1. Parenteral Medications Unit XIII
Keith Rischer, RN, MA, CEN, CCRN

2. Definitions Parenteral Intradermal (ID) Subcutaneous
Intramuscular (IM)
Intravenous (IV)
WE have talked about oral and topical – now we are going to consider the parenteral method of medication administration.
Parenteral – Other than alimentary or respiratory, eye, ear, intrathecal.
it is NEEDLE delivery. Injecting something into the body
Requires aseptic technique, sterility of equipment, and medication.
WHEN NEEDLE PIERCES SKIN IS RISK OF INFECTION
Intradermal – Under the epidermis (into the dermis)
Subcutaneous
Intramuscular
Intravenous
Medications are absorbed much more quickly than oral route, must be careful in dosage. 2

3. If not done correctly… A drug response that is too rapid or too slow
Nerve injury with associated pain
Localized bleeding
Tissue necrosis
Sterile abscess
Decreased therapeutic effect

4. Syringes Syringe Parts Tip Barrel Flange Plunger Safety Shield
Tip - Narrow end of the syringe that fits into the needle hub. Can be slip tip or leur lock.(sterile)
Barrel – long tubular portion of syringe that will contain fluid, graduated in some way ( minims, ml) (sterile)
Flange – Part of barrel that spreads out at base of barrel, opposite end from tip.
Plunger – Entire portion of syringe that is long and moves up and down inside the barrel (includes rubber tip, long portion or plunger, and plunger end). (sterile)
Safety Shield – (sheath) – plastic encasement which can be moved up or down to cover needle. Typically seen on subcutaneous syringes.
THE TIP IS DESIGNED TO BE LUER LOK OR NON-LUER-LOK.
The picture above is a non luer lok tip
Must keep barrel, tip, plunger sterile on syringe 4

5. Syringes Risks Syringe Sizes Hypodermic Insulin TB
Use single use sterile syringes, which are inexpensive and easy to manipulate.
Here are examples of types of syringe sizes – explain different uses. Many different sizes, for many uses. Range from 0.5 cc to 60 cc.
3 mL, 5 mL, 10mL
Insulin range from 0.3 mL to 1 mL.
Tuberculin mantoux test, and to give doses smaller than 1mL. Calibrated in 100ths of a mL with capacity of 1mL. Can be used to give subcut and intradermal. 5

6. Needles Parts of the Needle Hub Shaft Bevel Lumen Sheath
Most needles are made of stainless steel and are disposable, must be kept sterile.
Hub – end of needle opposite point, fits into tip of syringe – sterile inside
Shaft – long portion of needle, sterile
Bevel – slanted tip of needle, sterile
Lumen – opening of needle near point
Sheath – needle cover, cap 6

7. Needles Length 1/2” to 1 1/2” Intradermal 25 to 27g
Three eighths to five eighths of an inch
Subcutaneous
Intramuscular
20 to 25g
One half to 1 1/2 inches
With needle choices – consider the length and the gauge.
The smaller the gauge number, the larger the needle diameter
Choice of needle length is based on client’s muscle development, weight, and type of injection, and type of medication to be injected
Gauge (or diameter of the shaft) varies from , the smaller the gauge number, the larger the needle diameter ( lumen is bigger)
Selection is based on viscosity of the solution and the medication to be administered.
Smaller gauge produces less tissue trauma, larger gauge are necessary for viscous medications such as penicillin. 7

8. Safe Administration Handwashing Gloving Asepsis 6 Rights Allergies
Sites
Knowledge of Meds
Check for Tissue Injury
Recapping Needles
Sharps Container
Needle Sticks
REVIEW EACH ITEM ABOVE. - THE EMPHASIS IS ON SAFETY
Do not use any of these sites if tissue injury, presence of nodules, lumps, abscesses, tenderness, redness, scar tissue.
Recapping procedure tomorrow, long lab day.
Needle sticks – key is to prevent. Can spread Hep B, HIV.
In the practice lab –
If you see uncovered needles on practice trays and no available caps, please carefully place in sharps container.
If you stick yourself with a needle, please put it in the sharps container Immediately.
If removing a needle from a syringe, be sure you put the needle cap on it BEFORE trying to remove it.
If you are having trouble getting needle covers off without accidentally pulling the needle off the syringe the answer:
To remove needle cover, pull it straight off, do not twist at all.
Twist only when your intention is to remove the needle from the syringe.
In the Nursing Lab:
Encourage bleeding
Wash the area with soap and water
Report the incident immediately, complete an injury report, seek follow-up
May need to start medications immediately. 8

