Preparation for Practice - Injections Helen Ballinger May 2012

Aim Staff will gain an understanding and appreciation of the role and responsibilities of the nurse and Assistant Practitioner in the administration of subcutaneous (SC) and intra-muscular injections (IM).

Learning Outcomes On completion of the workbook, and clinical skills session the staff will be able to: Explain the reasons for giving medication via different routes. Identify the anatomical sites for giving injections. Recognise the Nursing and Midwifery Council (NMC) Code of Conduct (2008). Demonstrate the procedure for the safe administration of subcutaneous/ intramuscular injections.

What needle?

Why drugs are given by Injection. Cannot be absorbed orally e.g. Insulin Pt NBM or unconscious / intubated Absorption of drug is quicker than oral route, e.g. analgesia Might need slower absorption, e.g. depot injections Vaccinations Anti coagulant therapy

Standard precautions before and after giving an injection BEFORE: Wash hands Wear gloves (apron if barrier nursing) The 6 Rights AFTER: Correct disposal of sharps Documentation Wash hands

Giving an Injection in the community- things to consider You may not wish to wash your hands! Use of alcohol gel Small portable sharps bin & equipment Safe transport / storage of drugs in pt’s home Recognise potential for anaphylaxis / adverse reaction to drug given Effectiveness of the drug

Routes by which an injection may be administered IntradermallyHormones SubcutaneousInsulin / fragmin IntramuscularHydroxocobalmin (B12) IntravenousAntibiotics Intrathecalwithin a sheath e.g. cerebro–spinal fluid e.g. chemotherapy

Routes of Administration A = Muscle B = Intadermal C = Subcutaneous

What measures can be used to reduce injection discomfort? Use larger gauge needle so pressure of injection is lower Change needle before administering drug Select a site free from irritation Rotate injection sites Numb skin with EMLA cream or ice pack Insert and withdraw needle without hesitation

Muscle Avoid bony areas- take care in choosing sites Patient to lay prone and point toes inward when receiving the injection into the Dorsogluteal site Perform deep breathing and other relaxation techniques before receiving an injection Avoid watching when the injection is given Ambulate or move the extremity where the injection was the injection as much as possible

Points to consider before giving an injection: Think about the NMC’s ‘Code of Professional Conduct & Guidelines for the Administration of Medicines’ Reflect on what you have seen in practice.

Consider – The Medication Have I read the code of conduct? Have I read the Trust policy? Do I know what to do if the client has an anaphylactic reaction? Do I know what the drug does? Do I know why the client is prescribed the drug? Do I know how to give the drug correctly? Do I know the contra-indications and side effects? Have I read the drug chart correctly?

Consider – The Equipment Plastic tray or appropriate clean surface Syringe- correct for the amount of fluid to be injected Needles x 2 – correct size for the type of injection and size of client Drug/sharps box Alcohol swab Gloves (? Apron) Patient’s drug chart

Consider – The Patient Obtain consent Check patient's name band or verbally DOB Check with drug chart/patient’s notes and patient for allergies Check when drug was last given Does patient know what the drug is for and if they have any side effects? Have you checked the prescription chart? Check dose of drug and expiry date

Things to ensure about your practice: You are competent to administer the injection That it is given on a patient specific basis You have gained consent from the patient You understand about the drug you’re giving You complete the documentation

Information on drugs Can be found: On the patient leaflet in the drug packet BNF & BNF on-line MIMs Textbooks Pharmacist Drug Information (CGH or GRH)

Points to consider each time you give an injection: The type of injection This will help to decide on the site, the size of the needle and the angle of administration. The patient as an individual Their age / size and general wellbeing. Any damaged/ scarred tissue. Poor muscle tone, clotting factors or mobility factors.

The drug and quantity The volume of the drug will influence the route you use. Only small volumes, 0.5 – 1.0 ml can be given subcutaneously. The speed of absorption, IM for more rapid absorption, SC for slower absorption The drug may only be licensed to be given via certain routes / sites.

Previously used sites Insulin is absorbed at different rates depending on the site used. Therefore injection sites should be rotated within the same anatomical area. Inspect site used before for inflammation, oedema, redness or lipohypertrophy. Should not repeat injection in the same place as will cause lipohypertrophy.

