AUTHOR: KHRISH MADAVI
A tray containing:
1. Syringes and needles of various sizes according to the need in a covered tray (sterile).
Purpose: there should be minimum two needles: one to withdraw the medicine from the vial and the other one to administer the injection. The needle which is used to pierce the rubber stopper should not be used to give the injection.
2. Transfer forceps in a jar containing antiseptic solution.
Purpose: to handle the sterile articles.
3. Sterile lotion swabs and gauze pieces in sterile containers.
Purpose: to clean the skin at the site of injection.
4. Methylated spirit in a container.
Purpose: to clean the skin.
5. Bowl with water.
Purpose: to receive the used syringes and needles.
6. Kidney tray and paper bag.
Purpose: to receive the wastes.
7. Water for injection (distilled).
Purpose: to dilute the powdered medications.
8. Drug ordered.
9. File to cut open the ampoules.
10. Small covered tray (sterile).
Purpose: to carry the prepared injections (syringes and needles with medication) to the bedside.
To Give Intradermal Injections
Select an area where the skin is healthy, free of any irritation, swelling, oedema, discoloration and where the clothing will not irritate the skin. Usually the intradermal injections are given at the inner aspect of the lower arm, upper aspect of the anterior chest and upper aspect of the posterior chest.
1. Select the medication.
Read the physician’s order. Copy it to the medicine card. Compare the label of the medicine with the medicine card and physician’s orders.
Purpose: observe ‘5 rights of the administration of medicine’ to ensure safety.
2. Wash hands.
Purpose: to practice ‘asepsis’ in the administration of injection.
3. Prepare the medication.
Select appropriate syringe and needle.
Purpose: syringes and needles are handled with the sterile forceps.
Check the whether they are in good working order.
Purpose: to practice economy of time, material and effort.
Obtain spirit swab.
Purpose: to clean the stopper of the vial or ampoule to promote asepsis.
Select the solvent.
Purpose: if the medication is in the powder form.
Recheck the order, medicine card with the label of the medicine and expiry date etc.
Purpose: second safety check to prevent errors.
Calculate the dosage of the medication, the amount of the solvent to be added to obtain the required dosage. If premixed,ascertain the amount of the solution to be drawn for injection.
Purpose: for the accuracy of medication. To prevent underdosage and overdosage of the medication.
Take the solvent in the syringe and introduce it into the vial or ampoule of medication after cleaning the top, and opening them as directed.
Purpose: the medication should be in the form of solution; otherwise it will be lost in the container.
Mix the powder with the solvent by rotating the vial in the palm of the hand (use a strong needle to pierce the rubber stopper).
Purpose: when mixed well, the solution will be clear without lumps.
When mixed well, take out the required amount of solution in the syringe. Change the needle that is used for piercing the rubber stopper. Cover the needle with a cover.
Purpose: when piercing the rubber stopper, the bevel of the needle might bend and become a hook which can traumatize the tissue. A protective cover prevents the needle being contaminated by the air.
4. Keep the syringe with medication in the sterile tray and cover it. Check the order in the medicine card and compare it with the label of the medication. Make sure that you have taken the right medicine and the right dosage.
Purpose: Third safeties check to prevent errors. The needle should not be exposed to the air; air can contaminate the needle.
5. In multi-dose vial, reconstitute the label with identifying data; client’s name, dosage, strength, date and time, and the signature of the nurse who prepared it.
Purpose: for the later use.
6. Return the medication to its proper place (refrigerator if necessary).
Purpose: proper storage prevents deterioration of the medication.
7. Carry medication to the client
8. Identify the client.
Check the bed number, room number etc.
Call the client by name in a questioning manner.
Ask the client to repeat the name.
Ask someone who knows the client.
Check the medication order.
Purpose: at least two checks are essential to prevent errors.
9. Prepare the site for the injection.
Select the site.
Clean the site with spirit swab, using surgical asepsis.
See that the client is in a comfortable position and completely relaxed.
