Basic procedures in healthcare 1 (SOL / VCA81) TOPICS: 6a) Preparation and application s. c. inj....

Basic procedures in healthcare 1 (SOL / VCA81)

TOPICS:6a) Preparation and application s. c. inj.6b) Preparation and application i. m. inj.6c) Dilution of drugs

explanation of the terms

way of application

choosing an injection site, the most common application site

tools

general procedure

technique when applying with conventional syringe

technique when applying with insulin syringe

technique when applying with insulin pen

technique when applying with originally packaged syringe

complications of applications

6a) Preparation and applications. c. inj.


Definition:

- it is application of a small amount of medical solution into the dermis,

- administered mainly for therapeutic reasons, exceptionallyfor diagnostic reasons,

- onset of action is slow, it comes in 10 - 20 min.

Way of application

- usually is applied 1-2 ml of medicament,

- the application is performed either 1 or 2 ml syringe, originalsyringe with medication or insulin pen.


Choosing the injection site:

it is important to choose a suitable application site, because it can influence the effectiveness of the medicine,

the rate of absorption is also affected by the depth of injectionand the fat layer,

when long-term application in the same site lipodystrophy can occur (i.e.. fat loss in the application site),

w.g. insulin is faster absorbed from the stomach area than from the thighs,

the most frequently applied medicines s. c. - insulin, anticoagulants.


The most common application site:

the outer side of the arm (in m. biceps brachii),

outer thighs (m. quadriceps femoris),

abdomen (in m. rectus abdominis),

dorsogluteal area (around m. gluteus medius),

application site must be changed!

*

6a) Preparation and application s. c. inj.

The most

common

application

site:

application site s. c. injections


Tools

syringe, insulin syringe, original syringe with drug…(individual depending on the type of drug to be administered),

subcutaneous injection needle (25-30 mm), chosen accordingto the physical constitution of the patient,

disinfection,

kidney / vomit bowl and container for used needles,

cellulose,

adhesive plaster.

*


General procedure:

preparation of the drug on the basis of written prescription (checking of name, concentration, quantity, expiration date, appearanceof the drug and whether the drug is prescribed for that application),

tools preparation,

checking of the identity of the patient, explanation of the procedure, allergies control (drug, disinfection, adhesive plaster),

hands disinfection,

appropriate patient positioning and choice of application site (we never apply in the places of edema, scarring, hematoma, inflammation),

disinfecting the injection site.


Technique when applying with conventional syringe:

see general procedure (slide no. 7),

create a skin fold and administer the injection under the angleof 45°,

loose the skin fold, aspirate (If you see blood in the syringe,it is necessary to exchange the syringe),

apply the drug,

pull out the needle (while holding thecellulose square on the application site),

check the injection site after administration. *


Technique when applying with insulin syringe:


technique of the application of the injection depends on the lengthof a needle, on the physical constitution of the patient and on application site, it is usually recommended to apply it under the angle of 90° without the skin fold, if the length of the needle is 4 mm when applied to the abdomen,

if the estimated distance from the surface of the skin to the muscle is less than the length of the needle → create the skin fold,

if the needle length is ↑ 6 mm, it is always recommended to createthe skin fold (except obese patients),

in cachectic patients, it is applied under the angle of 45 with the skin fold,

insulin is absorbed the fastest from the subcutaneous abdominal,the slowest from the buttocks.


Technique when applying with insulin syringe:

administer the injection under the angle of 90°(45°) with or without the skin fold (according to the needle length, physical constitution of the patient…),

loose the skin fold (if it was created), aspirate (if you see bloodin the syringe, it is necessary to exchange the syringe),

apply insulin,

pull out the needle (while holding the cellulose squareon the application site).

*


Source: http://www.myclickfine.com/injection-technique.aspx, downloaded: 31. 5. 2015

ways of application of s. c. injections


Technique when applying with insulin pen:


on the basis of written prescription count number of units of insulin,

administer the injection under the angle of 90°with or withoutthe skin folds (according to the needle length, physical constitution of the patient …),

it is not possible to aspirate,

press the plunger, and wait approximately 10 seconds,

if the skin fold was created, loose it before pulling out the needle,

pull out the needle (while holding the cellulose squareon the application site).

insulin pen needles to insulin pen

insulin pen


Technique when applying with originally packaged syringe:

- mostly low molecular weight heparins,

follow the information on an instruction leaflet, the best place for the application of the abdomen, do not remove the air from the original syringe, administer the injection under the angle of 90° in the skin fold

and hold it for the whole time of the drug application, do not aspirate, apply medication straight, pull out the needle and slowly loose the skin fold, after application do not massage

the injection site (hematoma inception)!


