Intramuscular Injections IM’s Chapter 22 Perry & Potter

Review – IV Fluids Order: ½ NS @ 125cc/hr Drop factor: 15 gtt/ml Drop rate: 31.25 gtt/min (31-32) 125 cc/hr x 15 gtt/ml = 31.23 (31-32) 60 min Order: D5 ½ NS @ 100 ml/hr Drop factor: 10 gtt/ml 16.6 gtt/min (16-17)

Review – IV Medications Order: Maxeran 10 mg IVPB ½ hour ac meals Available: 10 mg/ml Further dilute: 50 ml NS, infuse over 15 min What is the rate: 200 ml/hr 50 ml X ? = 200 ml/hr 15 min 60 min What is the drip rate (drop factor 15 gtt/ml): 50 gtt/min

Order: Pantoprazole 40 mg IV now Available: 40 mg vial Reconstitute with 10 ml NS (final concentration 4 mg/mL). Reconstituted solution may be given intravenously (over 2 minutes) or may be added to 100 mL D5W, NS, or LR (for 15- minute infusion). Stable in D5W, LR, NS. Y-site administration: Incompatible: Midazolam, zinc. How much do you add to the minibag: 10 ml What is the rate: 440 ml/hr What is the drip rate with drop factor of 15 gtt/ml: 110 gtt/min (this will be difficult to count)

What would you do? Reason for primary infusion & reason for IV med Primary line: NS with 40 meq KCL @ 75 ml/hr Order: Pantoprazole 40 mg IV now What do you need to know before you begin? Reason for primary infusion & reason for IV med Drug information (expected & unexpected) Client’s history & allergies Client’s knowledge of medication IV compatibility!!!

Video Review IV therapy IV Medications Monitoring an IV Site, checking Infusion Rate, and Changing an IV Solution Container Replacing IV Solution Container and Administration Tubing IV Medications Administrating IV Medications by Piggyback Infusion

Review – Subcutaneous Medication/Insulin Order: Lovenox 40 mg SC OD Available: 300mg/3ml (100mg/ml) Info: Lovenox is a sterile aqueous solution containing enoxaparin sodium, a low molecular weight heparin. Lovenox® is indicated for the prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE) How much do you withdrawl? 0.4 ml Identify the appropriate syringe: 1 ml Where are you going to administer this medication? Outer aspect of abdomen (never arms)

Video Review Mixing Two Insulin's in One Syringe Important information you need to know? If insulin’s are compatible Is it safe to give (know clients blood sugar) Insulin(s) information (onset, peak, duration) Draw up rapid acting insulin first (unmodified) Check dose with RN/instructor Know S&S of hyper/hypoglycemia Injections sites

Intramuscular Injections (IM’s) Faster absorption Less danger of causing tissue damage Risk of injecting into blood vessels exists Muscle is less sensitive to irritating and viscous drugs Large well developed muscles (adults) can tolerate as much as 5 ml of medication (infants 0.5-1ml, toddler 1-2ml, preschool 2-3ml, adolescents 3-5ml) Usual max dose: 3mL in adult

Vastus lateralis and ventraogluteal sites used in infants Deltoid used in well developed children and adolescents In estimating needle length in children, grasp muscle between thumb and index, needle length showed be half the distance between fingers. Insert needle as close to 90 degrees as possible Rotate sites to decrease risk of hypertrophy

Needle Gauge Gauge often determined by length Most water soluble medications use: 22-27 gauge needle More viscous medications use: 18-25 gauge needle Older or cachectic clients may need shorter smaller gauge needle

Needle length Average length: Children: 5/8 – 1 inch Adults: 1- 1 ½ inches

Assessment Assess integrity of a muscle prior to injection Help client assume a position that reduces strain on the muscle. Area must be free of infection or necrosis, bruising or abrasions, underlying bones, nerves & major blood vessels.

