ADMINISTERING INJECTIONS (PARENTERAL ROUTE)

REFERENCES Sienkiewicz, S. & Palmunen, J. (2017) Clinical nursing calculations. Burlingotn, MA: Jones & Bartlett Learning. Taylor, C., Lillis, C., Lynn, P., & LeMone, P. (2015). Fundamentals of nursing (8th ed.). Philadelphia, PA: Wolters Kluwer.

SYRINGE SIZES AND CALIBRATIONS Syringe Size (volume) Calibration 0.5 mL tuberculin Hundredth ( 0.01 mL) 1 mL tuberculin Hundredth (0.01 mL) 3 mL standard Tenth (0.1 mL) 5 mL large volume Two-tenths (0.2 mL) 10 mL large volume 20 to 60 mL large volume (Sienkiewicz & Palmunen, 2017, p. 232) Whole number (1 mL)

RULES BASED ON SYRINGE SIZE Volume to give Syringe size Rounding rules Less than 1 mL and does not calculate evenly to tenths ( ex: 0.542 mL) Use 1 mL or 0.5 mL syringe (calibrated in hundredths) Round to the nearest hundredth ( 0.54 mL) Less than 1 mL but greater than or equal to 0.5 mL; calculates exactly in tenths (0.8 mL) 1 mL or smaller (calibrated in hundredths) or 3 mL (calibrated in tenths) No need to round…volume can be measured in tenths 1 mL to 3 mL (ex: 2.68 mL) (Sienkiewicz & Palmunen, 2017, p. 233) 3 mL (calibrated in tenths) Round to the nearest tenth ( 2.7 mL)

NEEDLE GAUGES AND LENGTHS SUBCUTANEOUS INJECTION ** 25 – 30 GAUGE ** GAUGE DEPENDS ON SOLUTION/MEDICATION ** 3/8 INCH TO 1 INCH BUT MOSTLY 3/8, ½ AND 5/8 INCH ** LENGTH DEPENDS ON BUILD (AMOUNT OF SUBCUTANEOUS TISSUE) INTRAMUSCULAR INJECTION ** 18 – 25 GAUGE (MORE VISCOUS, OIL BASED THE LOWER THE GAUGE) ** 5/8 INCH TO 1 ½ INCH (LENGTH DEPENDS ON SITE AND AGE) Also see Sienkiewicz & Palmunen, 2017, p. 76

MAXIMUM INJECTION VOLUMES FOR ADMINISTRATION SITES Route/Site Maximum Volume Intradermal (ID) 0.1 mL Subcutaneous (SQ) 1 mL (adult) 0.5 mL (child) Intramuscular (IM) Adult: vastus lateralis ventrogluteal deltoid Child: vastus lateralis 6 – 12 years vastus lateralis 0 – 5 years vastus lateralis premature inf. (Sienkiewicz & Palmunen,2017, p. 232) 3 mL 1 mL 2 mL 0.5 mL

SYRINGE CALIBRATION PRACTICE SEE HANDOUT FOR DIRECTIONS.

SITES FOR INJECTIONS SUBCUTANEOUS SITES ** UPPER LATERAL ARM ** ABDOMEN (COSTAL MARGIN TO THE ILIAC CRESTS) ** ANTERIOR THIGH ** UPPER BACK ** UPPER GLUTEAL AREA INTRAMUSCULAR SITES ** VENTROGLUTEAL (adults) ** DELTOID (adults and children over 1 yr.) ** VASTUS LATERALIS (LATERAL/MIDDLE THIGH) (all ages) (Taylor, et al., 2015, pp. 778-783)

DOSAGE CALCULATION – CASE APPROACH C = CONVERT to like units of measurement A = APPROXIMATE or estimate the amount to administer S = SOLVE or perform dosage calculation (ratio-proportion; dimensional analysis; or formula method) E = EVALUATE or check the dosage calculation and compare to approximated amount (Sienkiewicz & Palmunen, 2017, p. 158)

Ratio-proportion calculations Order reads: Administer thiamine 75 mg IM three times a day Supply of med (dosage strength): thiamine 100 mg/mL CONVERT: order and supply are both in milligrams so no conversion of units is needed APPROXIMATE: Ordered dose, 75 mg, is ¾ of the amount supplied in 1 mL. So, 0.75 mL will be needed to administer the correct dose. SOLVE: One of the three methods of calculation Ratio-proportion supplied dose = ordered dose dosage unit amount to administer (x) EVALUATE: redo the equation with the answer figured (Sienkiewicz & Palmunen, 2017, p. 163)

CONVERSION TO LIKE UNITS ORDERED DOSE: 0.35 g SUPPLY: 250 mg/5 mL CONVERT using Ratio-proportion: set up known equivalency on the left against the unknown equivalency on the right 1 g = 0.35 g 1,000 mg x mg x = 1,000 X 0.35 x = 350 mg (Does this make sense?) ( or move decimal 3 places to right when multiplying) (Sienkiewicz & Palmunen, 2017, p. 159)

DETERMINING AMOUNT TO ADMINISTER CALCULATION PROBLEMS 1. ORDER: GENTAMICIN 65 mg IM every 8 hours SUPPLY: GENTAMICIN 40 mg/ mL Now, convert, approximate, solve, evaluate. 2. ORDER: LORAZEPAM 1 mg IM one time dose, 2 hours before surgery SUPPLY: LORAZEPAM 2 mg/mL 3. ORDER: 30 mg of med SUPPLY: 20 mg/mL (Sienkiewicz & Palmumen, 2017, pp. 236 – 237)