Complications of applications:

application to the vein,

application to the muscle,

superficial applications,

hypertrophy of subcutaneous binder(injection site is not changed),

lipodystrophy,

skin atrophy,

infecting the injection site.*

explanation of terms

the most common application site

tools

choosing a needle

procedure to locate the injection site in m. gluteus medius

procedure to locate the injection site in m. quadriceps femoris

application technique

application using „Z-track“

complications during and after application

6b) Preparation and applicationi. m. inj.


Definition

- administration of effective drug into the muscle in a volumeof 1-20 ml, for therapeutic or prophylactic purposes,

- effect starts after 5 - 10 minutes,

- administered drugs forms: solutions, emulsions, suspensions.

*



• m. gluteus medius,

• m. gluteus maximus,

• m. quadriceps femoris,

• m. vastus lateralis,

• m. deltoideus.

passing of the sciatic nerve through gluteal muscles



Source: http://what-when-how.com/nursing/administration-of-injectable-medications-pharmacology-and-administration-of-medications-nursing-part-2/, downloaded: 31. 5. 2015


Tools:

prescribed drugs,

syringe 1-20 ml,

intramuscular injection needle 38-76 mm,

kidney / vomit bowl and container for used needles,

disinfectant solution,

cellulose,

adhesive plaster.

*


Choosing a needle:

we choose a shorter needle (4 - 5 cm) in cachectic patients,

we choose a longer needle (5 - 7 cm) with a wider lumenin patients with well-developed muscles or obese,

we choose a needle with a wider lumen at oily substancesor ATB suspensions.

*

different types of needles


Procedure to locate the injection site in m. gluteus medius:

put the wrist on the greater trochanter, toes are pointing upto the head,

we use for the left side the right hand and for the right sidethe left hand,

put a forefinger on the front upper iliac spine, outstretched middle finger put off towards the back and feel the iliac crestand press under it,

the triangle that creates the forefinger, the iliac crest and middle finger is the site for injection.


Procedure to locate the injection site in m. gluteus medius

Source: http://eamos.pf.jcu.cz/amos/kos/modules/low/kurz_text.php?identifik=kos_392_t&id_kurz=&id_kap=13&id_teach=&kod_kurzu=kos_392&id_kap=13&id_set_test=&search=&kat=&startpos=2,

downloaded: 18. 6. 2015

feeling the injection site for i. m. application to gluteal muscles


Procedure to locate the injection site in m. quadriceps femoris:

Source: http://ose.zshk.cz/vyuka/osetrovatelske-postupy.aspx?id=30, downloaded: 18. 6. 2015

the injection site is the middle third of the muscle – the area between the iliac spine and the patella.


Application technique:

see general procedure (slide no. 7), feel the appropriate injection site, stretch the skin with the thumb and the forefinger of the second hand, make a quick and vigorous needle mark under the angle of 90°,

the needle introduce 3-5 cm deep (in cachectic patients underthe angle of 45°- 60°),

aspirate (If you see blood in the syringe, it is necessary to exchange the syringe),

apply the drug slowly (throughout the application hold the needle conus),

pull out the needle after the application (always hold the needle conus, not only the syringe),

the injection site cover with adhesive plaster.


Application using „Z-track“:

suitable for application of drugs strongly irritating subcutaneous - prevents the escape of the drug from the muscles tothe hypodermis,

with the hand shift the skin and hypodermis of about 3 cm from the injection site,

apply the injection and still holdthe skin stretched out to pull the needle,

after withdrawing the needle returnthe skin to its normal position.

*


Source: http://nursingcrib.com/wp-content/uploads/ztrack1.jpg, downloaded: 1. 6. 2015

application using „Z-track“


I. m. injection complications:

• stabbing of nerve (inappropriately chosen injection site)– feeling like tingling, pain shooting to the legs, slight paralysis,

• stabbing of blood vessel (inappropriate injection site) – during aspiration blood appears in the syringe,

• drug encapsulation and abscess formation – in particular when applying on oily solution, when applying badly in adipose tissue or fascia, the cause may be a short needle and inappropriate injection site (the site is reddish, swollen, stiff),

• inflammatory process- resulting from the introduction of infectioninto the injection site during non-sterile procedure (site is reddish, warm, painful, fever can increase),

• stabbing of bone – especially in cachectic patients:→ a hook can be created in case of an impact of the top of the needle to the bone. This can damage tissue when pulling the needle out,→ or the needle can be broken because of the sharp impact.


Stabbing of bone in i. m. inj.

- solution:

if you feel the impact of the needle into the bone, never start with application of a solution in the syringe,

the main principle – do not panic and keep the needle in place and in the same position!!!

gently try to pull up the needle, max. 1-2 mm – if it is possible to pull it out and we do not feel any resistance, pull out the needle,

if we feel it is not possible to pull out the needle – we hold it still in place and we call a physician who should solve this situation surgically (application of anaesthetics, incising of tissue and withdrawing the needle).

