Anintroductiontothe principlesandpracticeof safeandeffective administrationofinjections

Introduction
Givinganinjectionsafelyisconsideredtobearoutine nursingactivity.Howeveritrequiresknowledgeof anatomyandphysiology,pharmacology,psychology, communicationskillsandpracticalexpertise. Todaywewillemphasisetheresearchbasedpractices thatareknowntoencouragenursestoincorporate bestpracticeintoaneverydayprocedure.

IntendedLearningOutcomes
Recognisethefivereasonswhymedicationmaybegivenby injection(parenteralroute) Differentiatebetweenthestructuresinvolvedandusesofthe intramuscular(IM)andsubcuctaneous(SC) Outlinefactorsinfluencingchoiceofsyringesandneedles Outlinesites,basicpreparationandadministrationtechniquesfor theIMandSCroutes Recognisetheimportanceofuniversalprecautionswhengiving injections

Considerations
Equipment Route Site Technique Safety

Equipment
LuerLok

Forsecureconnections

EccentricLuerslip
Allowsonetogetcloser totheskin

ConcentricLuerslip
Forallotherapplications

Equipment
WhatneedleshouldIuseforIMinjections?

21Gor23G Greenorbluehub Lengthdependson patientandsite

Equipment
WhatneedleshouldIuseforSCinjections?

25gor26g Orangeorbrown hub Lengthdependson patientandsite

Equipment
ParticleContamination BluntFilter/FillNeedles Filteroutsubvisibleparticlesofglass,rubber, fibreandotherresidues.Theinfusionofthese particleshasbeenlinkedwith phlebitis,vascularocclusionandsubsequent embolism,formationofgranulomasand septicaemia. Theyareforusewhenwithdrawingdrugs fromvialsandglassampoules.

Equipment

BluntFill

BluntFilter

Injections
ReasonsforGivingMedicationbyInjection Rapidactionrequired Drugalteredbyintestinalsecretions Drugnotabsorbedbyalimentarytract Patientcannottakeoraldrug Drugunavailableinoralform

PreparationofPatient
Promotecomfortandrelaxation Explainreasonforinjection Describetheprocedure/obtaininformedconsent Checkforanyallergies/historyofanaphylaxis Checkprescription/drug/patientidentify Checkexpirydatesandrecordlotnumbers Avoidoverexposureofpatient Positioningofpatient

Injections
ProcedureforInjections

Selectsite Selectcorrectneedlelengthandsyringe Washhandsandapplygloves Prepareinjectionsusingaseptictechnique

Injections
ProcedureforInjections
Checkpatientidentity Skinpreparation(localpolicy) Injectslowlyandremoveneedle Documentprocedure Reviewtheindividualasappropriate

Injections
PreparationofskinpriortoInjections
Littleevidencetosupporttheneedfordisinfection oftheskinpriortosubcutaneousorintramuscular injection Ifsoiled,however,skinshouldbecleanedbysoap andwaterorcanbedisinfectedbyanalcoholswab (ifalcoholswabhasbeenusedallowthealcoholto evaporatebeforeinjecting) Refertolocalpolicy

Injections
IntramuscularRoute Howmanysitescanbeusedtogivean I.M.injection? 1)TheDeltoid. 2)TheVentroglutealsite. 3)TheDorsogluteal 4)TheVastusLateralis.

Injections
SitesforIMInjections
Deltoid Ventrogluteal Dorsogluteal VastusLateralis

Injections
Traditionallynurses weretoldtodivide thebuttocksinto fourquadrants

INJECTINTO THEUPPER OUTER QUADRANT

Injections
IntramuscularInjection Variabilityinsubcutaneoustissuethickness
Clinicalstudy Cockshott,etal.NewEngl.JMed,307(1982)
dorsoglutealinjectionsin213adults 1inch(or38mm)21ggreenneedle localisationusingCTscans

Conclusions
Only5%ofwomen Only15%ofmen actuallyreceivedIMinjections,allotherinjectionswentinto subcutaneoustissue

Injections
IntramuscularInjections
MRIcloseupscanofthebuttocks Thedistancefrom skintomusclein thispatient(line marked1)is42mm Aninjectiongiven witha38mm (11/2)needle stayedinthefatty SCtissue

Injections
ARecentAdaptationofthisApproach TheDoubleCross Dividethebuttockwithanimaginarycross THENdividetheupperouterquadrantby anotherimaginarycross Injectintotheupperouterquadrantofthe upperouterquadrant

Injections

TheDoubleCross

Injections

TheDoubleCross

Injections

TheDoubleCross

Injections
IntramuscularInjections
VastusLateralis

Bunchupinelderly, emaciatedorinfants Dividethighinto thirds,injectinto bottomoftop1/3

