Fundamentals of Nursing Care: Concepts, Connections, & Skills Chapter 37 Administering Intradermal, Subcutaneous, and Intramuscular Injections Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills First-Pass Metabolism Metabolism of oral medication by the liver, decreasing the effect of the medication Can be bypassed by using sublingual, buccal, and parenteral routes Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Advantages of Parenteral Administration • Bypasses gastrointestinal tract; no irritation Rapid onset time compared to oral route Ease of administration to uncooperative or unconscious patients Better absorption of drugs that are otherwise poorly absorbed via oral route Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Disadvantages of Parenteral Administration Invasive and uncomfortable for patient Expensive Requires additional supplies and equipment Requires qualified personnel to administer Carries risk of infection and nerve injury Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Types of Syringes Standard syringe Used for intramuscular or subcutaneous injections Insulin syringe Used only for injecting insulin Tuberculin syringe Used for small volumes of meds and TB test Prefilled syringe Single dose, ready to use syringes Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills True/False Question The nurse giving injections in a hospital setting knows that syringes are available in numerous sizes, ranging from 0.3 to 60 mL, with the most common sizes being 1 and 3 mL. A. True B. False Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Answer A. True Rationale: Syringes are available in numerous sizes, ranging from 0.3 to 60 mL, with the most common size being 3 to 5 mL. Each syringe has calibrations marked on the barrel in milliliters or units indicating the volume of medication to administer. Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Parts of a Syringe Barrel Plunger with flange on the end Tip for connecting to the needle Luer-Loc tip: has threaded grooves that screw onto the needle hub and lock it in place Slip-tip: has a smooth, slightly tapered tip that inserts into the needle hub Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Parts of a Needle Angled bevel on the tip of the needle Cannula or shaft Plastic hub Safety guard Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Sites for Subcutaneous Injections Back of the upper arms Abdomen (staying a minimum of 2” from the umbilicus) Anterior aspect of thighs Area of the back just below the scapulae Upper buttocks Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Injection Sites Ventrogluteal: site of choice for those 7 months and older Deltoid: common site for injection of small volumes Vastus lateralis: second choice for injections larger than 1 mL Rectus femoris: last choice of sites, used only in adults (Dorsal gluteal: ONLY if no other site is accessible) Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Maximum Volume to Inject Intramuscularly 3 mL for injecting a large gluteus medius or gluteus minimus of the ventrogluteal site or a very large vastus lateralis muscle of the leg, in an adult 1 to 2 mL for the vastus lateralis muscle in a trim, average size adult, older children with adequate muscle development, older adults, and thin patients 0.5 to 1 mL for the deltoid muscle in small children up through older adults (not infants) 0.5 to 1 mL for the ventrogluteal site and the vastus lateralis muscle in infants older than 7 months and small children Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Gauge of a Needle Refers to the diameter of the needle and is indicated by numbers; the larger the number, the smaller the diameter Gauge used depends on Viscosity of the medication Route of medication Size of patient and muscle mass Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Length of Needles for Injections Intradermal: 1/4” to 5/8” in length with a very tiny diameter between 25 and 30 g Subcutaneous: between 3/8”and 7/8” in length with a diameter between 24 and 29 g Intramuscular: 1” to 1.5” in length, with a diameter between 20 and 22 g Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Administering an Intradermal Injection Position needle with the angled bevel upward Use a 15-degree angle for insertion of the needle Do not aspirate Instill the medication between the layers of the dermis to create a bleb (fluid-filled blister) Do not apply pressure to or massage injection site Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Administering a Subcutaneous Injection Administer the injection at a 45-degree angle; angle of needle insertion and length of needle may vary, based on the percentage of body fat and size of the patient Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Administering an IM Injection IM: use dominant hand to inject at a 90-degree angle into the body of the target muscle Needle should swiftly pierce skin and muscle in one smooth motion Stabilize needle with nondominant hand Aspirate; if no blood, then instill medication slowly Remove needle Cover site with 2” x 2” gauze using nondominant hand, massaging site gently while activating the needle safety guard with dominant hand Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Administering a Z-Track Injection Place lateral aspect of nondominant hand against patient’s skin next to intended insertion site Pull/displace skin and subcut layer 1” to 2” to one side, holding the tissue back Using dominant hand, insert needle swiftly, piercing the skin, tissue, and muscle with one smooth motion Aspirate; if no blood, instill drug slowly Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Z-Track Injection (cont.) After drug is instilled, wait for 5 to 10 seconds before withdrawing needle As you are withdrawing needle, release the tissue held back by your nondominant hand, allowing tissue to close over the needle track in the muscle layer Avoid massaging injection site Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills True/False Question The only part of a needle that can be touched is the barrel. A. True B. False Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Answer B. False Rationale: The only part of a needle that may be touched is the plastic needle cap. The hub of the needle that attaches to the syringe must be kept sterile while you prepare to attach it. Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Safety Reminders Do not recap a needle either new or used (except when you must carry it down the hall to the room) Do not inject air directly into medication Do not contaminate any part of the needle or syringe Avoid using single-dose vials more than once; they do not have preservatives (although multiple-dose vials do) Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Safety Reminders (cont.) Never use multiple-dose vials of bacteriostatic diluent with preservatives to reconstitute drugs intended for newborn injection! Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Causes of Complications From Intramuscular Injections Needle puncture Incorrect technique Drug solution itself Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Types of Medication Incompatibilities Physical: visible reactions such as color changes, precipitate formation, cloudiness, gas formation, or haze Chemical: involves the degradation of the drug resulting from a chemical reaction Therapeutic: occurs within the patient, as the result of two concurrently administered drugs that interact Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Types of Diluents Sterile bacteriostatic normal saline 0.9% (multiple-dose vial with preservatives) Sterile normal saline 0.9% (single-dose vial without preservatives) Sterile bacteriostatic water for injection (multiple-dose vial with preservatives) Sterile water (single-dose vial without preservatives) Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Two Medications Requiring Dosage Verification With Another Nurse Insulin Very rapid-acting, rapid-acting, intermediate-acting, longacting, and very long-acting Heparin 1,000 units/mL, 5,000 units/mL, 10,000 units/mL, and 20,000 units/mL Can be life threatening if incorrect dosage is administered Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills True/False Question When administering insulin or heparin, the nurse should apply gentle pressure to the injection site after removing the needle for better absorption. A. True B. False Copyright © 2011 F.A. Davis Fundamentals of Nursing Care: Concepts, Connections, & Skills Answer B. False Rationale: When giving a subcutaneous injection, the nurse should apply gentle pressure to the site after removing the needle and gently massage to distribute the medication into the tissue for better absorption, unless administering insulin or heparin. Copyright © 2011 F.A. Davis