Injection Technique By Greg Dix Begin

Introduction GOOD LUCK! Previous Next Welcome to this interactive learning pack on injection technique. You are required to complete this package before attending the practical skill session, it should take you approximately 60 minutes. There will be a knowledge test at the beginning of the practical session to review your learning. GOOD LUCK! Previous Next

Learning Outcomes Discuss the usage of commonly used needles and syringes Identify the differences between the intramuscular and subcutaneous routes Identify and locate the anatomical sites for intramuscular and subcutaneous injections Describe the procedure for preparation and administration of intramuscular and subcutaneous injections Describe the method used to administer intramuscular injections using the Z-track technique Previous Next

Contents Page ( ) Needles Syringes Intramuscular Injections Quiz (IM) Subcutaneous Injections Quiz (SC) Previous Next

Types of Needle Needles come in a variety of colours and sizes. For intramuscular injections (in adults) a green needle should be used, unless the patient is extremely thin, with little muscle mass. In such cases a blue needle would be the needle of choice. However each patient should be assessed individually. Very rarely are children given intramuscular injections. An orange needle should be used for subcutaneous injections, although some drugs by this route are already assembled in pre-wrapped syringes with needles attached. 21g (Green) 23g (Blue) 25g (Orange Previous Next

Types of Syringes Syringes come in a variety of sizes from 1ml to 50 mls, however for injection purposes you will only use the following four: 1ml 2ml 5ml Insulin Syringe Depending on the amount of fluid to be injected, would influence your choice as to what size syringe to use. For example, if you are injected 2mls of fluid you would use a 2ml syringe, rather than a 5 ml syringe. Please note that insulin syringes are marked in international units and not millilitres! Previous Next

Intramuscular Injections The Intramuscular route is used to deposit a drug into the muscle layer, which lies beneath the subcutaneous tissue. The rate of absorption is quicker by this route than via the subcutaneous route, because of the rich blood supply within the muscle fibres Skin Subcutaneous Layer Muscle Layer Previous Next

Intramuscular Injections… If two drugs are to be administered, check compatibility. If the drugs are incompatible, separate syringes and sites must be used for each drug The intramuscular route may be contraindicated for some patients. For example, those with blood clotting disorders. The local code of practice for drug administration and the standards for the administration of medications (NMC 2002)http://www.nmc-uk.org must be adhered to at all times. Previous Next

Intramuscular Injections Sites There are five sites commonly used for intramuscular injections: Deltoid Dorsogluteal Rectus Femoris Vastas Lateralis Ventrogluteal Previous Next

Locating the deltoid site This is located by drawing an imaginary horizontal line, 2-3 finger breadths (2.5-5cms) below the lower edge of the acromion process. The injection should be given into an imaginary triangle, whose base is the central half of this horizontal line and whose apex is formed inverted on the midpoint of the lateral aspect of the arm in line with the axilla Due to the small area of this site, the number and volume of injections (not usually more than 1ml) which can be given into this site is limited. For example, vaccines which are usually small in volume are often given in the deltoid muscle www.drugguide.com/muscleinjection.asp Previous Next

Locating the dorsogluteal site Often referred to as the upper outer quadrant, the method of dividing the buttock into four equal areas by drawing imaginary lines, to bisect it vertically and horizontally has been utilised by many nurses over the years to locate this injection site. This site is better located by palpating the greater trochanter and posterior iliac spine, then injecting laterally and superior to the midpoint of an imaginary line joining these points The presence of major nerves and blood vessels, and the relatively slow uptake of medication from this site (because of a thick layer of adipose tissue) makes this site less favourable. Please check hospital policy prior to using this site www.drugguide.com/muscleinjection.asp Previous Next

Locating the rectus femoris site Located midway between the patella (knee) and superior iliac crest on the mid-anterior aspect of the thigh. The uptake of drugs from this region is slower than from the arm, but faster than from the buttocks. This site is often utilised by patients who administer their own medication, as it is readily available in the sitting or lying position. Injections into this site may cause considerable discomfort Rectus femoris (Workman 1999) Previous Next

Locating the vastus lateralis site This is located on the lateral aspect of the thigh between the greater trochanter of the femur and the lateral femoral condyle of the knee. Divide into thirds with the middle third being the injection site. One of the advantages of this site is that it is easy to access, but most importantly there are no major blood vessels or significant nerve structures in the vicinity of the site. This muscle, like the rectus femoris is associated with the quadriceps femoris group of muscles and has similar absorptive properties www.drugguide.com/muscleinjection.asp Previous Next

