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HOW TO GIVE AN INJECTION
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INJECTION OVERVIEW - USING INJECTIONS
There are two main reasons to prescribe an injection. The first is because a fast effect is needed, and the second is because the injection is the only dosage form available that has the required effect. A prescriber should know how to give injections, not only for emergency and other situations where it might be necessary, but also because it will sometimes be necessary to instruct other health workers (e.g. a nurse) or the patients themselves. Many injections are prescribed which are unnecessarily dangerous and inconvenient. Nearly always they are much more expensive than tablets, capsules and other dosage forms. For every injection the prescriber should strike a balance between the medical need on the one hand and the risk of side effects, inconvenience and cost on the other. When a drug is injected certain effects are expected, and also some side effects. The person giving the injection must know what these effects are, and must also know how to react if something goes wrong. This means that if you do not give the injection yourself you must make sure that it is done by someone who is qualified. A prescriber is also responsible for how waste is disposed of after the injection. The needle and sometimes the syringe are contaminated waste and special measures are needed for their disposal. A patient who injects at home must also be aware of this problem.
PRACTICAL ASPECTS OF INJECTING
Apart from the specific technique of injecting, there are a few general rules that you should keep in mind.
1. Expiry Dates: Check the expiry dates of each item including the drug regularly and before using.
2. Drug: Make sure that the vial or ampoule contains the right drug in the right strength.
3. Sterility: During the whole preparation procedure, material should be kept sterile. Wash your hands before starting to prepare the injection. Disinfect the skin over the injection site.
4. No bubbles: Make sure that there are no air bubbles left in the syringe. This is more important in intravenous injections.
5. Prudence: Once the protective cover of the needle is removed extra care is needed. Do not touch anything with the unprotected needle. Once the injection has been given take care not to prick yourself or somebody else.
6. Waste: Make sure that contaminated waste is disposed of safely.
PREPARING FOR INJECTIONS - ASPIRATING FROM AMPOULES (GLASS, PLASTIC)
Materials Needed: Syringe of appropriate size, needle of required size, ampoule with required drug or solution, gauze.
1. Wash your hands.
2. Put the needle on the syringe.
3. Remove the liquid from the neck of the ampoule by flicking it or swinging it fast in a downward spiralling movement.
4. File around the neck of the ampoule.
5. Protect your fingers with gauze if ampoule is made of glass.
6. Carefully break off the top of the ampoule (for a plastic ampoule twist the top).
7. Aspirate the fluid from the ampoule.
8. Remove any air from the syringe.
9. Clean up; dispose of working needle safely; wash your hands.
PREPARING FOR INJECTIONS - APIRATING FROM A VIAL
Materials Needed: Vial with required drug or solution, syringe of the appropriate size, needle of right size (im, sc, or iv) on syringe, disinfectant, gauze.
1. Wash your hands.
2. Disinfect the top of the vial.
3. Use a syringe with a volume of twice the required amount of drug or solution and add the needle.
4. Suck up as much air as the amount of solution needed to aspirate.
5. Insert needle into (top of) vial and turn upside-down.
6. Pump air into vial (creating pressure).
7. Aspirate the required amount of solution and 0.1 ml extra. Make sure the tip of the needle is below the fluid surface.
8. Pull the needle out of the vial.
9. Remove possible air from the syringe.
10. Clean up; dispose of waste safely; wash your hands.
PREPARING FOR INJECTIONS - DISSOLVING DRY MEDICATION
Materials Needed: Vial with dry medicine to be dissolved, syringe with the right amount of solvent, needle of right size (iv, sc or iv) on syringe, disinfectant, injection needle, gauze.
1. Wash hands.
2. Disinfect the rubber cap (top) of the vial containing the dry medicine.
3. Insert the needle into the vial, hold the whole upright.
4. Suck up as much air as the amount of solvent already in the syringe.
5. Inject only the fluid into the vial, not the air.
7. Turn the vial upside-down.
8. Inject the air into the vial (creating pressure). 9. Aspirate the total amount of solution (no air).
10. Remove any air from the syringe.
11. Clean up; dispose of waste safely; wash hands.
SUBCUTANEOUS INJECTION (SC) DESCRIPTION
Subcutaneous injection is the route of administration that is most commonly chosen for injection because it provides a greater comfort level. Alternate sites in order to prevent absorption problems, the risk of infection, or soreness, which may occur if one site is used repeatedly.
Supplies: Syringe with the drug to be administered (without air), needle (Gauss 25, short and thin; on syringe), liquid disinfectant, cotton wool, adhesive tape.
