesn’t matter what size syringe is used to deliver an IM injection.

Answer 18

True

Question 19

True or false: It does not matter what size and length of needle is used to deliver an IM injection.

Answer 19

False

Question 20

True or False: You do not need to cleanse the top of a vial if there was an intact top present.

Answer 20

False

Question 21

When should and when shouldn’t you aspirate when injecting a patient?

Answer 21

Never aspirate heparin! - Get increased hematoma formation which can cause lots of bruises around belly button

Aspirate all intramuscular (usually vaccines) to make sure not going into a blood vessel and ineffective, can also aspirate insulin.

Question 22

Name 2 drugs that require two people to prescribe ?

Answer 22

Insulin and heparin much smaller needles - need two to prescribe because considered more lethal

Question 23

What preparation checks should you do before administering an injection?

Answer 23

● Check the prescription of the medication to be given - drug, dose, date & time to be given, route & method of administration and prescriber’s signature (N.B. mL = millilitre, Unit ≠ mL).
● Check that the medication has not already been given.
● Check that medications and/or diluents are compatible before mixing (e.g. Gentamicin is compatible with 0.9% Sodium Chloride in water) and in date.
● Check that the medication is licensed for the site that you are about to inject into (i.e. if not, another site must be chosen).
● Use standard precautions, including gloves.

Question 24

What rights does the patient have around injections and what should you check with hem before administering ?

Answer 24

9 Rights;
* Right Patient
* Right Medication
* Right Dosage
* Right Time
* Right Route of administration
* Right Reason
* Right Response
* Right Documentation
* Allergy status

Question 25

How do we classify needle diameter?

Answer 25

Needle diameter is described by the gauge, which is usually abbreviated to G. The larger the number the smaller the diameter, i.e. 19G is larger than a 23G. (Nurses may refer to as ‘Green’ (23G) or ‘White’ (19G)

Choice of needle – depends on type of injection (IM, SC, ID), viscosity of medication, medication being given, site of injection and individual patient attributes.

Question 26

When drawing fluids from glass ampoules what type of needle should be used and why?

Answer 26

Where available, “Filter needles” should be used when drawing fluid from ampoules so that glass particles are not injected causing complications. Complications from particles if a filter needle is not used → phlebitis, vascular occlusion & subsequent embolism, formation of granulomas and/ or septicaemia.

Question 27

How do you snap a glass ampoule?

Answer 27

Make sure the blue dot is at the opposite side from you facing away, put on places and hold around orange rings and snap. (orange rings may be a different colour and with no blue dot in some but similar process)

Question 28

What type of a needle can be used for withdrawing medication and what must you make sure to do when done with drawing up the medicine?

Answer 28

There are specially designed blunt needles which have no bevel. This eliminates the risk of needle sticks when transferring drugs/fluids from or into vials OR drawing up of the medication. Wherever such needles are available they should be used. If used, make sure to replace the blunt needle with a sharp needle prior to injecting patient.

Question 29

What are Luer-Lok syringes and why are they used?

Answer 29

A syringe with a Luer-Lok design should be used (this minimizes the chance of the needle and syringe becoming detached during the procedure). Best Practice and National Patient Safety Agency recommend Luer-Lok design for all injectables and non-Luer-Lok for enteral and oral.

Question 30

How should you dispose of needles and what is important to never do?

Answer 30

Dispose of all needles immediately after use into a sharps bin – NEVER resheath or bend used needles. Do not confuse replacing the sheath on clean needles (this will be demonstrated in class) with recapping used needles. You should dispose of the needle & syringe as a single unit after the injection has been given (Or in some facilities now; needle disposed of in a sharps container and syringe in an orange bag or a black bag).

Question 31

What should be done to vials once removing the cap and before drawing up the fluid?

Answer 31

Vials should always be disinfected with an alcohol swab after the loose caps have been removed as the vial caps do not provide sterility.

Question 32

How are Insulin syringes packaged and what is important to remember when it comes to ml’s and units?

Answer 32

All one unit and measurements are in Units (Unit does not equal mL)

Question 33

What is an insulin pen?

Answer 33

Insulin pens – insulin is contained in a cartridge and is for single patient use only

Question 34

What is a Jet infusion set?