6c) Dilution of drugs

explanation of the terms

drug preparation from the ampoule

drug preparation from the vial

dilution of drugs process

examples how to calculate the concentrations of drugs


Definition:

- number of drugs are supplied in vials as a powder which is necessary to dilute,

- dilution is done in sterile conditions right before its administration, drugs are diluted according to an instruction leaflet.

For dilution is used:

aqua for injectione,

saline (NaCl 0,9%),

5% glucose,

diluent, which is partof the package.


Drug preparation from the ampoule: check the drug in the ampoule (name, concentration, quantity,

expiration date, appearance of the drug and whether the drug is prescribed for that application),

remove sterile syringe and needle,, shake the drug in the ampoule so there is non in a neck, disinfect the neck of the ampoule before opening, suck the volume of the ampoule through needle into the syringe

(for sucking use the needle which we will not use for the drug application, do not suck only with the conus of the syringe – it is not sucked the whole amount of drug),

mark syringe barrel (room number / bed number, patient´s name, year of birth, the name and quantity of the drug),

apply as soon as possible after the sucking.


Srug preparation from the vial: check the drug in the ampoule (name, concentration, quantity, expiration

date, appearance of the drug and whether the drug is prescribed for that application),

remove sterile syringe and needle, disinfect the access point of the vial, stab the vial with the suction needle and to suck the drug into the syringe, leave the suction needle with the syringe in the vial with the drug till

the time of application, mark syringe barrel (room number / bed number, patient´s name, year

of birth, the name and quantity of the drug – if we leave needle withthe syringe in the vial with the drug it is not necessary to write nameand amount of the drug),

apply as soon as possible after the sucking, when applying with the needle always replace aspiration needle for application!

ampicillin for injection administration


Dilution of drugs process:

prepare a vial with the drug, remove the metal cover, disinfect the rubber stopper, prepare the diluent, inject diluent into the vial, ensure proper dissolution of the drug

(mix it gently, do not shake), suck the required amount of drug into the syringe, tap the syringe to make bubbles collect at the top of the syringe, replace the needle with an application according to the method

of application (bolus i. v. injection, bolus through a peripheral venous catheter, i. m.), or prepare an infusion with diluted drug.

*


Examples of dilution #1

Prokain Penicilin G

• it supplied in bottles in powder form of volume: 1 500 000 u.,

3 000 000 u., 5 000 000 u. • diluting of vial with volume of 1 500 000 u. 7,5 ml saline we get

a solution having in 1 ml 200 000 u.

• diluting of vial with volume of 1 500 000 u. 15 ml saline we get a solution having in 1 ml 100 000 u.

– How many do I apply, if I administer 350 000 u.?

– How many ml a units will be left in the vial?



Streptomycin

• the vials with volume of 1g Streptomycin are diluted 5 ml saline, then we get a solution having in 1 ml 200 mg (0,1 mlof saline contains 20 mg STM)

- How many do I apply, if I administer 280 mg STM to a child?

- How many do I apply, if I administer 500 mg STM to a child?



• The vial PNC-G containing in powder form 600 000 u., we should administer 100 000 u. With how many ml of saline we dilute the vial, how many we apply and how many we will have left - in the vial in ml and number of units.


Solution – example #3

• 600 000 u. we dilute with 6 ml of saline, then we will have in 1 ml of solution 100 000 u.

• if I should apply 100 000 u., I administer 1 ml of solution

• 5 ml solution will be left in the vial. It will contain 500 000 u.


Examples of dilution #4In the vial there is 1 500 000 IU PNC. You have to apply 1 200 000 IU.

How many ml of PNC you will suck in the injection, if you dilute the amount of the vial:

a) 10 ml NaClb) 5 ml NaCl

----------------------------------------------------------------------------------------

a)

b)


Solution – example #4In the vial there is 1 500 000 UI PNC. You have to apply 1 200 000 UI. How many ml of PNC you will suck in the injection, if you dilute the amount of the vial:

a) 10 ml NaClb) 5 ml NaCl

----------------------------------------------------------------------------------------a) 1 ml = 1 500 000 PNC : 10 NaCl = 150 0001 200 000 : 150 000 = 8 ml PNC when diluting 10 ml NaCl

b) 1 ml = 1 500 000 PNC : 5 NaCl = 300 0001 200 000 : 300 000 = 4 ml PNC when diluting 5 ml NaCl


Examples of dilution #5The vial of Streptomycin (STM) contains 1 g of an active substance.