- Alcohol swabs.
- Needle and syringe for subcutaneous injection.
- Band-aid strip.
- Gauze pads.
- Sharp's container.
Procedure Technique Summary:
1. Wash hands.
2. Reassure the patient and explain the procedure.
3. Uncover the area to be injected (upper arm, upper leg, abdomen).
4. Disinfect skin.
5. ‘Pinch’ fold of the skin.
6. Insert needle in the base of the skin-fold at an angle of 20 to 30 degrees.
7. Release skin.
8. Aspirate briefly; if blood appears: withdraw needle, replace it with a new one, if possible, and start again from point 4.
9. Inject slowly (0.5 to 2 minutes).
10. Withdraw needle quickly.
11. Press sterile cotton wool onto the opening. Fix with adhesive tape.
12. Check the patient's reaction and give additional reassurance, if necessary.
13. Clean up; dispose of waste safely; wash hands.
INSULIN MEDICATION - SUBCUTANEOUS INJECTIONS
An insulin syringe has four parts: a cap, a needle, a barrel, and a plunger.
The needle is short and thin and covered with a fine layer of silicone to allow it to pass through the skin easily. A cap covers and protects the needle before it is used.
The barrel is the long, thin chamber that holds the insulin. The barrel is marked with lines to measure the number of medication units.
The plunger is a long, thin rod that fits snugly inside the barrel of the syringe. It easily slides up and down to push the insulin out through the needle. The plunger has a rubber seal at the lower end to prevent leakage. The rubber seal is matched with the line on the barrel to measure the correct amount of medication.
Subcutaneous injection sites (such as insulin) for pregnant women.
Subcutaneous injection sites (such as insulin) for non-pregnant people.
SUBCUTANEOUS INJECTION PROCEDURE
Note: These are a general guidelines for giving an injection using a standard needle-syringe injection unit. Be sure to consult with your health care provider about the medication you are using and follow any product-specific instructions that may be required for your particular situation.
Wash your hands with soap and water. Roll the bottle (vial) gently between your hands. This will warm the medication if you have been keeping the bottle in the refrigerator. Roll a bottle of cloudy insulin until the white powder has dissolved.
Wipe the top of the medication vial for injection with an alcohol swab or a cotton ball dipped in alcohol. If you are using a bottle for the first time, remove the protective cover over the rubber lid.
Remove the needle guard (plastic cap-cover) from the needle and syringe, saving the needle guard. Do not touch the needle. Be sure you are using a proper syringe for subcutaneous injections. Pull back on the syringe plunger to draw up an amount of air equal to the amount of medication that will be used for the injection.
Pull the plunger of the syringe back and draw air into the syringe equal to the number of units of medication to be given.
Holding the vial of medication in an upright position (such as sitting it on a table top), slowly insert the needle into the rubber stopper on top of the vial while holding the syringe barrel carefully. Do not bend needle. Then push the plunger to discharge all the air into the vial. This prevents vacuum.
Insert the needle of the syringe into the rubber lid of the medication bottle. Push the plunger of the syringe to force the air into the bottle. This equalizes the pressure in the bottle when you remove the dose of medicine. Leave the needle in the bottle.
With the needle in the vial, turn the vial upside down and hold both the vial and the syringe together in one hand. The tip of the needle should be in the solution. Hold the vial between the thumb and forefinger, supporting the syringe with other hand, pull the plunger back in a slow, continuous motion until you have drawn into the syringe the amount of medication to be given. Be sure the needle stays in the fluid in vial. Do not touch inside of plunger.
Turn the bottle and syringe upside down and hold them in one hand. Position the tip of the needle so that it is below the surface of insulin in the bottle. Pull back the plunger to fill the syringe with slightly more than the correct number of units of insulin to be given.
Check for clear air bubbles inside of syringe. Small bubbles are not harmful but take up space in syringe. With bubbles present, correct amount of medication may not be prepared. If air bubbles have formed in the syringe, dislodge them by gently tapping the syringe with your free hand while continuing to hold the syringe and vial in the inverted position. Bubbles should rise to the top of the syringe, and then you can push them back into the vial by moving the plunger and slowly pull the medication into the syringe again, stopping at the correct dose. Repeat this procedure until there are no large air bubbles in the syringe. Always double check to make sure you have the correct amount of medication in the syringe. If necessary, draw more solution into the syringe.
Tap the barrel of the syringe so that trapped air bubbles move into the needle area. Push the air bubbles back into the medication bottle. Make sure you have the correct amount of medication in your syringe.