Answer 34

Jet infusion set – insulin pen devices that deliver insulin without the use of a needle by driving drug through the skin with rapidly released carbon dioxide from a compressed gas cartridge

Question 35

Whats the difference between single dose and multi-dose vials and what is better?

Answer 35

Single dose vials/ampoules and multi-dose vials – it is always better to use single dose containers if available

Question 36

If using a multi-use vial what is important to do once you have finished your procedure?

Answer 36

if not using all immediately, write the date & time on the vial when first accessed and your initials.

If drawing up two drugs/fluids for injection, it is important not to contaminate the medication/fluids in one vial with the medication/fluid from the other.

Question 37

If drawing up two drugs/fluids for injection how do you choose what order to draw up medicine from a multidose vial and an ampoule?

Answer 37

If one is in a multidose vial and the other is in an ampoule, draw up from the vial first as it may be used again.

Question 38

If drawing up two drugs/fluids for injection how do you choose what order to draw up medicine from a multidose vial and a single dose vial?

Answer 38

If one is in a single dose vial and the other is in a multi-dose vial, draw up from the multi- dose first then the single dose so as not to contaminate the multi-dose,

Question 39

If drawing up two drugs/fluids for injection how do you choose what order to draw up medicine from 2 multidose vials?

Answer 39

If drawing from 2 multi-dose containers, you will need to use 2 separate syringes and needles (to not contaminate either), then combine them.

Question 40

What are the different parts of a needle?

Answer 40

• Metal Needle (also shaft)
• Hub of needle (bit that goes in bin)
• Hub of syringe
• Syringe

See image in workbook

Question 41

What would happen if you injected a vaccine into the subcutaneous layer instead of intramuscular?

Answer 41

Practitioners may accidentally inject into the subcutaneous; the slower vascular absorption will not allow the antigen to present properly to the immune system, resulting in the very low levels of antibody. However,forthosewhohaveablood clotting disorder or are hyper-anti-coagulated, it is recommended to be given deep subcutaneous injection to reduce the risk of bleeding but special attention must be paid to the titre level of the patient who is given a vaccine as a deep subcutaneous injection.

Question 42

What is the Z-track technique?

Answer 42

Z-track is a type of IM injection technique used when a medication stains and/or is extremely irritating. This type of IM injection prevents medication from leaking back up through the needle track and staining or causing irritation. This method will be demonstrated in this session and is now recommended for all IM injections in Scotland by CSMEN (Clinical Skills Managed Educational Network).

Put hand like a karate chop on patients arm to fan out layers when injecting and release after ?

Question 43

How many ml of intramuscular injection is recommended for each site in adults?

Answer 43

● 5 mL maximum should be given in the vastus lateralis, rectus femoris
● 4 mL maximum should be given in large muscles [e.g. dorsogluteal (dorsal part of gluteus maximus)]
● 2.5 mL maximum should be given in the ventrogluteal (ventral part of gluteus maximus)
● 1 mL maximum should be given in the deltoid

Current guidance for IM injections of vaccines recommends that the deltoid or the vastus lateralis should be used (not the gluteal due to the significant subcutaneous tissue layer). Current guidance is to aspirate if using the Dorsogluteal site for IM injection and not to aspirate if using the other sites.

Question 44

What is the most common nerve injury when giving injections?

Answer 44

Nerve injury – the most commonly quoted is the sciatic nerve which can be damaged from incorrectly placed injections in the gluteal region.

Question 45

What do you do if you have blood in the syringe?

Answer 45

Blood in syringe – throw all away in a sharps container and start over - (!!! If you accidently hit a vein or artery do NOT inject the medication!!! – but do press on the injection site until bleeding stops to limit bruising!).

Question 46

If a patients has a blood clotting disorder how should you give a vaccine?

Answer 46

Patients with blood clotting disorders due to diseases such as Haemophilia or anti- coagulation medication for treatment of another condition (e.g. Warfarin as part of Atrial Fibrillation management): in these circumstances, IM injections are contra- indicated due to the risk of developing a large haematoma. In such circumstances, it is suggested that vaccines “be given deep subcutaneous injection to reduce the risk of bleeding” (Salisbury, p.27).