Ventrogluteal Site Previous Next Located by the nurse placing the heel of his/her opposing hand (i.e right hand for left hip) on the patients greater trochanter. The index finger of the hand is placed on the patients anterior superior iliac spine and the middle finger stretched dorsally towards but below the iliac crest. The triangle formed by the index finger, the third finger and the crest of the ilium is the injection site This site is free of penetrating nerves and blood vessels and has attracted significant attention in the nursing literature. It is the opimum site for IM injections. The extent to which this muscle is used in the United Kingdom is unknown. www.drugguide.com/muscleinjection.asp Previous Next

Preparing the Injection Injections should be drawn up in a clean, designated area. Always check that the packaging of all equipment is intact prior to use and check expiry date. Check the drug to be administered against the patients prescription Wash hands. Prepare the equipment- syringe and 21g/23g needle (check hospital policy). Check that the plunger of the syringe moves freely in the syringe barrel. previous Next

Preparing the Injection The drug may be contained within an ampoule or a vial. If drawing up a drug from an ampoule, tap the stem of the ampoule while holding it vertically. Using a snapping motion, break off the top of the ampoule along the scored line at its neck. Draw up the drug into the syringe. Holding the syringe with the needle uppermost, tap the side of the syringe to allow any air bubbles to rise and expel the air gently. Change the needle. Drawing up from a vial previous Next

Preparing the patient Take the receiver and the prepared drug and prescription chart to the patient. Check the patient’s identity with the prescription chart and identity band. Ensure privacy, then assist the patient into a comfortable position and expose the site to be injected. Clean skin as per hospital protocol. Previous Next

Administering the Injection Stretch the skin to one side around the injection site (Z-track technique). Holding the barrel of the syringe firmly between thumb and index finger, plunge the needle into the skin at an angle of 90 degrees leaving a third of the needle exposed (just in case the needle snaps). Steady the barrel and pull back gently on the plunger to observe if blood is aspirated. If blood is present discontinue the procedure and reassure the patient. Dispose of the drug and all equipment and repeat as appropriate. Previous Next

Administering the Injection cont… Inject the drug by pushing the plunger of the syringe using your thumb, with a slow continuous movement. The fingers steady the syringe and act as a counterforce. Injecting slowly allows time for the tissue to be displaced and is less painful. Inject solution at a rate of 1ml per 10 seconds. Wait a few seconds to allow diffusion through the muscle, then withdraw the needle. Apply pressure to the site if necessary. Make the patient comfortable and dispose of sharps according to hospital policy. Never re-sheath the needle Sign the patient’s prescription chart and document the time the drug was given. Previous Next

Z – Track Technique A B C Using your non-dominant hand, pull the skin and subcutaneous tissue 2-3 cms sidewards Pierce the skin with a quick dart-like motion at 90 degree’s. Aspirate for blood, if none, slowly inject the medication Withdraw the needle and release the skin to create a disjointed pathway which locks in the medication. Note – remember to use a long enough needle to reach the target muscle so that the medication is not deposited into the subcutaneous tissue. Previous (Rodger & King 2000) Next

Complications of IM injections Complications can occur at the site of the injection following IM drug administration. For example, seepage of the injection solution and/or bleeding from the injection site onto the skin, pain, irritation and even skin lesions. Such complications have been widely researched and one possible cause being some degree of fault in the IM injection administration technique itself. Previous Next

Quiz The following quiz consists of a list of 8 multiple choice questions pertaining to intramuscular injections. Please click the mouse over the sound symbol for the answer you believe to be the correct one. If you hear the sound of a gun shot, then unfortunately, you have chosen the incorrect answer. A round of applause indicates the correct answer. Good Luck Previous Next

Question 1 What colour needle would you normally use to administer an intramuscular injection to an adult? A - Blue B - Green C - Orange Previous Next

Question 2 When administering an intramuscular injection, a blue needle is only used when the patient is.. A - Obese B - Thin C - A diabetic Previous Next

Question 3 A 2ml syringe is used for every intramuscular injection A - Yes B - No C - Doesn’t matter Previous Next

Question 4 When administering an IM injection, the angle of the needle should be at… A – 45 degrees B – 90 degrees C – 60 degrees Previous Next

Question 5 The intramuscular layer lies beneath the.. A – Subcutaneous layer B – Skin Previous Next

Question 6 The rate of absorption via the IM rate is quicker than the SC route because of… A – Rich blood supply B – More nerve endings C – thick muscle Previous Next