Potential problems when giving an injection Hitting a blood vessel – wrong site chosen, not aspirating. IM injection S/C rather than IM – inappropriate needle selection, wrong site Nurse gets needle stick injury following IM injection – nurse attempting to re- sheath needle, sudden movement of pt Hitting a bone – wrong site, wrong size needle

Nerve damage – wrong landmarks used to identify site Muscle fibrosis and contracture – repeated injections into same site Septic and sterile abscess formation – repeated injections into same site Intramuscular haemorrhage – extensive trauma, repeated use of site, poor technique, wrong size needle

Lipodystrophy – using the same subcutaneous site eg insulin Pain – the injection itself, technique Anaphylactic shock – reaction to the drug Medication given to the wrong pt – pt not identified correctly Wrong medication, dose or route – drug not checked correctly Embolism – if drug injected into vein by mistake

Adverse reactions: Allergic / anaphylactic reaction to drug: Urticarial rash Wheezing Shortness of breath Flushing of face Facial oedema Abdominal pain Diarrhoea Vomiting Feeling of impending doom. Collapse

Priorities in community: Call for help Position appropriately Loosen clothing Reassurance Administer adrenaline if they have it Patient observations BLS if the patient arrests

Priorities in Hospital: In addition to the Community: Fast bleep / arrest call for help Oxygen Other drugs such as anti-histamine, steroids etc Patient observations Emergency equipment. From airway adjuncts to defibrillator

Before giving any injection - think What is the correct angle for the injection? What technique to use? Do you need to aspirate? Do you swab the site before & after the procedure? Correct way of disposing of sharps? What to do if a needle stick injury occurs?

Subcutaneous Injections Example of drugs used S/C & side effects: Insulin – varied dose depending on pt need, can cause hypoglycaemia, lipodystrophy Fragmin – 2500 – 5000 iu for prophylaxis, can cause bruising, heamorrhage

Subcutaneous Injection A subcutaneous injection is administered beneath the epidermis and dermis, into the fat and connective tissue of the subcutaneous layer. For subcutaneous injections the skin should be gently pinched to lift the subcutaneous tissue away from the underlying muscle. S/C given at 45º or 90º angle

Factors to consider giving S/C injection Size of person Length of needle Site of injection Amount of adipose tissue For a needle greater than ½ inch in length it is recommended to give at 45˚ Pre-prepared syringes tend to have shorter needles and are recommended to be given at 90˚ Pinch skin to free adipose tissue from underlying muscle

Advantages & Disadvantages of S/C sites SiteAdvantagesDisadvantages AbdomenRapid absorption Easily accessible Thicker s/c tissue Large surface area, room to rotate in site Avoid umbilicus – at least 5cm away. ThighsEasy to accessSlow rate of absorption ButtocksSlowest absorption. Difficult to reach if self administering

SiteAdvantagesDisadvantages Upper ArmInjection thought to be less painful in this site Slow absorption of drug ScapulaeUseful site for confused or needle phobic patients Hard to self administer

Intramuscular Injection Examples of drugs used IM and side effects: Diamorphine – mgs, can cause respiratory depression, N&V, Constipation, Hypotension, Hallucinations & Dysphoria Hydroxocobalmin – 1mg 3x week for 2 weeks then 1mg every 3 months. Can cause, Nausea, headache, dizziness, fever, hypersensitivity, hypokalaemia (low potassium), chromaturia (abnormal colour of urine).

Intramuscular Injection An intramuscular injection is administered through the epidermis, dermis and subcutaneous tissue into the muscle. All IM injections are administered at a 90° angle. After quickly plunging the needle into the skin, the plunger is pulled back slightly to see if any blood is aspirated. If no blood is aspirated, then the injection is given depressing the plunger approximately 1ml per 10 seconds. If blood should appear when the plunger is pulled back then withdraw the needle and complete the process again explaining to the patient what has occurred. The Z Track Technique is the preferred method of giving the IM injection.

IM injection sites Advantages & Disadvantages SiteAdvantagesDisadvantages Deltoid (upper arm) Easy access Thought to be less painful Small muscle, injections limited to 1ml May hit radial nerve or artery Vastus Lateralis (outer thigh) Easy access No large nerves or blood vessels Good for thin patients May hit bone if thin person or wrong area Limited to 1-5mls of drug

Dorsogluteal (top of buttock) Large muscle – can give bigger volumes May hit sciatic nerve if site not identified correctly. Drug may end up in subcutaneous tissue Ventrogluteal (Outer hip) No large nerves or blood vessels Less fatty than other sites Not yet widely used in practice Rectus Femoris (Front of thigh) Useful site in children and self administration

Z Track Technique Recommended when giving IM injection Stretching skin prevents drug seeping into subcutaneous tissue & reduces discomfort Stops drug from leaking out so pt gets the dose Video of Z track technique: placs/nctl176_ztrack/index.html