9. Selection of Injection Site
Amount and character of medication
What is the amount and condition of the muscle mass?
What is the frequency of the injection?
These are variables to consider when choosing a site for injection.
Viscosity or thickness 9

10. Preparing an Injection
Ampules
Vials
Multi dose vials
Carpujects
DO NOT CONTAMINATE NEEDLE…TOUCH OUTSIDE EDGE OF VIAL, OR ANYTHING NOT STERILE
Ampules…P p&p
Fluid in neck-tap or spin
Once opened-draw medication quickly…do not allow to stand open
OPEN SYSTEM…DO NOT NEED TO ADD AIR
Materials you need for ampule are
filter needle
gauze
syringe
Vial – p
CLOSED SYSTEM-NEED TO ADD AIR…WHATEVER YOU ARE PULLING OUT-THIS IS WHAT YOU ADD
FAILURE TO INJECT AIR CREATES VACUUM-MAKES DIFFICUKLT TO REMOVE
need to inject air onto the vial in order to get medication out.. So here we need to put air onto the vial. Closed system.
Cleanse with ETOH and friction…allow to dry
Always use sterile syringe and needle to access vial. Never use once used on pt.
Use single dose vials whenever possible…never use on another pt
Multidose vials
Anesthesiologist infected 19 pts with hep C by improperly reusing syringes and contaminating multidose vial
Always date and time after first opened…and or date expiration
Insulin is example of dating 28 days after opened
Use on 1 pt whenever possible
Cartridge (vial)is placed in the carpuject. Needleless system often used.
Demonstrate carpuject
ELIMINATE AIR BUBBLE BEFORE ADMINISTERING
These systems will be demonstrated tomorrow.
Both techniques will be demonstrated tomorrow. 10

11. Reconstituting Medications
Make sure correct solution
Roll gently
If viscous use 18g needle
p.741
NORMAL SALINE OR STERILE WATER MOST COMMON
PROTONIX…10CC NS…
Gently roll

12. Site Preparation Hand hygiene Prevent contamination Cleanse site
Syringe
Needle
Cleanse site
Alcohol swab
Chloroprep
Apply gloves

13. Intradermal Injection
Indications
Needle Size
Syringe Size
Angle of insertion
Amount
Site
Inner Forearm
Upper Back
Medication is deposited WITHIN the skin (NOT below the skin).
Indications: allergy testing, tuberculin testing, vaccinations
Needle Size: Small, short needle – 25 or 27 gauge, 3/8-5/8 inch in length
Syringe Size: calibrated in minims or tenths and 100ths of a milliliter
Angle of Insertion: 5-15 degrees-BEVEL UP
Amount: Small amount of solution – 0.1 ml.
Positive mantoux…10mm 2-3 days after injection 13

14. Subcutaneous Injection
Advantage
Disadvantage
Needle Size
Syringe Size
Angle
Amount
Advantage – Injection in the loose connective tissue under the dermis.
Give vaccines, insulin, heparin
Smaller needle size causes less tissue trauma
Disadvantage – Slower absorption than with IM…EXCEPT FOR HEPARIN!
NEEDLE SIZE: gauge (may range up to 31), 3/8-5/8 inches long (up to 1 inch)
AT ALLINA 28G X ½”
Insulin – gauge 5/16-1/2 inch needle (preattached needle)
AT ALLINA…29G X ½”
SYRINGE SIZE: 1-3 ml
Angle: 45 – 90degree
AMOUNT – ml of water soluble medication should be injected because the tissue is sensitive to irritating solutions and large volumes.
Needle length and angle of insertion is chosen based on the clients body weight.The preferred needle length is one half the width of the skinfold.
For obese clients insert longest needle choice at base of skinfold.
Your text states: 5/8 “ and 25 gauge needle at 45 degrees or ½ “ needle and 25 gauge needle at 90 degrees will get into the subcutaneous tissue of a “normal” person.
General rule of thumb: if you can grasp 2 “ of fat, insert at 90 degrees. If you can grab 1 “ of fat, insert at 45 degrees.
Insulin pens are inserted at 90 degrees. 14

