injections

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some information about injections intramuscular . subcutaneous . insulin

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Injections Done by : Mohammed A Qazzaz

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Routes of Medication Administration Parenteral medication: administration of a medication by injection into body tissues Subcutaneous (SC) – into tissue below dermis of skin Intramuscular (IM) – into the body muscle Intravenous (IV) – into a vein Intradermal (ID)– into the dermis just under the epidermis

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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

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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 it’s storage between successive withdrawals i.e Insulin

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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 2 mils in the Deltoid and up to 3 mls in the gluteal muscle in adults Drugs that are altered or not absorbed by other methods of administration

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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 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

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Syringes Three main parts: Barrel – chamber that holds the medication Plunger – part within the barrel that moves back and forth to withdraw and instill medication Tip – part that the needle is attached to Calibration: Syringe sizes from 1 ml to 50 ml Measure to a 1/10 th or 1/100 th depending on calibration

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Needles Shaft of the needle Length chosen depends on the depth to which medication will be instilled Tip of shaft is beveled or slanted to pierce the skin more easily Gauge: width of the needle (18 – 27 gauge) – a smaller number indicates a larger diameter and larger lumen inside the needle

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Considerations when choosing a syringe and needle Type of medication Depth of tissue penetration required Volume of medication Viscosity of medication Size of the client

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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 gauge = 10mm long (3/8 inch) or 16mm long(5/8 inch) or 25mm long (1 inch) Blue needles = 23 gauge = 25mm long 9 (1 inch) Green needles = 21 gauge = 38mm long (1.5 inches)

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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

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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

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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

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The 7 Rights of Drug Administration Right client Right medication Right dose Right route Right time Right reason Right documentation

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INTRADERMAL INJECTIONS

INTRADERMAL INJECTIONS:

INTRADERMAL INJECTIONS Most often used for PPD Site: the inner aspect of the forearm Needle size is 25 - 27 gauge, 1/2 to 5/8 inch Insert needle at 15 o angle Injection made just below the outer layer of skin If injection does not form a wheal or if bleeding is noted, the injection was probably too deep and should be repeated

INTRADERMAL INJECTIONS:

Review the provider’s order for accuracy Ask the patient/parent if the patient is allergic to the medication Wash your hands and gather supplies, equipment Select proper needle size, length and gauge INTRADERMAL INJECTIONS

INTRADERMAL INJECTIONS:

6 Rights of medication administration Check the expiration date of the medication Check for discoloration etc., discard if questionable INTRADERMAL INJECTIONS

INTRADERMAL INJECTIONS:

Explain procedure to patient/parent Ask for assistance with children Position patient appropriately Prepare injection site with alcohol - air dry Support skin with thumb With bevel up, completely insert bevel at a 15 o angle INTRADERMAL INJECTIONS

INTRADERMAL INJECTIONS:

Inject medication gently, place a cotton ball over the site after needle removal A visual wheal will be produced at the site Dispose of needle as per policy Wash hands Document procedure and patient’s response INTRADERMAL INJECTIONS

INTRADERMAL INJECTIONS:

INTRADERMAL INJECTIONS Correct Technique Tip of needle can be seen directly beneath the surface of the skin Resistance should be felt when medication is injected Tense white wheal 5-10 mm in diameter appears at the point of the needle Incorrect Technique Little resistance and a shallow bulge Needle inserted too deep - will cause an induration that is difficult to measure and interpret

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Subcutaneous injection

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Insulin is the most important drug in the subcutaneous injections

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Insulin Indications Type I diabetes mellitus, type II diabetes mellitus, hyperkalemia, DKA/diabetic coma MOA Stimulating peripheral glucose uptake and inhibiting hepatic glucose production Patient Info Hypoglycemia (BG < 70 mg/ dL ) esp with higher doses Anxiety, blurred vision, palpitations, shakiness, slurred speech, sweating Weight gain Insulin Indications Type I diabetes mellitus, type II diabetes mellitus, hyperkalemia, DKA/diabetic coma MOA Stimulating peripheral glucose uptake and inhibiting hepatic glucose production Patient Info Hypoglycemia (BG < 70 mg/ dL ) esp with higher doses Anxiety, blurred vision, palpitations, shakiness, slurred speech, sweating Weight gain

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Where does it work?

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Insulin ( cont ) Administration: Subcutaneous injection Rotate site Check blood sugars regularly Storage: Refrigerate until use Once vial is punctured, it is good for 28 days and can be left at room temperature (except for glargine which is 90 days)

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Insulin ( cont ) Dosing: Starting daily dose: 0.5-1 unit/kg/day in divided doses Adjust according to fasting ( premeal ) blood glucose of 80-130 mg/ dL and peak postprandial blood glucose < 180 mg/ dL Provide 50% as long acting insulin and 50% as prandial insulin 1 unit of can account for 30 grams of carbohydrate (14-50) 1 unit can lower 50 mg/ dL blood glucose (10-100) Special Population Consderations : Renal dysfunction CrCl 10-50 mL/min: 75% of normal dose CrCl < 10 ml/min: 25-50% of normal dose; monitor closely Exercise??? ---- Acute Stress???

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Insulin Action Rapid/immediate Fast Intermediate Slow 0 2 4 6 8 10 12 14 16 18 20 22 24 Blood concentration Time (hr)

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Insulin Dosing Normal insulin secretion Long-acting Long-acting & Short-acting 70/30 pre-mixed

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Insulin Administration

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Insulin ( cont ) Cautions/Severe Adverse Reactions Severe hypoglycemia (seizure/coma) (BG < 40 mg/ dL ) Edema Lipoatrophy or lipohypertropy at injection site CONTRAINDICATIONS Severe hypoglycemia Allergy or sensitivity to any ingredient of the product

SUBCUTANEOUS INJECTION:

SUBCUTANEOUS INJECTION

INTRAMUSCULAR INJECTION:

INTRAMUSCULAR INJECTION

INTRAMUSCULAR INJECTION:

INTRAMUSCULAR INJECTION

IM INJECTION SITES:

IM INJECTION SITES Deltoid Dorsogluteal Ventrogluteal Vastus lateralis

DELTOID MUSCLE:

DELTOID MUSCLE

GLUTEUS MAXIMUS:

GLUTEUS MAXIMUS

GLUTEUS MEDIUS:

GLUTEUS MEDIUS

VASTUS LATERALIS:

Institute of Nursing Theory and Practice, Prague 2007 VASTUS LATERALIS

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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