Question 47

What is the maximum volume of medicine that should be injected Subcutaneously and what needle size are used?

Answer 47

Needle gauge sizes most often used are 25G, 26G, 29G or 30G. No more than 2mLs should be injected subcutaneously in any one site. In some patients, who are very thin with little adipose tissue, even less of a volume may be advisable.

Question 48

What technique should you use when giving subcutaneous injections ?

Answer 48

The length of the needle is dependent on patient’s adipose tissue and chosen site. A skin fold (“skin pinch”) technique is used when any needle over 5mm in length is used in adults. There are needles shorter than 5mm now for injecting insulin. The site is dependent on what medication you are injecting.

Question 49

Where do you inject rapidly acting, intermediate acting, premixed and slow acting insulin?

Answer 49

You should also be aware that the drug absorption times/rates differ at different injection sites (e.g. thigh- slow absorption, arm-medium absorption, abdomen-fast absorption, buttocks- slow absorption).

For rapidly acting insulin, the preferred sites are the abdomen and arms.

For intermediate acting insulin, the preferred site is the thighs.

For pre-mixed and slow acting insulin, the preferred site is the buttocks. To reliably predict the effect of a dose of insulin, it is necessary to keep the site consistent for each time of day (and rotate the sites within that site).

Question 50

Where and how do you inject subcutaneous anticoagulants?

Answer 50

While this is not a specific module on anti-coagulants, another one of the most common injections given subcutaneously is heparin/Low Molecular Weight Heparin (e.g. Dalteparin). The most commonly used site for this is the lower abdomen with the upper inner arm and thigh being used when the lower abdomen becomes unviable. Do not rub the site after injecting heparin or LMWH. Do not aspirate the syringe after you insert it. When injecting Heparin, ensure that you use the skin fold technique so that it is NOT injected into the muscle. Per the ‘Scottish Patient Safety Programme’, it is recommended that anti-coagulants be administered at a standard date and time in the day in order to enable clinicians to respond to INR or APTT
Injection Tissue Layers: Subcutaneous
results (under-dosing increases risk of a thromboembolic event and overdosing increases the risk of bleeding); follow local policy/guidelines.

Question 51

What is Lipodystrophy?

Answer 51

Lipodystrophy (disorder of the fatty tissue) is sometimes seen in diabetic patients. It is more likely with poor injection habits e.g. not correctly rotating sites or inappropriately re-using needles. It can be disfiguring and may lower self-esteem. While using a site with Lipodystrophy may be less painful (and so preferred by the patient), the absorption of insulin is unpredictable and can lead to unstable glycaemic profiles.

Insulin needles on insulin pens should not be left attached in-between injections [Insulin crystallizes and needle clogs – inability to inject or blocking during the injection (i.e. full dose not administered)]. If giving an injection via an insulin pen, then you MUST also dispose of the needle.

● Every healthcare facility should have a protocol or guideline for the management of hypoglycaemia/hyperglycaemia. You should understand and be aware of how to access the protocol BEFORE injecting insulin.

Question 52

Why do we do intradermal injections?

Answer 52

Intradermal injections have a local rather than systemic effect and are used primarily when using local anaesthesia or for diagnostic purposes (e.g. allergy testing, Tuberculin testing). Volumes of 0.5mL or less.

Question 53

Where do we do intradermal injections?

Answer 53

ID injection Sites

● Anterior forearm is used for Mantoux Test/Two-step (result to be read 48-72 hours after ID injection)

● Skin over the scapulae or the anterior forearm is used for allergy testing at times

● Local anaesthesia (LA) is injected wherever it is required (works in about 10 seconds)

Question 54

What is the intradermal injection technique?

Answer 54

The bevel should always face upwards and a 10-15o angle to the skin should be used. The needle bevel should be inserted so that it disappears just through the epidermis before injecting (i.e. only the bevel and not the whole needle is inserted). If technique is done correctly, you should have a wheal/ bleb present.

Question 55

What complications may you run int when injecting?

Answer 55

Complications (by any route of injection)
Bevel in “Bevel Up” position

● A patient receiving an incorrect dose of medication is an avoidable error (this is considered a ‘Never Event’). Such errors can be due to poorly written prescriptions, incorrectly written prescriptions, misinterpretation of a prescription, wrong equipment, staff drawing up incorrect dose or a prior dose not being documented.