15. Sub-q Injection Sites Upper Arm Anterior Thigh Upper Back Lower Back
Abdomen
A general rule you can use to determine the angle of injection is if you can grasp 2 inches (5 cm) of tissue, insert the needle at a 90-degree angle; if you can grasp 1 inch (2.5 cm) of tissue, insert the needle at a 45-degree angle.
No need to intentionally rotate sites with genetically engineered human insulins
Can keep giving in same area at a time
Outer aspect of upper arms
Anterior aspects of the thighs
Scapular areas of the upper back
Upper ventrogluteal and dorsogluteal areas
Abdomen 15

16. Sub-q Heparin DO: DO NOT: Inject into an area of ecchymosis
Abd. only
3/8” 25/26 g.
90 degree angle
DO NOT:
Inject into an area of ecchymosis
Aspirate prior to injection
Massage area following injection
Read above
Special precautions because of the drug’s anticoagulant properties
Select a site on the abdomen, 2 inches away from the umbilicus and above the level of the iliac crests.
Use a 3/8 inch, 25- or 26-gauge needle, and insert it at a 90-degree angle. 16

17. Intra-Muscular Injection: IM
Advantage
Disadvantage
Needle Size
Syringe Size
Angle
Amount
Z-Track
ADVANTAGES: Faster drug absorption than SC…10-30” vs. 30+ “ for subq due to greater blood supply to muscle.
Can tolerate larger doses (volume) without discomfort compared to SC.
DISADVANTAGE: Larger needle size causes more tissue trauma.
Pain
Risk of nerve damage
Risk of injury to artery
ADVANTAGE
FASTER ABSORPTION THAN SUBQ
Disadvantage
Injury to nerves-blood vessels due to depth
But ventrogluteal is free of these complications
NEEDLE SIZE: 1-1 ½ inch length gauge (depends on size of muscle and size of client)
Smaller gauge for deltoid ( #23-#25), Viscous solutions - #18g
SYRINGE SIZE: Generally use a 3 ml syringe.
ANGLE – 90 degrees
AMOUNT OF SOLUTION – Adult maximum 3 ml.(!!!!)
Deltoid site – 1ml.
Children, elderly, thin – 2ml
Infants, small children – 1ml.
Z-TRACK TECHNIQUE – refer to slide.
Speed-1cc every 10 seconds…ASPIRATE FOR 5 SECONDS…keep in for 10 seconds after insertion 17

18. IM Sites: Ventrogluteal
Location
Risk
Position
Uses
EXCELLENT SUMMARY P.751 BOX 35-26
SITE: Injection into the gluteus medius muscle. PREFERRED SITE FOR ADULTS.
GREATER THICKNESS OF MUSCLE…FREE OF LARGE BLOOD VESSELS AND NERVES
MOST CONSISTENT LAYER OF ADIPOSE TISSUE-LESS THAN 1 ½” EVEN WITH THE VERY OBESE
CAN BE USED IN PRONE-SUPINE OR SIDELYING POSITIONS IF NEEDED
LOCATION: located by placing the heel of hand over greater trochanter of hip, spread finger. Use R hand for L hip.
With the index finger on th eclient’s anterior superior iliac spine, the nurse stretches the middle finger dorsally, palpating the crest of the ilium and then pressing below it.
The triangle formed by the index finger, the third finger, and the crest of the ilium is the injection site.
RISKS: Don’t use in children < 7 months.
ADV: Site does not contain large nerves or blood vessels, greatest thickness of gluteal muscle, is sealed off by bone, contains less fat than the buttock area.
POSITION: Prefer to lie on side with knee flexed forward
USES – BEST site to deliver any IM medication
NEEDLE size and volume gauge and 1-3 mL 18

19. IM Sites: Vastus Lateralis
Location
Risk
Position
Uses
Anterior-lateral aspect of the thigh. Preferred site in infants since gluteal muscles are not yet fully developed.
LOCATION: Handbreadth above knee and below trochanter of the femur. Divide this area into thirds and select the middle third.
RISKS: None. Lacks major BV and nerves. Rapid absorption if active movement.
POSITION: The client can assume a supine or sitting position
USES – No contraindications 19