Purpose: to remove the surface bacteria.
10. Inject the medications.
Purpose: correct technique is essential to the safety of the injection.
For Intramuscular Injection:
Spread the tissue between the thumb and forefingerto make the skin taut. Needle is inserted at a 90 degree angle, holding the syringe in the right hand, using a steady push on the needle. With the right hand on the syringe, aspirate blood by pulling back the piston with the left hand. If blood appears in the syringe, quickly withdraw the needle. If no blood comes, give medication slowly by pushing the piston. Remove the needle quickly and massage the site for the quick absorption of drug.
Observation of the Site After Intradermal Injections
If tuberculin test is done (with p.p.d) ask the client to report after 48 hours. Reddened, raised area at the site of injection shows a positive reaction. If the area is not discolored or rashed, it is a negative reaction.
If a test done is given for penicillin injection, observe the area for reactionary changes after 20 minutes to 1 hour. The area will be reddened, the wheel will be increased in case of reactionary changes. The client may complain of itching at the site and elsewhere in the body. If the client is sensitive to penicillin, he may develop the signs and symptoms of anaphylactic shock within few minutes after the injection.
Any unusual symptoms observed should be reported to the charge nurse and the physician. Any client, who is developing increased pulse rate, respiration rate, giddiness, vomiting, wheezing, itching, cyanosis etc., should be treated immediately. Inform the doctor but do not wait for the doctor to come to initiate the treatment. Delay to act can cause the death of the client. Give antihistamines as early as possible.
Preparation of the Client and Environment
1. Identify the client correctly.
2. Explain the procedure to the client to win his confidence and cooperation. Explain the sequence of the procedure and tell the client how he can cooperate in the procedure.
3. Provide privacy with curtains and drapes, if needed.
4. Restraint the site of the injection, in case of children.
5. As far as possible avoid meal timings.
6. Keep the attention of the client away from the injection by friendly conversations and curious articles.
7. Offer bedpan if the client has to remain on the bed for a considerable time before, during or after the injection.
8. Place the client in a comfortable and relaxed position suitable for the type of injection. If the injections are given on the hand, let the client take a lying down position with the hands flexed at the elbow. If the injections are to be given in the buttocks, place the client in a prone position or a lateral position with the knees flexed.
9. Select a site suitable for the route of administration, quantity of medication to be given and the characteristics of medication.
Give intramuscular Injections
Dorsal gluteal site: identify the greater trochanter of the femur and the posterior superior iliac spine. Draw an imaginary line between these two bony landmarks. Site will be the upper and outer quadrant or divide the buttocks into four regions by imaginary lines. Select the site at the upper and other quadrant for the intramuscular injections.
Venous gluteal site: place the tip of the index finger on the anterior superior iliac spine of the client, the middle finger just below the iliac crest. The ‘V’- shaped area is the area in which the injection can be given safely.
Vastus lateralis site: it is located on the lateral aspect of the thigh. It is the area between mid anterior thigh and mid lateral thigh, one hand’s breadth from below the greater trochanter to one hand’s breadth above knee.
Mid deltoid site: locate the lower edge of the acromion process and form a rectangle. The deltoid area is used to inject very small quantities of non-irritating drugs. otherwise most of the intramuscular injections are to be given at gluteal site.
To Give Subcutaneous Injections
Any site is acceptable if it meets the following criteria:
The skin and underlying tissues are free of abnormalities.
Not over bony prominences.
Free of large blood vessels and nerves.
The subcutaneous injections are usually given on the outer aspect of the upper arm, posterior chest wall below the scapula, anterior abdominal wall from below the breasts to the iliac crests and the anterior and lateral aspect of the thigh.
Administration of Injections – Articles, Preparation, Procedure and After Care of Client
Take the following Precautions:
The needle should be long to reach the muscles. Long needle is used for the fatty people and short needle for thin people.
Do not touch the shaft of the needle because it goes into the tissues.