Question 7 The Z track technique A – Deposits the drug into subcutaneous tissue B – Deposits the drug into the target muscle C – Deposits the drug into both the subcutaneous tissue and the target muscle Previous Next

Question 8 The Dorsogluteal muscle can be found… A – Front of leg B – Buttocks C – Side of leg Previous Next

Subcutaneous Injections Drugs that need to be absorbed steadily and slowly are given via the subcutaneous route. A subcutaneous injection is administered beneath the epidermis into the fat and connective tissue underlying the dermis. Examples of drugs given via this route include insulin and low molecular weight heparin. The majority of injections given to children is via this route. Skin Subcutaneous Layer Muscle Layer Previous Next

Subcutaneous Injection Sites Rotation of the injection sites will reduce the likelihood of local reaction and improve absorption of the drug: Abdomen Thigh Deltoid area Loins www2.mc.duke.edu/ivf/injectio.htm Previous Next

Procedure for Administration of SC injections Follow the same procedure for drawing up the drug as if you were drawing up an IM injection. However remember that some drugs are available in pre-filled syringes. Expose the injection site and clean the skin according to hospital policy. Grasp the skin to elevate the subcutaneous tissue. A topical local anaesthetic can be applied to the injection site for children. Distraction therapy may also be necessary. SC injections are normally given at an angle of 45 degrees when they are more than half an inch long (an orange needle) If the needle is half an inch or less (pre-filled syringes), the needle should then be inserted at an angle of 90 degrees. Previous Next

Procedure cont…1 There is no need to pull back to aspirate as there is very little blood supply in the subcutaneous layer. Administer the injection at a rate of 1ml per 10 seconds. Withdraw the needle and apply pressure to the site if necessary. Make the patient comfortable and dispose of sharps according to hospital policy. Never re-sheath the needle Sign the patient’s prescription chart and document the time the drug was given. Previous Next

Complications of SC Injections Complications can occur at the site of injection following SC administration. For example: Excessive bruising, especially following heparin administration Repeated cleaning of the injection site with alcohol swabs and/or repeated use of the same site may result in hardening of the skin. Previous Next

Quiz The following quiz consists of a list of 7 multiple choice questions pertaining to subcutaneous injections. Please click the mouse over the sound symbol for the answer you believe to be the correct one. If you hear the sound of a gun shot, then unfortunately, you have chosen the incorrect answer. A round of applause indicates the correct answer. Good Luck Previous Next

Question 1 What colour needle would you normally use to administer a subcutaneous injection A - Orange B - Blue C - Green Previous Next

Question 2 An insulin syringe is marked in… A - International mls B - International mgs C – International units Previous Next

Question 3 When administering a SC injection with a needle less than half an inch, the angle of the needle should be.. A – 90 degrees B – 45 degrees C – 30 degrees Previous Next

Question 4 When administering a SC injection with a needle longer than half an inch, the angle of the needle should be… A – 60 degrees B – 45 degrees C – 90 degrees Previous Next

Question 5 Aspirating for blood is required prior to administration of a S/C drug.. A - Sometimes B – Always C - Never Previous Next

Question 6 A common site for a SC injection is the… Abdomen Shoulder Calf Previous Next

Question 7 Rotating SC sites will… A – Decrease pain B – Reduce Swelling C – Prevent hardening of the skin Previous Next

Further Reading It is recommended that you access the resource file for articles upon injection technique. The articles in yellow bold on the following page are those we recommend you read.

References Previous Next Beyea S; Nicoll LM (1996) Back to basics. Administering intramuscular injections the right way. American Journal of Nursing. Vol 91. No 1. P 34-35 Greenway.K (2004) Using the Ventrogluteal Site for Intramuscular Injection. Nursing Standard. Vol18, No 25. p.39-42. King L (2003) Subcutaneous insulin injection technique. Nursing Standard. Vol 17. No 34. P45-52. Pritchard AP; Mallett J (1994) Manual of clinical nursing procedures. Blackwell Scientific Publications. Oxford. Rodger MA; King L (2000) Drawing up and administering intramuscular injections: a review of the literature. Journal of Advanced Nursing. Vol 31. No 3. P 574-582. Royal College of Paediatrics and Child Health (2002) Position Statement on Injection Technique. London: Royal College of Paediatrics and Child Health. Workman. B (1999) Safe Injection Techniques. Nursing Standard. Vol13. No.39 p47-53. www.2.mc.duke.edu/ivf/injectio.htm - accessed 30/5/04 www.drugguide.com/muscleinjection.asp -accessed 30/5/04 Previous Next

The End I hope you found this learning pack useful and informative. Thank -You Previous