Remove the needle from the vial by pulling it straight out. VERY CAREFULLY replace the needle guard without touching the needle. If the medication needs to be refrigerated, place in the refrigerator.
Remove the needle from the medication bottle. Now you are ready to give the injection.
Prepare the injection site by cleaning the area with an alcohol swab. To do this start at the center, apply pressure, and cleanse in a circular motion working outward. Do NOT retrace your steps. (If this is a wound repair using sutures, wash the wound thoroughly with sterile saline solution and gently dab dry with sterile gauze pads (4X4s) before injecting with anesthetic medication. Do not use alcohol for cleansing sensitive episiotomy or tears in the perineal area of the body.)
Wait a few seconds until the alcohol has dried. This reduces the sting. Remove the needle guard from the needle and syringe filled with medication. Hold the syringe as you would a pencil.
With your free hand, gently pinch up the skin at the injection site. Holding the syringe at a right angle to the site, insert the needle using a quick smooth motion. Going slowly will cause more pain. A 45 degree angle may be used for children or thin adults.
Gently pinch up the skin at the injection site and insert needle in a quick, smooth motion at a right angle to the site.
When the needle is in place, slowly pull back on the plunger to see if any blood flows into the syringe. If some blood does enter the syringe (a rare occurrence), remove the needle and discard the syringe and medication, and prepare another injection. According to Mosby: Nursing Interventions and Clinical Skills Skill 40.3, Routine aspiration is no longer recommended. If no blood enters the syringe, let go of the skin and slowly inject the medication by gently pushing the plunger until the syringe is empty.
Put alcohol swab over needle gently, and pull needle out quickly at the same angle it was inserted. Check for medication leakage at site. Apply pressure to the injection site with a dry, sterile gauze pad. You may note a drop of blood, but there is no cause for concern. If desired, apply a bandage. Without replacing the needle guard on the needle, dispose of the needle into a sharps container.
INTRAMUSCULAR (IM) INJECTION
Follow the same instructions above except these injections are usually given in the large muscle of the buttock. To locate the correct area, divide the buttock into four areas. The injection should be given in the upper, outer portion of the buttock.
The needle should go into the skin on a 90 degree angle, should go into the skin the entire 1.5 inches (the entire length of the needle). A consistent even motion should be used when an injection is administered. The person who is getting the injection should lay face down on the bed or lean over the bed.
When the needle is in the muscle, steady the syringe with hand and pull back on the plunger to look for possible blood in the syringe (this would indicate that the needle is in not in the correct area). Should this occur, simply remove the needle and find a new injection site. You may still use the same medication, but attach a new needle to the syringe. If after pulling back on the plunger no blood was noted, medication remains clear, slowly push on the plunger to administer the entire medication in the syringe.
Pull the needle out straight and quickly. Some blood may appear at the surface of the skin. Place a band-aid at the injection site. Dispose of all needles in a safe manner using a sharps container. Gently massage the area.
Intramuscular injection Supplies: Syringe with the drug to be administered (without air), needle (Gauss 22, long and medium thickness; on syringe), liquid disinfectant, cotton wool, adhesive tape.
IM INJECTION TECHNIQUE PROCEDURE SUMMARY
1. Wash hands.
2. Reassure the patient and explain the procedure.
3. Uncover the area to be injected (lateral upper quadrant major gluteal muscle, lateral side of upper leg, deltoid muscle).
4. Disinfect the skin.
5. Tell the patient to relax the muscle.
6. Insert the needle swiftly at an angle of 90 degrees (watch depth).
7. Aspirate briefly; if blood appears, withdraw needle. Replace it with a new one, if possible, and start again from point 4.
8. Inject slowly (less painful).
9. Withdraw needle swiftly.
10. Press sterile cotton wool onto the opening. Fix with adhesive tape.
11. Check the patient's reaction and give additional reassurance, if necessary.
12. Clean up; dispose of waste safely; wash your hands.
INTRAVENOUS (IV) INJECTION
Sometimes patients must receive medication very rapidly. Other times, medications must be given slowly but constantly. In both of these circumstances, intravenous medication administration may be required. Taking pills or liquids by mouth may not be fast enough to get certain medications into the body. In an emergency setting, medicine must be absorbed quickly. Also, enzymes in the stomach may break down certain delicate medications. As a result, these have to be given directly into the blood stream.
Intravenous is a term that means "into the vein". Intravenous medication administration occurs when a needle is inserted into a vein and medication is administered through that needle. The needle is usually placed in a vein near the elbow, the wrist, or on the back of the hand. Different sites can be used if necessary.
