Preparing for the Administration of Injections

Sue Cressey Clinical Nurse Trainer

Aims of this session

To understand the reasoning behind the process of collecting the correct equipment administering the correct drug in the correct form at the correct time to the correct person in the correct manner

Objectives of this session

The safe administration of drugs via intramuscular injection - in a safe and controlled manner - having assessed risksand - causing minimal physical and psychological harm, but, maximum benefit to the patient

What is an injection?
Injections are sterile solutions, emulsions or suspensions. They are prepared by dissolving, emulsifying or suspending an active ingredient and any other substances in water for injection. Injecting is the act of giving medication by use of syringe and needle to obtain the desired therapeutic effect taking into account the patients safety and comfort

How are drugs for injections presented?

Single dose preparations a pre - prepared volume of measured drug, in a syringe for single dose use i.e. Flu vaccines, Pneumovax and B12. Multidose preparations multi-dose preparations contain a antimicrobiacteral preservative, are used on more than the one occasion and great care is required for its administration but especially its storage between successive withdrawals i.e Insulin

Where are injectable drugs kept

The label on the packet should in most cases give guidance about storage conditions for individual preparations Drugs should be stored away from light The Cold Chain involves preparations being stored between 2 and 8 degrees and has a traceable record Best Practice ensures all medication is stored in a locked cupboard or fridge If you are in any doubt about the storage requirements for any preparation you should check with the lead nurse, Dr or pharmacist

Why give drugs in injection form

Injections usually allow rapid absorption Can produce blood levels comparable to those of intravenous bolus injections Injections can be given from 1ml and up to 2mils in the Deltoid and up to 5mls in the gluteal muscle in adults Drugs that are altered or not absorbed by other methods of administration

Needle length and size

For intramuscular injections e.g flu, pneumonia and B12, the needle should be long enough to penetrate the muscle and still allow a quarter of the needle to remain external to the skin (Workman 1999) When choosing the needle it is important to assess the amount of muscle, subcutaneous fat and weight of the patient - which in the majority of cases will be a blue needle

Which is which needle?

The correct needle is the key to delivering the drug to the correct area for the maximum effect with the least amount of discomfort The colour at the top of the needle reflects its size the higher the number the smaller the lumen (bore) Orange needles = 25 guage = 10mm long (3/8 inch) or 16mm long(5/8 inch) or 25mm long (1 inch) Blue needles = 23 guage = 25mm long 9 (1 inch) Green needles = 21 guage = 38mm long (1.5 inches)

How do assess the depth of muscle and subcutaneous fat

The deltoid and vastus lateralis muscles should be grasped between the thumb and forefinger to determine the depth of muscle and/or the amount of subcutaneous fat at the injection site

Intramuscular Injections and Pain

Factors that can cause pain are The needle The technique The speed of the injection The solution and composition of the drug The volume of the drug The approach and attitude of person administering the injection

(Workman 1999 and Torrence (1989)

Asepsis and reducing the risk of infection

Good hand washing

Good hand drying

Aseptic technique Good observation and questioning of the client Skin preparation if required

Clinical room preparation for the administration of injections

Protocols/procedure/standards information is available Hand basin for washing hands and/or alcohol hand rub. Area for the client to lie down if unwell Panic button/phone to call for assistance sharps container Gloves Resuscitation /anaphylaxis equipment/drugs Oxygen and appropriate mask if available adequate time for procedure

Equipment for the administration of injections

Clean tray or receiver in which to place drug and equipment 21g needle to ease reconstitution and drawing up (23g if from a glass ampoule Syringe of appropriate size Swabs saturated with isopropyl alcohol 70% Sterile topical swab if drug is presented in ampoule form Drug to be administered Patients prescription to check dose, route and timing Notes available to record administration in accordance with law Gloves, Apron

Procedure for preparation of injections in adults

Action
Collect and check all equipment Check the the packaging of all equipment is intact and drug information leaflet is available

Rationale
To prevent delays and enable full concentration on procedure To ensure sterility. If seal or packaging is damaged discard information leaflet for guidance and prescriptive information To prevent contamination of medication and equipment

Wash hands with soap and water or bactericidal hand rub

Prepare the needle, syringe etc on a tray or receiver Inspect all equipment

To check that none is damaged, if so discard

Preparation cont:

Action
Consult the patients prescription and ascertain the following : Drug Dose is appropriate for the pts age date and time (if applicable) of administration Route and method of administration Diluent as appropriate (if necessary) validity of prescription Signature of doctor

Rationale
To ensure that the patient is given the correct drug in the prescribed dose using the appropriate diluent (if required) and by the correct route

Preparation cont:

Action
check all details with nurse mentor - select the drug in the appropriate volume dilution or dosage and check expiry date Proceed with the preparation of the drug using protective clothing if necessary Evaluate the patients knowledge of the medication being offered. If this knowledge appears to be faulty or incorrect refer to nurse mentor offer explanation of the use, action, dose and potential side effects of the drug involved

Rationale
To minimise any risk of error - to reduce wastage and expiry date ensures drug is safe to give and is still pharmacologically effective