● Allergic reactions usually occur in the first 20 minutes after injection
-This may present in a variety of ways with one or a combination of the following: dizziness, fainting from acute hypotension, tachycardia, wheezing due to bronchospasm, sneezing, itching, widespread urticarial rash, swelling of vocal cords or face, nausea and/or vomiting

● Serious allergic reactions (anaphylactic or anaphylactoid reactions) where there is cardiovascular collapse or severe bronchospasm may require
-ABCDE approach with IM adrenaline and resuscitation, as necessary.

Question 56

What equipment do you need for administering an injection ?

Answer 56

Equipment List
● Clean Tray
● Gloves
● Appropriate size needle and syringe (or Insulin syringe)
● Alcohol based hand gel
● Orange clinical waste bag
● Blue sharps container
● Apron (as needed)
● Cleansing agent (as per local policy)

Anaesthetic transdermal cream pack (if required) OR
1% Lidocaine (if LA required) & 1 mL syringe with 25G or 23G needle

Question 57

What are the steps for a Intramuscular procedure with Z-Track?

Answer 57

1. Identify patient (First Name, Surname, DOB against Patient ID band).
2. Explain reasons for injection, the procedure and possible complications in the particular patient
3. Obtain and document informed valid consent
4. Choose appropriate site for volume and type of drug. Assess site for counter-indications of use.
5. Check the prescription is correct (N.B. are there any allergies; is the dose appropriate for the patient’s weight, laboratory results where applicable).
6. Gather equipment (gloves, medication, syringe, needles, alcohol swab, dilutent if necessary) and prepare medication using aseptic technique. Note: a vial top needs to be disinfected by swabbing with an alcohol swab after cap taken off. Gloves should be worn if drawing up medications. And check all for expiration date.
7. Perform hand hygiene, apply gloves and disinfect top of vial.
8. Attach needle to syringe
9. Draw up amount of air into syringe equal to amount of medication/fluid withdrawing and then withdraw cap from needle.

10.Puncture rubber top of vial with the needle and inject air into vial.

11.Inverting vial & make sure needle bevel is below fluid level, withdraw amount of medication/fluid into syringe from vial. Remove the needle from the vial.

12.Change the needle.

13.Make sure all air is removed from the syringe and the correct amount of fluid/medication is in the syringe. Remove gloves. Clean up work area.

14.Take all equipment to the patient’s side. Perform step 1-3 again. Perform hand hygiene. Apply gloves.

15. Disinfect skin** for at least 30 seconds and allow to dry for 30 secs (do NOT touch site after decontamination).

16.Stretch skin, insert needle at 90o angle – (quick & smooth– like a dart)

17.If injecting into the Dorsogluteal site…..Aspirate (at least 5 – 10 secs). If no blood aspirated then, inject slowly (≈1ml per 10secs). Inject when muscle relaxed.

18.Wait 10secs.

19.Remove the needle from the site and engage safety mechanism.

20.Dispose of needle and syringe IMMEDIATELY into sharps container – NEVER resheath used needles. ***

21.Do not massage the site. Clean up, remove gloves and Perform hand hygiene. Discard equipment as per local policy.

22.Document the procedure including any complications, that the medication was given and site given.

23.Reassess the patient for any problems after 20 minutes, 2 – 4 hours, 48-72 hours (depending on medication given).

Question 58

What are the steps for a Subcutaneous procedure?

Answer 58

1. Identify patient (First Name, Surname, DOB against Patient ID band).
2. Explain reasons for injection, the procedure and possible complications in the particular patient
3. Obtain and document informed valid consent
4. Choose appropriate site for volume and type of drug. Assess site for counter-indications of use.
5. Check the prescription is correct (N.B. are there any allergies; is the dose appropriate for the patient’s weight, laboratory results where applicable).
6. Gather equipment (gloves, medication, syringe, needles, alcohol swab, dilutent if necessary) and prepare medication using aseptic technique. Note: a vial top needs to be disinfected by swabbing with an alcohol swab after cap taken off. Gloves should be worn if drawing up medications. And check all for expiration date.