Injections
IntramuscularInjections Deltoid
IdentifytheGreater Tuberosity Move5cms(12inches) belowthesite Rotatearmtoconfirmsite

Injections
IntramuscularInjections
ZtrackingProcedure
Pullskin tautthen Insert needle Removeneedle andrelease skin

Injections
IntramuscularInjections
ZtrackingProcedure
Pullskintaut Keepingskintautwithheelofhandinsertneedleata90%angle Aspirateplungerover510secondsnotinganyblood Ifclearinject1mlevery10seconds Wait10secondsbeforeremovingneedle(Beyea&Nicoll1995) Keepskintautuntilneedleremoved Dontmassagethesite Checkpatientandsite(30minutes)

Injections
IntramuscularInjections
ZtrackingProcedure
Pullskin tautthen Insert needle Removeneedle andrelease skin

Injections
Recommendedmedicationvolumesper musclesite
Ventrogluteal Upto4mlinawelldevelopedmuscle Upto2mlinlessdevelopedmuscle Vastuslateralis Upto4mlinawelldevelopedmuscle Upto2mlinlessdevelopedmuscle Deltoid Upto1mlinawelldevelopedmuscle Upto0.5mlinlessdevelopedmuscle

Injections
SubcutaneousRoute

Injections
SpeedofAbsorptioninInjectionSites

Injections
ProcedureforSubcutaneousInjections
Liftskinfold Punctureskinat90degrees Donotaspirate Injectslowlyandremoveneedle Releaseliftedskinfold

Injections
Scan:ThinPatient
Injectionsperformed withan8mmneedle, Withoutaliftedskin fold(left) Withaliftedskinfold (right) Abdomen

Thigh

Injections
Noliftedskinfold Liftedskinfold

Injections
Correctlyliftedskinfold IncorrectlyLiftedskinfold

Injections
PotentialComplications
Infection
Incorrectlocationofinjectate

Pain Anaphylaxis

Injections
PotentialComplications
Longandshorttermnervedamage Intramuscularhaemorrhage Hittingabloodvessel Sterileabscess Lipodystrophy

LegalandProfessional

Understandthelegal&professionalresponsibilities whenadministeringaninjection.

LegalandProfessional
Traininganddirectsupervisionwithmentor CarryoutprocedureinaccordancewithTrustpolicy Developcompetence Practiceyourskillregularly Donotproceedunlessconfident Documentation

SafetyIssues
Whogetsinjured? 35%areNursingStaff Wheredoestheinjuryoccur? 37%inthepatientsroom/ward Wasthesharpcontaminated? 78%Yes 36%NSIoccurduringuse 19%NSIoccurduringaninjection (intramuscular/subcutaneous)
TM EPINet dataforNeedlesandSyringes2003

Safety
IfIamstuckwithaninfectedneedle whatistherisk?

HBV HCV HIV

1in3 1in30 1in300

Safety
Costtopractitioner
Immeasurablestress Lifestylechanges Possibleprematuredeath

Costtoemployer
Coveringsickness Treatmentcosts Litigation Recruitmentandretentionofstaff

Safety TheNationalAuditOffice(NAO2003)
Thereportstatedneedlestickandsharpsinjuriesaccounted for17%ofaccidentstoNHSstaffandwerethesecondmost commoncauseofinjury,behindmovingandhandlingat18%. AtleastfourUKHCWsareknowntohavediedfollowing occupationallyacquiredHIVinfection Since1996,theHPAhasreceivedreportsofnineHCWswho havebeeninfectedwithHCVbecauseofoccupational exposure With40,000reportedincidentsayearandatleastasmany unreported,needlesticksandsharpsinjuriesareasignificant issue.
Themanagementofhealth,safetyandwelfareissuesforNHSstaffNewedition2005

Safety
StandardPrecautions
Skin Cutsorabrasionsinanyareaofexposedskinshouldbecovered. Gloves Wellfittingcleanglovesmustbewornduringprocedureswheretheremaybe contaminationofhandsbyblood/bodyfluids. HandWashing Theuseofglovesdoesnotprecludetheneedforthoroughhandwashingbetween procedures. Aprons Wherethereisapossibilityofbloodspillage. EyeProtection Wherethereisadangerofflyingbloodsplashes. SharpsContainer Needlesarenottoberesheathedpriortodisposalintoapprovedsharpscontainer.

Safety
SAFEDISPOSALOFSHARPS
Immediatelyafteruse Neverresheathorbendneedles Ifpossible,disposeofneedleandsyringeasa singleunit Dontoverfillsharpsboxes Reportanyaccidents/incidentsinaccordance withyourlocalhospitalpolicy

ManagementofNeedlestick injury
Bleedwoundunderrunningwater Washwithsoapandwater AttendOccupationalHealthdeptassessriskand takeappropriateaction Identifysourceofcontaminationegpatientdetails DocumentandReportincident