RECONSTITUTION OF POWDERED MED LOOK FOR DIRECTIONS FOR RECONSTITUTING ON PACKAGE INSERT AND LABEL LOCATE CORRECT DILUENT AS SPECIFIED ON LABEL (CHOICES ARE BACTERIOSTATIC WATER, STERILE WATER, STERILE NORMAL SALINE AND SOMETIMES LIDOCAINE WHICH WOULD BE ORDERED) ** DRAW UP CORRECT AMOUNT OF DILUENT INTO SYRINGE ( BE SURE OF ROUTE OF DRUG!!) ( SEE SKILL 5-4 REMOVING MEDICATION FROM A VIAL ) ** ADD DILUENT TO POWDERED MEDICATION/ SHAKE TO DISSOLVE ** KNOW THE RESULTING DOSAGE STRENGTH ** CALCULATE THE AMOUNT OF RECONSTITUTED MEDICATION NEEDED TO ADMINISTER THE PRESCRIBED DOSE ** DETERMINE THE NUMBER OF DOSES IN THE MULTI-DOSE VIAL ** LABEL MULTI-DOSE VIAL WITH DATE, TIME, DOSAGE STRENGTH, STORAGE INSTRUCTIONS, DISCARD DATE AND INITIALS (Sienkiewicz & Palmunen, 2017, pp. 239 – 256) (Taylor, et al., 2015, p.778)

REMOVING MEDICATIONS FROM A VIAL 1. WHAT IS THE DOSAGE STRENGTH OF YOUR RECONSTITUTED POWDERED MED? 2. YOU ARE TO ADMINISTER 100 mg of medication SUBCUTANEOUSLY. 3. PREPARE YOUR SYRINGE USING THE CORRECT SYRINGE AND NEEDLE. 4. WHAT SITE (s) WILL YOU ADMINISTER THIS INTO? 5. PRACTICE SUBCUTANEOUS INJECTION TECHNIQUE. (SKILL 5-7) (Taylor, et al., 2015, p. 776)

INSULIN ADMINISTRATION 1. USES THE SUBCUTANEOUS ROUTE 2. USES AN INSULIN SYRINGE CALIBRATED AT 100U (UNITS) / ML 3. USE A 30U SYRINGE FOR LESS THAN 30 UNITS; 50U SYRINGE FOR LESS THAN 50UNITS AND 100U SYRINGE FOR LESS THAN 100 (THE SMALLER THE DOSE, BETTER TO USE THE SMALLER UNIT SYRINGE FOR ACCURACY) 4. UNDERSTAND THE DIFFERENT TYPES OF INSULIN 5. UNDERSTAND THE BASICS OF HYPERGLYCEMIA AND HYPOGLYCEMIA AND DIABETIC CONTROL 6. UNITS AND TYPES ORDERED ARE GIVEN TO MAINTAIN STEADY BLOOD GLUCOSE LEVELS (TAKING INTO ACCOUNT PATIENT DIET, EXERCISE, STRESS, BASAL METABOLIC NEEDS, BODY WEIGHT) (Taylor, et al., 2015, pp. 777-778)

MIXING MEDICATIONS FROM TWO VIALS IN ONE SYRINGE (INSULIN) 1. REFER TO SKILL 5-5. ** MODIFIED INSULIN (NPH – CLOUDY) IS ROLLED OR AGITATED TO MIX. ** INJECT EQUAL AMOUNTS OF AIR IN MODIFIED VIAL FIRST…….STOP…..INJECT EQUAL AMOUNT OF AIR (TO MED WITHDRAWN) INTO UNMODIFIED VIAL (REGULAR) WITHDRAW UNMODIFIED MED THEN GO BACK TO MODIFIED AND WITHDRAW CORRECT AMOUNT OF INSULIN 2. REVIEW SLIDING SCALE ORDER SHEETS. 3. EPIC (OHIO HEALTH) INSULIN ADMINISTRATION REVIEW. 4. PRACTICE DRAWING UP TWO DIFFERENT INSULINS WITH ORDERS ON CARDS. 5. CHECK EACH OTHER’S ORDER AND SYRINGE BEFORE ADMINISTRATION. 6. PRACTICE SUBCUTANEOUS INJECTION TECHNIQUE. (SKILL 5-7) (Taylor, et al., 2015, pp. 814-817)

REMOVING MEDICATION FROM AN AMPULE; USING IM INJECTION TECHNIQUE 1. CHECK MED. 2. OBTAIN CORRECT SYRINGE AND NEEDLE FOR VOLUME, SITE, (ADULT) AND CONNECT FILTER NEEDLE FIRST TO SYRINGE. 3. OPEN AMPULE USING ASEPTIC TECHNIQUE….FLICK MED FROM NECK OF AMPULE DOWN INTO BODY OF AMPULE. 4. USE ALCOHOL PAD OR 2X2 PAD TO BREAK AMPULE 5. USING FILTER NEEDLE DRAW UP CORRECT AMOUNT OF MED. 6. WITH A SMALL AMOUNT OF AIR IN SYRING BARREL, SCOOP FILTER NEEDLE CAP BACK ON, REMOVE FROM SYRINGE AND ATTACH ADMINISTRATION NEEDLE APPROPRIATE FOR THIS INJECTION. 7. PRACTICE ADMINISTERING AN IM INJECTION (SKILL 5-8) (Taylor, et al., 2015, pp. 775-776)

INTRADERMAL INJECTION 1. USE TUBERCULIN SYRINGE 2. WITHDRAW 0.05 mL from reconstituted vial. 3. FOLLOW SKILL 5-6. (ANGLE OF ADMINISTRATION IS _____________________) ( WHAT SHOULD APPEAR ON THE SKIN _______________) (Taylor, et al., 2015, p.778)

REFERENCES SEE SLIDE #2 FOR TWO LISTED REFERENCES.