Insertion and withdrawal of the needle should be gentle and quick to minimize the pain.
Aspirate the piston to prevent accidental intravascular deposition of the drug.
The syringe and needle are held firmly throughout the procedure to minimize the tissue injury.
Expel the air from the syringe by holding the syringe with needle vertical at the eye level, taking care not to expel the drug.
Practice Z-track and air lock techniques to prevent tissue damage from irritating medications. Do not massage the area. Massaging the site spreads the medication into the tissue, causing a stain.
Diverting the attention of the client by conversations helps to achieve relaxation of the client.
To Give subcutaneous (hypodermic) Injections:
Much controversy exists among the nurse about the length of the needle and angle of insertions for the subcutaneous injections. A 90 degree angle is normally used with a 5/8 inch needle for obese clients. A 45 degree angle is used with a needle ¾ inch long or longer for an average client or in a thin client.
The technique of giving injection for hypodermic injections will be same as in I.M. injections except the following:
Use only non irritating medications.
Use only a small quantity of medication.
Deposit the medication in a fold formed by picking up a layer of skin and fat.
Be sure to insert the needle beyond the thickness of the skin (the medicine is to be deposited in the subcutaneous tissue).
To Give Intradermal Injections:
This method is used for skin tests to detect allergies. The skin is held taut, by grasping it under the forearm. With the bevel of the needle facing up, insert the needle at an angle of 10 to 15 degree angle to the skin. The needle enters between the two layers of the skin – the bevel should be practically visible through the skin. Inject the medication slowly, to produce a wheel on the skin. A quantity of 0.01 to 0.1 ml of medication is injected intradermally.
Take out the needle quickly. Do not try to clean or massage the area.
Purpose: in order to avoid errors in reading the tissue reaction, a control injection of normal saline is given on the other arm and a careful record is kept.
To Give Intravenous Injection:
Locate the vein and apply the tourniquet between the site chosen and the heart to obliterate the venous circulation. Ask the person to clench and unclench the hands. By pulling the skin taut, place the needle in line with the vein at an angle of 15 to 45 degree angle. Follow the course of the vein and insert the needle into the into the vein. When back flow of blood occurs into the syringe, release the tourniquet and inject the medication very slowly. Apply pressure at the site of the venipuncture after the needle is withdrawn.
Purpose: the intravenous injections may be given when the drug is irritating to the tissues or if a quicker effect is desired.
After Care of the Client and Articles
1. Inspect the area for bleeding. If bleeding takes place apply pressure, but do not massage.
2. Help the client to dress up and take a comfortable position.
3. Ask the client to take rest for 15 minutes to 1 hour especially when the drug is expected to produce some form of allergic reaction in the client.
4. Ask the client to move the limbs to check whether any nerve injury has taken place.
5. Watch for the signs and symptoms of allergic reactions.
6. If the client develops numbness or weakness on walking, it may be due to nerve injury. Ask him to take rest, and inform the doctor.
7. If the client develops pain, redness, induration etc., at the site of injection, apply warmth. Inspect the area for abscess formation. The nurse can prevent these complications using correct method of injection and by rotation of sites.
8. The equipment used for injection – the syringes and needles are put in the bowl of water to prevent the piston stucked into the barrel of the syringe. The particles of blood, drug and tissues may remain dried in the lumen of the needle and it may become blocked.
9. Take all articles in the duty room. Wash with cold water first and then with warm soapy water. Push water through the needle to dislodge any particles present.
Check the needle for any ‘hook’ on the bevel and if found, discard it. After thorough cleaning and drying, send them for autoclaving.
10. Clean all other articles and replace them in their proper places.
11. Wash hands.
12. Record the procedure on the nurse’s record, with date and time. Record the name of the medication, strength, amount administered, the route of administration, the time, the effect, any untoward reactions that have taken place etc. if any allergic reactions took place after the injection, it has to be recorded in capital letters and in red ink, so that it could be easily visible to others and also for the future reference.