There are two kinds of intravenous (IV) medication administration. An IV "push" is a one time, rapid injection of medication into the bloodstream. An IV infusion is a slow "drip" of medication into the vein over a set period of time, to deliver a constant amount of therapy.
Often, an IV "line" is created to allow easy treatment. This is a cannula or catheter that is placed into a vein to allow medication to be administered often.
Before any IV medications are administered, a health care professional must follow the six "rights" of medication administration. These are:
1. The right patient.
2. The right medication.
3. The right dose.
4. The right time.
5. The right route.
6. The right documentation followup.
Sometimes, an IV medication is given as a "push" or "bolus" dose with a syringe directly into the vein. More often, an IV "line" or peripheral venous catheter (PVC) is inserted for quick and safe access over time.
To insert a venous catheter, a needle is inserted into a vein, most often near the wrist. A thin plastic tube called a catheter is then pushed over the needle. The needle is removed, and the tube remains. Other tubes can be connected to this one with a connecting "hub" or "tap" that remains outside the body.
When an IV line is inserted an IV "drip" is usually started. A drip is a constant flow of sterile liquid from a bag hanging above the patient. The liquid is often a saline (salt) solution. Other medications can be added to this saline solution, and infused into the blood slowly over time. Sometimes a pump is attached to the IV line and pumps liquid into the catheter in a very slow, steady fashion.
For patients who are very sick or who are receiving regular IV therapy for chemotherapy or other reasons, a central line or central venous catheter may be inserted into a vein in the neck or chest.
If you feel anything unusual while beginning IV therapy, tell the health professional treating you. Discomfort and other sensations may be normal. However, they may also be a sign of an allergic reaction, toxicity, or a complication of therapy.
INTRAVENOUS INJECTION PROCEDURE
IV Materials Needed: Syringe with the drug to be administered (without air), needle (Gauge 20, long and medium thickness; on syringe), liquid disinfectant, cotton wool, adhesive tape, tourniquet.
1. Wash your hands.
2. Reassure the patient and explain the procedure.
3. Uncover arm completely.
4. Have the patient relax and support his arm below the vein to be used.
5. Apply tourniquet and look for a suitable vein.
6. Wait for the vein to swell.
7. Disinfect skin.
8. Stabilize the vein by pulling the skin taut in the longitudinal direction of the vein. Do this with the hand you are not going to use for inserting the needle.
9. Insert the needle at an angle of around 35 degrees.
10. Puncture the skin and move the needle slightly into the vein (3 to 5 mm).
11. Hold the syringe and needle steady.
12. Aspirate. If blood appears hold the syringe steady, you are in the vein. If it does not come, try again.
13. Loosen tourniquet.
14. Inject (very) slowly. Check for pain, swelling, hematoma; if in doubt whether you are still in the vein aspirate again.
15. Withdraw needle swiftly. Press sterile cotton wool onto the opening. Secure with adhesive tape.
16. Check the patient's reactions and give additional reassurance, if necessary.
17. Clean up; dispose of waste safely; wash your hands.
COMPLICATIONS WITH INTRAVENOUS MEDICATION ADMINISTRATION
Providing medication intravenously can potentially be dangerous. Infection is possible at the injection site. The entire IV medication administration process must be done with sterile equipment and sterile technique. This should be done by trained professionals, due to the risk of infection.
Some IV drugs that are given as infusions over time can accidentally be given too rapidly as a "push". This may cause toxicity or damage the vein near the site of injection. Phlebitis, or inflammation of the veins, is a risk with intravenous medications.
A vein may be damaged during injection or by the use of an IV catheter line. This is sometimes called "infiltration", where the medication leaks into surrounding tissue rather than going into the blood stream. This can cause damage at the site of entry.
Another risk is an air embolism. If there is air in the syringe or in the bag attached to the IV drip, and the line runs dry, air bubbles can enter the vein. This can lead to air bubbles travelling to the heart and lungs. This causes severe problems in circulation.
Blood clots can form due to IV therapy, and deep vein thrombosis can be very dangerous. Clots become stuck in important blood vessels and cause tissue damage or death.
Medications administered intravenously act on the body very quickly. Toxicity, side effects, and allergic reactions will therefore happen fast. A patient on IV medication should be under observation at all times.
Intravenous drugs are potentially very dangerous. Only qualified practioners such as registered nurses, doctors, or other trained professionals should administer IV therapy.
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