Assessment Review order (medication rights) Obtain medication information Review history and assess factors contraindicating injection (muscle atrophy, shock, impaired circulation) What would you do if contraindicated? Call prescriber for alternative route! Medical history, allergies, medication history Client’s knowledge/concerns

Prepare Medication 6 rights, 3 checks Prepared correct dose from vial/ampule Replace needle with needle for injection Children: 5/8 – 1 inch Adults: 1- 1 ½ inches (22-27 gauge) : 1 ½ inch (18-25 gauge) viscous medications Check arm band/compare with MAR Explain procedure, locate site, BE CONFIDENT

Ventrogluteal Site: #1 A deep site, situated away from major nerves and blood vessels, less chance of contamination in incontinent clients or infants because it is away from rectum. Easily identified by prominent bony landmark. Safe for all clients

Ventrogluteal Land marking (p. 599): Place heel of hand over the greater trochanter of the client's hip right hand over left hip left hand over right hip

Ventrogluteal con’t… Point thumb towards client's groin Index finger over anterior superior iliac spine Extend middle finger back along the iliac crest toward the buttock Create a triangle between index finger, middle finger and the iliac crest (towards the buttocks) Inject in the middle of this triangle Flexing of the knee and hip helps person to relax

Vastus Lateralis site Vastus Lateralis - lacks major nerves and blood vessels, rapid drug absorption, developed muscle Site used for giving children IM medication (preferred for immunizations) Client should lie with the knee slightly flexed or in a sitting position

Vastus Lateralis Cont’d Land marking (p.600): Located on the anterior lateral aspect of the thigh Handbreadth above the knee to a handbreadth below the greater trochanter of the femur. In width, from the midline of the thigh to the midline of the thighs outer side. Inject into the middle third of the muscle.

Deltoid site Not well developed in most adults & children (not recommended for use in infants or children) Radial & ulnar nerves & brachial artery lie within the upper arm along the humerus Used when other injection sites are inaccessible Used for small amount of drugs (1 ml or less)

Deltoid site con’t… Landmarking (p. 600): Expose upper arm Palpate lower edge of the acromion process (base of triangle) Inject in the middle of the triangle (3-5 cm below the acromion process)

Dorsogluteal site No longer a recommended site Runs risk of striking underlying sciatic nerve, greater trochanter, major blood vessel. Often used by nurses in hospitals (4 quadrant landmarking), practice is slowly changing

Z track Method Minimizes tissue irritation by sealing the drug within the muscle tissues and decreasing pain. Recommended technique for all IM’s when possible

Z track Method

Implementation Privacy Wash hands Expose only required area Select appropriate injection site & ensure client is comfortable Landmark site Cleanse site with antiseptic (center and rotate outward ~ 5 cm) With nondominant hand, pull skin 2.5-3.5 cm down or lateral (Z track), hold this position until medication is administered. Gauze in nondominant hand

Remove cap (pull straight off) Hold syringe like a dart Inject quickly at 90 degrees Hold lower part of syringe to stabilize syringe Pull back on plunger 5-10 sec, if no blood inject medication slowly (1 ml/10 sec) Wait 10 sec, slowly withdrawl needle, place gauze over site Assess site Observe response to medication Record on MAR, record response (i.e prn/STAT) Document and report undesirable effects

Video: Intramuscular Injection

Practice Examples Order: Demerol 50 mg IM q4h, prn Order: Gravol 25 mg IM, q4h, prn Supplied : Demerol 50 mg / ml (ampule) Gravol 50 mg / ml (vial) How much do you need of each? Demerol: 1 ml Gravol: 0.5 ml (Draw up medication from vial first, using filtered needle)

Practice Examples 2. Order: Diphenhydramine 25mg IM stat Supplied: 50 mg/ml 3. Order: Dimenhydrinate 50mg IM/IV/PO q4-6 h prn Supplied 50 mg/ml

Example Order: Solumedrol 100 mg IM stat Directions for Reconstitution Available 40 mg: Aseptically add 1 mL Bacteriostatic Water for Injection Available 125 mg: Aseptically add 2 mL Bacteriostatic Water for Injection How much do you draw up in the syringe? 1.6 ml 125 mg X 100 mg = 1.6 ml 2 ml ? Or Dose X Stock 100 mg X 2ml = 1.6 ml Have 125 mg

Lets Practice Next Lab: Sterile Dressings Perry & Potter: Chapter 38 & 39