1. Administration of medication – Intramuscular, Subcutaneous and Intradermal Ms. Lalith Sivanathan

2. I NTRAMUSCULAR I NJECTIONS

3. G OAL : -After this session student will be able to confidently : -Perform giving IM injections. -Demonstrate correct technique for giving IM injections. -Identify equipment used for giving IM injections. -Demonstrate correct disposal of used needle. -Explain and be able to identify how the patient tolerated the IM injection.

4. T HE S IX R IGHTS OF D RUG A DMINISTRATION Right Person Right Drug Right Dose Right Time Right Route Right Documentation

5. L OCATING INJECTION LANDMARKS

6. - C HOOSING THE SITE TO ADMINISTER MEDICATION - -There are several different sites an IM injection Site determination - -Stage of patients development. -Body build -Physical condition -Amount of the medication to be given

7. I NTRAMUSCULAR I NJECTION S ITES Deltoid Dorsogluteal Ventrogluteal Vastus lateralis Rectus femoris

8. L ANDMARKS : 2-3 FINGER WIDTHS DOWN FROM THE ACROMION PROCESS ; BOTTOM EDGE IS AT AN IMAGINARY LINE DRAWN FROM THE AXILLA. Deltoid

9. D ELTOID The deltoid site may be used on a child that is one year old and walking, depending on the child’s muscle mass Assess the deltoid muscle of the adult to determine if it has sufficient mass for the injection Bunching of the muscle may be needed with smaller muscle mass

10. D ORSALGLUTEAL Watch out for the sciatic Have patient stand or lay face down with toes pointing inward. (relaxes muscle) Divide the buttocks into 4 quadrants; give the injection in the outer, upper quadrant toward the hip. DO NOT give to children who are not walking yet. (Muscles are not developed enough)

11. V ENTROGLUTEAL Good for adults and small children. Find the upper part of the hip. Place palm on hip (greater trochanter), with fingers point to the ground, and make a very large “V” with your pointer finger and middle finger. In the middle of the “V” is where the injection can be done.

12. Vastus Lateralis Landmarks: Place one hand below the greater trochanter and one hand above the lateral femoral condyle, mid- lateral thigh

13. T HE MUSCLE OF CHOICE FOR IM INJECTIONS IN A CHILD LESS THAN 12 MONTHS OF AGE Vastus Lateralis in Infants

14. R ECTUS F EMORIS On the anterior thigh, above the knee. Used mostly by people who have to get themselves injections. This is painful, because the muscles in the anterior thigh are tense when given.

15. I NJECTION S ITE A SSESSMENT Do not use a site with any of the following: Muscle atrophy Inflammation Edema Scarring, tattoo, mole, or lesion IV port/ access Surgery in the limb/lymph node problems

16. Parts of a syringe. S YRINGE

17. N EEDLES Made of 3 parts - hub, shaft, bevel or slanted tip Range in length from l/4 to 3 inches Choose needle based on: client's size, weight, type of tissue Length: IM’s = I – 1 ½ inches SC'S = 3/8 – 5/8 inches

18. N EEDLE GAUGE Determine appropriate needle gauge IM : 19 - 25 gauge Lower gauge number = bigger needle Use for more viscous medications Usual needle length/gauge for IM vaccines is 19 - 25 G 1”

19. U SE THE CORRECT NEEDLE LENGTH FOR IM INJECTIONS 1” minimum needle recommended 1½” to 2” needle for larger arm Longer needles: Hurt less Cause fewer local reactions Assures proper route and a valid dose of vaccine

20. -E QUIPMENT NEEDED TO PERFORM AN IM INJECTION - -Syringe with needle -Medication to be administered. -Gloves -Band-Aid -Alcohol swab

21. T ECHNIQUE OF G IVING AN I NTRAMUSCULAR I NJECTION Check the 6 rights of medication administration. Choose the site for IM injection. Check the patient for any allergies. Gather the supplies needed to perform IM injection. Wash your hands. Put on gloves. Open alcohol swab and in a circular motion, clean area in a 2 inch diameter at the site of the intended IM injection. Let fully dry.

22. C ONTINUED … Pull skin around the clean site taut. take needle in dominate hand between the thumb and the index finger. At a 90 degree angle, plunge the needle into the skin in a dart like motion. Depending on the site and the condition of the patient, determine how far the needle is going to have to go into the skin to be in the muscle. pull back on the plunger and aspirate or blood. If there is blood aspirated back into the needle, remove and dispose in a sharps container. start from the beginning.) Push the medication at a slow and steady pace. Remember to hold the needle as steady as possible.

23. C ONTINUED.. To take the needle out, quickly pull up at a 90 degree angle. Apply some pressure at the site with the alcohol swab that was used to clean the site. Massage the site to help disperse the medication that was just given. Cover site with Band-Aid. Dispose of needle into a sharps container. Dispose gloves and wash hands. Observe the patient for signs of any allergic reaction, N&V, or any other adverse reactions that may go along with the medication. Always remember to document.

