1. Chapter 34 Parenteral Medications

2. Question
Is the following statement true or false?
The parenteral route means a route of drug administration other than oral or through the gastrointestinal tract.

3. Answer
True.
The parenteral route means a route of drug administration other than oral or through the gastrointestinal tract.

4. Parenteral Administration Equipment
Syringes: all syringes contain a barrel, a plunger, and a tip or hub
Calibrated in milliliters (mL), cubic centimeters (cc), units (U), and in some cases minims (m)

5. Parts of a Syringe

6. Parenteral Administration Equipment (cont’d)
Needles are supplied in various lengths and gauges
Shaft: length of the needle
Gauge: diameter of the needle
Lengths vary from approximately 0.5 to 2.5 inches
Filter needles are used when withdrawing medication from a glass ampule

7. Parenteral Administration Equipment (cont’d)
Needle gauge refers to width
For most injections, 18- to 27-gauge needles are used; the smaller the number, the larger the diameter

8. Common Sizes of Syringes and Needles

9. Parenteral Administration Equipment (cont’d)
Modified safety injection equipment:
Avoids needlestick injuries to reduce the risk for acquiring a blood-borne viral disease such as hepatitis or AIDS
Plastic shields that cover the needle after use, needles that retract into the syringe, and gas-pressured devices that inject medications without needles

10. Parenteral Administration Equipment (cont’d)
Two techniques with standard equipment to prevent needlestick injuries:
Before administering an injection, the protective cap covering a needle is replaced by using the scoop method
After administering an injection, the needle is left uncapped and deposited in the nearest biohazard container

11. Safety Injection Devices

12. Ampule, Vial, and Prefilled Cartridge

13. Question What is the function of a syringe barrel?
a. Holds the medication
b. Withdraws the medication
c. Instills the medication
d. Attaches the needle

14. Answer a. Holds the medication
The barrel is the part of the syringe that holds the medication. The plunger is a part of the syringe within the barrel that moves back and forth to withdraw and instill the medication. The tip or hub is the part of the syringe to which the needle is attached.

15. Drug Preparation Ampule: sealed glass drug container
Vial: glass or plastic container of parenteral medication with a self-sealing rubber stopper
Reconstitution: process of adding liquid, known as diluent, to a powdered substance

16. Withdrawing Medication From the Ampule

17. Withdrawing Medication From the Vial

18. Drug Preparation (cont’d)
Prefilled cartridges: sealed glass cylinder of parenteral medication
Cartridge comes with an attached needle and the cylinder is made so that it fits in a specially designed syringe
Combining medications in one syringe: exact amounts must be withdrawn from each drug container; once the drugs are in the barrel of the syringe there is no way to expel one without expelling some of the other

19. Injection Routes
Intradermal injections: between the layers of the skin
Diagnostic purposes
Examples: tuberculin tests and allergy testing
Injection sites: inner aspect of the forearm

20. Injection Routes (cont’d)
Injection equipment: tuberculin syringe
25- to 27-gauge needle measuring one- half inch in length is commonly used
Injection technique: nurse instills the medication shallowly at a 10° to 15° angle of entry

21. Question
Which angle is used by the nurse to administer a subcutaneous injection to a thin client?
a. 90°
b. 15°
c. 10°
d. 45°

22. Answer
d. 45°
The nurse inserts the needle at a 45° angle for thin clients. For obese clients, and when administering intramuscular injections, the nurse inserts the needle at a 90° angle. When giving an intradermal injection, the nurse instills the medication shallowly at a 10° to 15° angle of entry.

23. Injection Routes (cont’d)
Subcutaneous injections: beneath the skin but above the muscle
Medication is instilled between the skin and muscle and absorbed fairly rapidly
Commonly used to administer insulin and heparin
Injection sites: insulin and heparin are administered in the abdomen

24. Injection Routes (cont’d)
Injection equipment used for a subcutaneous injection depends on the type of medication prescribed
Example: insulin is prepared in an insulin syringe and heparin is prepared in a tuberculin syringe

25. Injection Routes (cont’d)
Injection technique
For obese clients, the nurse inserts the needle at a 90° angle
For thin clients, the nurse inserts the needle at a 45° angle