NB. Insulin and anti-coagulants should ALWAYS be checked simultaneously by two staff members BEFORE it is injected into a patient.

7. Perform hand hygiene, apply gloves and disinfect top of vial.
8. Draw up amount of air into syringe equal to amount to be withdrawn and remove cap from needle – (put cap on alcohol swab; if not drawing up in the patient’s presence).
9. Puncture rubber top of vial and inject air into vial
10. Invert vial and withdraw amount of medication into syringe – making sure that needle bevel is below fluid level.
11. Make sure that you purge all air from syringe.
12. Scoop up cap – do NOT put cap on by holding the top of the cap with fingers (if not drawing up in the patient’s presence).
13. Take all equipment to the patient’s side. Perform step 1-3 again. Perform hand hygiene. Apply gloves.
14. Disinfect Injection site** (if unsure or immunocompromised patient) for at least 30 seconds & allow to dry for 30 seconds.

15.Pinch up skin to isolate adipose tissue (Use no more than 2 fingers to pinch - so that med isn’t injected into muscle).

16.Insert needle at an angle of 45-90o to the skin (based on needle length & amount of adipose tissue).

17. Stabilize needle (i.e. “stab” and then “grab”).
    Release skin by releasing the skin and Grabbing the needle with that hand. (Depending on needle length & depth of adipose tissue you may need to keep skin fold).
18. Inject medication – (N.B. NEVER ASPIRATE when injecting anti- coagulants!) – over ≈5 seconds.

19.After 5 seconds, Remove needle swiftly. Engage safety mechanism of needle.

20.Dispose of needle and syringe IMMEDIATELY into sharps container – NEVER resheath used needles.

21.Do not massage the site. Clean up, remove gloves and wash hands. Discard equipment as per local policy.

22.Document the procedure including any complications and site given.

23.Reassess the patient for any problems after 30 minutes, 2 – 4 hours, 48-72 hours (depending on medication given).

Question 59

What are the steps for a Intradermal Injection?

Answer 59

1. Identify patient (First Name, Surname, DOB against Patient ID band).
2. Explain reasons for injection, the procedure and possible complications in the particular patient
3. Obtain and document informed valid consent
4. Choose appropriate site for volume and type of drug. Assess site for counter-indications of use.
5. Check the prescription is correct (N.B. are there any allergies; is the dose appropriate for the patient’s weight, laboratory results where applicable).
6. Gather equipment (gloves, medication, syringe, needles, alcohol swab, dilutent if necessary) and prepare medication using aseptic technique. Note: a vial top needs to be disinfected by swabbing with an alcohol swab after cap taken off. Gloves should be worn if drawing up medications. And check all for expiration date.
7. Perform hand hygiene, apply gloves and disinfect top of vial.
8. Disinfect Injection site** for at least30 seconds & allow to dry for 30 seconds.
9. Attach needle to syringe (if syringe is not all one unit already).

10.Draw up amount of air into syringe equal to amount of medication/fluid withdrawing and withdraw cap from needle.

11.Puncture rubber top of vial and inject air into vial.

12.Inverting vial & make sure needle bevel is below fluid level, withdraw amount of medication/fluid into syringe from vial.

13.Make sure that you purge all air from syringe.

14. Disinfect skin per local policy if not already done so AND allow to dry.

15.Position needle bevel upwards and enter at a 10-15o angle to the skin through the epidermis until only the bevel is no longer visible (the bevel will be in the dermis).

16. Inject – if technique is done correctly, you should have a wheal/ bleb present (picture is only to show wheal presenting).

17.Withdraw needle and Engage safety mechanism of needle. Dispose of needle and syringe IMMEDIATELY into sharps container – NEVER resheath used needles.

18. Do not massage the site. Clean up (discard equipment as per local policy), remove gloves and Perform hand hygiene.

19.Document the procedure including any complications and site given.

20. Once the required amount of blood obtained, remove the needle and immediately apply direct pressure to site for 5 minutes or until bleeding stops (with cotton ball or gauze).

21.Reassess the patient for any problems after 5 minutes, 30 minutes, 2 – 4 hours, 48-72 hours (depending on medication given).