20. IM Sites: Deltoid Site Location Risk Position Uses
SITE – Lateral aspect of the upper arm
LOCATION – 2 or 3 finger breadths below acromion process
Crease of axilla bottom border – form triangle and center is safe zone.
RISK – Less developed, small muscle site – radial and ulner nerve and brachial artery run through this area.
Maximum of 1 ml to be delivered to this site.
POSITION – Any
USES – Good site for flu shots, Hep B vaccine in adults
#...1” NEEDLE
<130# 5/8” NEEDLE
>240# 1 ½” NEEDLE 20

21. Determining Site & Needle Size
Amount & Characteristic of Medication
Amount & Condition of Muscle Mass
Frequency of Injection
Type of Medication
Age
Recommended Route 21

22. Comfortable Injections
Appropriate Needle
Position of Client
Relax muscle
Proper Injection Site
Rotate sites
Insert Needle Quickly
Hold syringe steady
Diversion
Z-Track
Use the smallest suitable length and gauge to prevent trauma.
Position client to promote comfort and reduce muscle tension.
Be knowledgeable about proper anatomic marking to locate safe injection site.
Insert needle quickly and smoothly, and fully
Hold the syringe steady, inject the medication slowly and steadily.
ASPIRATE 22

23. IM Injection: Z Track Pull skin laterally 1-1.5”
Hold taut w/nondominant hand
Release skin after needle removed
Less pain and more effective delivery
SHOWN TO REDUCE PAIN, MINIMIZE SKIN IRRITATION-PREVENT LEAKAGE INTO SUBQ TISSUE
DO NOT NEED TO REPLACE NEEDLE AFTER WITHDRAWING..SQUEGEE EFFECT
Pull the overlying skin and subcutaneous tissues approximately 2.5 to 3.5 (1 to 1 1/2 inches) laterally to the side with the ulnar side of the nondominant hand.
Hold the skin in this position until you have administered the injection. After cleansing the site, inject the needle deeply into the muscle.
If there is no blood return on aspiration, slowly inject the medication. Keep the needle inserted for 10 seconds to allow the medication to disperse evenly.
Withdraw the needle and release the skin.
When correctly administered, the Z-track leaves a zigzag path that seals the needle track, preventing the medication from escaping the muscle tissue.

24. Complications of IM Injections
Infection
Lipodystrophy
Nerve Damage
Ecchymosis
INFECTION – Draw medication from ampule quickly
Avoid contaminating sterile parts of needle/syringe: no touching outer edges of ampule, outer surface of needle cap, nurse’s hands, counter top.
Avoid touching length of plunger or inner part of barrel syringe.
Wash skin soiled with dirt, drainage, feces, with soap and water and dry. Cleanse with alcohol in a circular motion from center of site outward in a 2 inch radius.
LIPODYSTROPHY – Localized changes in the fatty tissue used for an injection. Loss of subC fat, may notice dimpling.
Problem is that medication will not be adequately absorbed/distributed.
Rotate sites and document where the injection was last given. 24

25. Diabetes Mellitus: Patho
Insulin is secreted by the Islets of Langerhans (Beta Cells)
Insulin lowers blood glucose levels after meals
Insulin moves glucose from the blood into the muscle, fat, liver, and cells
Types
I-IDDM
II-NIDDM
Insulin is a HORMONE.
**Where it can be used for energy
Type I (IDDM) – Insulin is not produced
Type II (NIDDM) – Insulin becomes less effective at stimulating glucose uptake by the tissues 25

26. Diabetes Mellitus Normal Blood Glucose Type II Medications
99 mg/dl – upper level of normal
Hemoglobin A1c
Type II Medications
Stimulates the pancreas to release more insulin and to increase sensitivity of body cells to insulin
Given twice daily, before meals
Glyburide (Diabeta)
Glucophage (Metformin)
Rosiglitazone (Avandia)
Normal Blood Glucose – Individuals with DM should strive to keep their glucose below This is felt to be key to avoiding the deleterious long term effects of DM – small vessel deterioration, HTN, peripheral neuropathy, visual deterioration, nephropathy.
Glycosylated HGB – Provides an ave. of blood glucose level over a 6-12 week period of time. Assess long term glucose control.
Normal – 2.2-5%
Diabetic <6-8% or complications of DM.
Diabetics should test this every 3 months. 26