26. Injection Routes (cont’d)
Administering insulin: hormone required by some clients with diabetes
Common route for administration: subcutaneous or intravenous injection
Inhaled form of insulin: Exubera
Insulin syringe: calibrated in units

27. Injection Routes (cont’d)
Administering insulin (cont’d): injection site for insulin is rotated each time the injection is administered to avoid
Lipoatrophy: breakdown of subcutaneous fat at the site of repeated insulin injections
Lipohypertrophy: buildup of subcutaneous fat at the site of repeated insulin injections

28. Low-Dose and Standard Insulin Syringes

29. Injection Routes (cont’d)
Preparing insulin: when preparing other than rapid-acting and short-acting insulin or the long-acting insulin, glargine (Lantus), the nurse rotates the vial between the palms to redistribute the additive and insulin before filling the syringe
Mixing insulins: insulins tend to bind and become equilibrated
Should be injected within 15 minutes of being combined

30. Mixing Insulins

31. Injection Routes (cont’d)
Administering heparin: an anticoagulant drug administered subcutaneously as well as intravenously, heparin prolongs the time it takes for blood to clot
Nurse removes needle after withdrawal of the drug from a multidose vial and replaces it with another before administration

32. Injection Routes (cont’d)
Administering heparin (cont’d):
To prevent bruising in the area of the injection, the nurse changes the needle before injecting the client
The nurse rotates the sites with each injection to avoid a previous area where there has been local bleeding
The nurse does not aspirate the plunger once the needle is in place

33. Injection Routes (cont’d)
Intramuscular injections: in muscle tissue
Absorption from an intramuscular injection occurs more rapidly than from the other parenteral routes
Injection sites
Dorsogluteal site: upper outer quadrant of the buttocks

34. Injection Routes (cont’d)
Ventrogluteal site: gluteus medius and gluteus minimus muscles in the hip for injection
Vastus lateralis site: vastus lateralis muscle, one of the muscles in the quadriceps group of the outer thigh

35. Injection Routes (cont’d)
Rectus femoris site: anterior aspect of the thigh
Deltoid site: lateral aspect of the upper arm
Injection equipment: 3- to 5-mL syringes are used to administer medications by the intramuscular route

36. Injection Routes (cont’d)
Injection technique: nurses use a 90° angle for piercing the skin
Z-track technique: technique for manipulating the tissue to seal medication, especially an irritant, in the muscle

37. Giving Injection by Z-Track Technique

38. Reducing Injection Discomfort
Nurses use these alternative techniques to reduce discomfort associated with injections:
Use the Z-track method for intramuscular injections
Apply pressure to the site during needle withdrawal
Massage the site afterward, if appropriate

39. Reducing Injection Comfort (cont’d)

40. Question
Which intramuscular injection site is used for clients with debilitated and poorly developed gluteal muscles?
a. Deltoid
b. Vastus lateralis
c. Rectus femoris
d. Ventrogluteal

41. Answer b. Vastus lateralis
The vastus lateralis site is used for clients with debilitated and poorly developed gluteal muscles. The deltoid site is used for adults. The rectus femoris site is used for infants. The ventrogluteal site is used for children.

42. Nursing Implications
Nurses who administer parenteral medications may identify nursing diagnoses such as:
Acute pain
Anxiety
Fear
Risk for trauma

43. General Gerontologic Considerations
Clients with diabetes often have visual problems interfering with their ability to self- administer insulin
Clients who can administer insulin injections but cannot fill their own syringes may choose to use prefilled syringes or an insulin pen

44. General Gerontologic Considerations (cont’d)
Age-related changes and possible chronic diseases impair the older person’s ability to absorb and metabolize medications
Injections should not be administered into limbs that are paralyzed, inactive, or affected by poor circulation
For clients with mastectomy or with a vascular site for hemodialysis, avoid arm on the affected side

45. General Gerontologic Considerations (cont’d)
Deltoid or ventrogluteal muscles may be the preferred intramuscular sites for older adults experiencing impaired mobility
Dorsogluteal site should be avoided because of the risk of damage to the sciatic nerve with diminished musculature
Selection and identification of injection site may be difficult when working with clients experiencing dementia or musculoskeletal deformities such as contractures