24. Z- TRACK TECHNIQUE It’s pretty simple. It reduces leakage of medication through subcutaneous tissue and decreases skin lesions at the injection site. So, the patient gets the full dose of medication. It doesn’t hurt patients quite as much as a regular I.M. injection. 24

25. Z- TRACK TECHNIQUE pulling skin to the side, then giving the shot, cutting off the needle track.

26. Use dry gauze to apply very gentle pressure to the puncture site. Assess the site immediately after administering the injection and again 2 to 4 hours later. Properly dispose of all used equipment and supplies. 26

27. C HECK THE MEDICATION

28. D RAW UP THE MEDICATION

29. P REPARE THE SITE

30. I NSERT THE NEEDLE AT A 90  ANGLE

31. I NTRAMUSCULAR I NJECTION 90º

32. Locating the vastus lateralis muscle.

33. 33 Spreading the skin at the vastus lateralis site and darting the tissue

34. Location of rectus femoris injection site.

35. R EMOVE THE NEEDLE AND COVER THE PUNCTURE SITE

36. M ONITOR THE PATIENT

37. C OMFORTING R ESTRAINT FOR I NFANTS & T ODDLERS Hold the child on parent’s lap 1. One of child’s arms embraces parent’s back and is held under parent’s arm 2. Other arm controlled by parent’s arm and hand--for infants, parents can control both arms with one hand 3. Both legs anchored with the child’s feet held firmly between parent’s thighs, and controlled by parent’s other arm.

38. C OMFORTING R ESTRAINT FOR O LDER K IDS Hold the child on parent’s lap or have the child stand in front of the seated parent 1. Parent’s arms embrace the child 2. Both legs are firmly between parent’s legs

39. S UBCUTANEOUS I NJECTION

40. S UBCUTANEOUS I NJECTIONS (SC) Drug absorption is slower than intramuscular (IM) because subcutaneous tissue is not as richly supplied with blood as the muscle. As the area contains pain receptors, clients may experience discomfort during injection. Injection site must be free of infection, skin lesions, scars, bony prominence, and large underlying muscles or nerves.

41. P ARENTERAL A DMINISTRATION Subcutaneous Injections Injections made into the loose connective tissue between the dermis and the muscle layer Drug absorption slower than with IM injections Given at a 45-degree angle if the patient is thin or at a 90-degree angle if the patient has ample subcutaneous tissue Usual needle length is 1/2 to 5/8 inch and 25 gauge Used to administer insulin and heparin

42. S UBCUTANEOUS INJECTIONS Gauge-25-29 Length-3/8, ½ and 5/8 inches Angle-45 degrees

43. SC Inject at 90 degree in the average client - 45 degrees if the client has small amt of subcutaneous tissue (If you can pinch 2 inches, use 90 degrees, otherwise use 45 degrees) Heparin - use lower abdominal folds - Arms are moved frequently and are at greater risk for tissue disruption and bruising, do not inject heparin (or “blood thinners” into arms) Do not massage following the injection of Insulin or Heparin (cause more tissue disruption)

44. I NJECTION S ITES The preferred site for giving a subcutaneous injection of insulin and heparin is the abdomen. Additional or alternative injection sites for insulin are the outer back area of the upper arm, where it is fleshier, and outer areas of the thigh and upper buttocks

45. I NJECTION S ITES Rotating within one injection site, preferably the abdomen, is recommended rather than rotating to a different area with each injection The rate of drug absorption at various subcutaneous sites from fastest to slowest is abdomen, arms, thighs, and buttocks. 45

46. I NJECTION T ECHNIQUE To reach subcutaneous tissue in a normal-sized or obese person who has a 2-inch tissue fold when it is bunched, the nurse inserts the needle at a 90-degree angle. The tissue usually is bunched between the thumb and fingers before administering the injection to avoid instilling insulin within the muscle. 46

47. 47 Angles and needle lengths for subcutaneous injections.

48. I NTRADERMAL I NJECTIONS Introduction of a hypodermic needle into the dermis for the purpose of instilling a substance such as a serum, vaccine, or skin test agent Small volumes (0.1 ml) injected to form a small bubblelike wheal just under the skin Used for allergy sensitivity tests, TB screening, and local anesthetics A tuberculin syringe used with a 25-gauge, 3/8- to 5/8-inch needle

49. I NTRADERMAL I NJECTIONS Gauge-25-29 Length-1/4 to ½ inch Amount- 0.1 ml Angle-15 degrees

50. I NJECTION S ITES A common site for an intradermal injection is the inner aspect of the forearm. Other areas that may be used are the back and upper chest. 50

51. I NJECTION E QUIPMENT A tuberculin syringe holds 1 mL of fluid and is calibrated in 0.01-mL increments. It is used to administer intradermal injections. A 26- to 28-gauge needle measuring a half-inch in length commonly is used when administering an intradermal injection. 51

52. 52 Figure 34-9 A tuberculin syringe.

53. I NJECTION T ECHNIQUE When giving an intradermal injection, instill the medication shallowly at a 10- to 15-degree angle of entry

54. R EDUCING I NJECTION D ISCOMFORT Use the smallest-gauge needle that is appropriate. Change the needle before administering a drug that is irritating to tissue. Select a site that is free of irritation. Rotate injection sites. Numb the skin with an ice pack before the injection. Insert and withdraw the needle without hesitation. Instill the medication slowly and steadily. Use the Z-track method for intramuscular injections. Apply pressure to the site during needle withdrawal. Massage the site afterward, if appropriate.

55. M EDICATION A DMINISTRATION AND D OCUMENTATION Record all information concerning the patient and medication including: Indication for drug administration Dosage and route delivered Patient response to the medication—both positive and negative

56. S UMMARY Six rights of drug administration. Proper needle handling procedures. Proper documentation of medications administered. IM injection sites. Proper steps to perform an IM injection. Subcutaneous injection – sites and technique Intradermal injection – sites and technique Documentation