27. Insulin: Subcutaneous (35-10, p.743 P&P)
Rapid-acting
(lispro, aspart-Novolog)
Short-acting
(Regular) (CLEAR)
Intermediate-acting
(NPH) (CLOUDY)
Long-acting
Glargine (Lantus)*
Given to replace insulin that the pancreas does not produce
Type I Diabetes
Type II Diabetes
Perry and Potter page 743
Rapid – 15 min,PEAK 1 HOUR -2-3 hrs LENGTH
Short-acting – 30min,PEAK 2-4 HOURS 6-8 hrs
Intermediate-acting – 1-2 1/2 hrs-6-12 HOURS PEAK – 18 hrs
Long-acting (glargine) 1hr – 24hrs
LANTUS NEVER MIX
REG AND NPH MOST COMMON TO MIX…NOT AS COMMON ANYMORE 27

28. Insulin: Nursing Implications
Monitor & assess for hypoglycemia
Anxiety/restlessness
Tremors
Diaphoretic
Cool/pale
Altered LOC
Confusion…lethargy…unconscious
Glucagon
1mg dose-may repeat in 15”
Give subq or IM if unresponsive
S&S of Hypoglycemia: sweating, tremors, tachycardia, palpitations, Headache, hunger, nervous, lethargy, confused, loss of consciousness.
Glucagon given if unconscious
Glucagon – (Hormone) Emergency Tx of severe hypoglycemia. SC, IM, IV if unable to swallow.
Stimulates the liver to release glucose.
Onset of action IV 1”
Subq-IM 10”

29. Insulin: Subcutaneous
Given 1-4 times daily
Room Temperature for 30 Minutes
Gently roll, look for flocculation
Must use syringe that matches the insulin (U-100)
Verify dosages with another Nurse
If mixing do not keep in syringe longer than 15 minutes
There are no insulin syringes that are calibrated to deliver U500 insulin. Often TB syringes are used to measure these small doses.
FLOCCULATION-fine particulates are caused to clump together into floc 29

30. Blood Glucose Monitoring
Done 2-4 times per day if on subq insulin
Done 3-4 times per week if on oral hypoglycemic (Oral Diabetic) therapy
Sliding Scale
Bedside Blood Glucose Test, Blood Glucose Monitoring, Self-Monitoring of Blood Gluc
Desire is to mimic the healthy body. Ideally the individual with DM does frequent BGT and adjusts insulin accordingly.
Blood glucose 220…low dose is Regular insulin…amount to be given
BS 288 with scheduled dose of 10 units Regular insulin…amount to be given 30

31. Heparin Mechanism of action Low dose High dose
Prevents conversion of prothrombin to thrombin
High dose
Prevents conversion of fibrinogen to fibrin
Exposure of the blood to proteins such as tissue factor initiates changes to blood platelets and the plasma protein fibrinogen, a clotting factor.
Platelets immediately form a plug at the site of injury; this is called primary hemostasis.
Secondary hemostasis occurs simultaneously:
Proteins in the blood plasma, called coagulation factors or clotting factors, respond in a complex cascade to form fibrin strands, which strengthen the platelet plug.[1]
The main role of the tissue factor pathway is to generate a "thrombin burst," a process by which thrombin, the most important constituent of the coagulation cascade in terms of its feedback activation roles, is released instantaneously.
which activates prothrombin to thrombin

32. Table Scenarios:
Heparin 5000 units subcut. For 65 yr old male who weighs 220 lbs
Morphine 4 mg IM for 88 yr female who weighs 92 lbs
Regular Insulin 10 units for 45 yr male who weighs 160 lbs
Ketorolac (Toradol) 60 mg IM for 60 yr male who weighs 310 lbs
Mantoux 0.1cc ID for 25 yr female nurse as part of yearly screening
6. Heparin 20,000 units/ml
12,000 units bid…amount?
7. Dilaudid 10 mg/ml
4 mg IM now…amount?
8.Ondansetron 4 mg/ml
6 mg IM now
9. Glucose 354
NPH 20 units with low dose scale…
10. Glucose 266
NPH 15 units with high dose