The patient has a right to information about treatment

Prefilled Syringes

Action
Check storage conditions check name and expiry date or signs of damage to the packaging on removing from packaging check name expiry date and syringe for any damage check vaccine is free from particles and colour is correct If you feel that the fixed needle length is not appropriate discuss with lead nurse, do not transfer drug into another syringe expell air from syringe place in receiver until ready to administer

Rationale
To ensure the drug is kept in the appropriate manner to ensure sterility to ensure client/patient does not receive unstable or contaminated medication vaccine not given into the muscle can be painful and have a reduced effect to ensure the correct amount of drug is in the syringe to ensure sterility is maintained help reduce risk of needlestick

Single Dose Ampoules of Solution

Action
Inspect solution for particles and colour if either or both present discuss appropriate methods for discarding with nurse mentor Tap the neck of the ampoule gently Cover the neck of the ampoule with a sterile topical swab and snap top off. If difficult use a file

Rationale
Ensure the patient does not receive contaminated or unstable drugs To ensure the solution is at the bottom of the ampoule To aid asepsis. To prevent aerosol formation or contact which may lead to sensitivity/reaction, prevent injury to the nurse To ensure risk of injecting foreign material into the patient

Check solution for glass fragments discard if present

Ampoules continued

Action
Withdraw the solution, the ampoule can be tilted if required with a needle with a gauge no larger than 21G Re sheath needle, tap syringe to dislodge any air bubbles. Expel air place in receiver until ready to use Note replacing sheath on needle should NOT be confused with resheathing needles AFTER use

Rationale
To avoid drawing up air and any glass particles prevent aerosol formation and ensure correct amount of drug is in the syringe maintains sterility and prevents dropping the syringe and reduces potential risk of needle stick injury

Anxious Patients and Fainters

Adopt a calm and sympathetic approach Prepare the vaccine if possible out of the sight of the patient where possible keep the conversation going to distract the patient If possible ask nervous friends to leave, discourage large groups of supporters explanation that an injection is not the same as having a blood sample taken The bigger they are the harder they fall Fainting more common in those who have not eaten If in doubt lay them down

Skin Preparation

Should the skin appear dirty it should be cleaned with soap and water. Should the client/patient have reduced immunity the skin can be cleaned with an alcohol preparation prior to the injection - but - the alcohol must be allowed to evaporate as it can affect the preparation and/or sting on administration of the preparation

Just before you give the injection

Action
fully expose the limb fully

Rationale
The injection may be given to low and end up as subcut. A tight sleeve can have the same effect as a tourniquet and encourage bleeding at the injection site To reduce discomfort and promote distribution of the drug Reduce risk of injury to the patient and the HCA/nurse from falls and needle stick injury To reduce the risk of error and promote patient safety

Encourage the patient to relax the muscle, by hanging the arm by their side or on their lap Patients should sit or lay down for their injection

Quickly review the pre injection

When not to give an injection

The client/patient is unable to confirm their identity using a variety of methods The client is unsure and records cannot confirm if the client has received the vaccine previously The Client withdraws or refuses to consent Incorrect storage of vaccine, past expiry date There is no prescription for the patient The prescription does not state the clients name, drug, time, dose or route of administration or the writing is illegible If patients have a temperature Pregnancy If clients report a severe local reaction or systemic reaction to the preceding dose refer to nurse mentor

Technique for Intramuscular (IM) Injection

Action
Hold the skin firmly (not bunched) with the free hand Introduce the needle at a 90 degree angle leaving a third of the shaft exposed Aspirate (draw back) the plunger to ensure a blood vessel has not been penetrated. If blood is aspirated remove the needle, change it and start again

Rationale
To allow easy entry of the needle through the skin and displace the subcutaneous fat To ensure the needle penetrates the muscle and facilitate removal of the needle should it break To ensure the needle is in the right place.

IM injection continued

ACTION
Inject the drug slowly

RATIONAL
To prevent pain. To ensure even distribution of the drug To prevent Haematoma formation (bruising) To maintain records, comply with law, prevent duplication, promote continuity of care To ensure safe disposal and reduce risk of injury to self and others To reduce risk of injury

Withdrawn the needle quickly and evenly and apply pressure to any bleeding point Record the administration of the drug according to policy and procedure Dispose of needle and syringe according to policy and procedure
Ensure patient is feeling well prior to discharge

Site on the Deltoid for Intramuscular Injections

An Intramuscular Injection

When It Goes Wrong

You give the wrong drug You give the right drug to the wrong person The client/patient faints The client remembers a previous bad reaction to a previous injection The client/patient complains The client/patient tells you post injection that they may be pregnant/on steroids/having chemotherapy or radiation

REFERENCES

Kassianous George, (2001) Immunization Childhood and Travel Health. Forth Edition. London. Blackwell Science.

Nursing and Midwifery Council

Jane Mallett and Lisa Dougherty, (2000) The Royal Marsden Hospital Manual of Clinical Nursing Procedures 233-236. FifthEdition. London. Blackwell Science UK Guidance on Best Practice in Vaccine Administration (2002)

www.google.com. Intramuscular Injection