You have to apply 280 mg of STM. How many ml you will apply if you dilute:

a) 10 mlb) 5 ml

------------------------------------------------------------------------------------------

a)

b)


Solution – example #5The vial of Streptomycin (STM) contains 1 g of an active substance. You have to apply 280 mg of STM. How many ml you will apply if you dilute:

a) 10 mlb) 5 ml

------------------------------------------------------------------------------------------a) 1 000 mg STM : 10 NaCl = 100 mg STM (1 ml STM)280 mg STM : 100 mg STM = 2,8 ml STM when diluting 10 ml NaCl

b) 1 000 mg STM : 5 NaCl = 1 ml STM = 200 mg STM280 mg STM : 200 mg STM = 1,4 ml STM when diluting 5 ml NaCl


Examples of dilution #6The vial of Ampicillin contains 2 g of an active substance. You have to

apply 1,5 g. How many ml you will suck in the injection if you dilute:

a) 20 mlb) 10 mlc) 5 ml

------------------------------------------------------------------------------------------a)

b)

c)


Solution – example #6The vial of Ampicillin contains 2 g of an active substance. You have to

apply 1,5 g. How many ml you will suck in the injection if you dilute:

a) 20 mlb) 10 mlc) 5 ml

------------------------------------------------------------------------------------------a) 2 000 mg AMP : 20 ml NaCl = 100 mg active substance in1 ml AMP

1 500 mg AMP : 100 mg AMP = 15 ml AMP when diluting 20 ml NaCl

b) 2 000 mg AMP : 10 ml NaCl = 200 mg active substance in 1 ml AMP1 500 mg AMP : 200 mg AMP = 7,5 ml AMP when diluting 10 ml NaCl

c) 2 000 mg AMP : 5 ml NaCl = 400 mg active substance in 1 ml AMP1 500 mg AMP : 400 mg AMP = 3,75 ml AMP when diluting 5 ml NaCl

Revision

For how long does the effect of s. c. injection start? What are the most common sites for s. c. injection? What is the procedure when the blood is sucked

into the syringe during aspiration? What will be the application technique of insulin in an obese patient? Do you remove the air from the syringe in the application of low molecular

weight heparin, if you apply it with syringe prepared in advance? Is it recommended to massage the injection site after the injection

application? Please list at least 3 complications of i.m. injection application? Why is it necessary to vary the sites when injecting? What solutions can be used to dilute drugs? f we dilute the drug, we aspire first drug or diluent? Explain why. The patient should receive premedication before surgery: Atropine 0.4 mg

vial containing 0.5 mg in 1 ml. Dolsin 30 mg vial contains 1 ml of 50 mg. How much of which solution will you apply?

Reference:

HŮSKOVÁ, Jitka a Petra KAŠNÁ. Ošetřovatelství - ošetřovatelské postupy pro zdravotnické asistenty. 1. vyd. Praha: Grada Publishing, 2009, 96 s. ISBN 9788024728537.

JIRKOVSKÝ, Daniel a Marie HLAVÁČOVÁ. Ošetřovatelské postupy a intervence: učebnice pro bakalářské a magisterské studium. Vyd. 1. Praha: Fakultní nemocnice v Motole, 2012, 411 s. ISBN 978-80-87347-13-3.

KELNAROVÁ, Jarmila. Ošetřovatelství pro střední zdravotnické školy - 2. ročník. 1. vyd. Praha: Grada Publishing, 2009, 228 s. ISBN 9788024731063.

POKORNÁ, Andrea, Alena KOMÍNKOVÁ a Nikola SIKOROVÁ. Ošetřovatelské postupy založené na důkazech. 1. vyd. Brno: Masarykova univerzita, 2013-2014, 2 sv. (124; 171 s.). ISBN 978-80-210-6331-0.

TONDROVÁ, Bc. Irena. Aplikace intramusculárních injekcí [online]. [cit. 2015-06-01]. Dostupné z: http://www.szsmb.cz/admin/upload/sekce_materialy/Aplikace_intramuscul%C3%A1rn%C3%ADch_injekc%C3%AD.pdf

VYTEJČKOVÁ, Renata, Petra SEDLÁŘOVÁ, Vlasta WIRTHOVÁ, Iva OTRADOVCOVÁ a Lucie KUBÁTOVÁ. Ošetřovatelské postupy v péči o nemocné III: speciální část. 1. vydání. 303 strany, iv strany obrazových příloh. Sestra (Grada). ISBN 978-80-247-3421-7.

IMAGES * (unless otherwise stated) pinterest.com, google.com (key words: „ok“, „not ok“, „injection“, „guestion mark“, … )

Basic procedures in healthcare 1 (SOL / VCA81) TOPICS: 6a) Preparation and application s. c. inj....

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