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of 44 Policy 136 – Administration of Medication by Injection V6 Oct-19

COMMUNITY SERVICES DIVISION CLINICAL POLICY

DOCUMENT

CLINICAL GUIDELINE – ADMINISTRATION OF MEDICATION VIA AN INTRADERMAL /

SUBCUTANEOUS / INTRAMUSCULAR INJECTION

Policy Number: 136

Scope of this Document: All staff within Community Services Division, who

administer medication via injection

Recommending Committee: N/A

Approving Committee: Clinical Standards Group

Date Ratified: October 2019

Next Review Date (by): October 2021

Version Number: Version 6 – 2019

Lead Executive Director: Executive Director of Nursing and Operations

Lead Author(s): Practice Nurse Development Team Leader

COMMUNITY SERVICES DIVISION CLINICAL POLICY DOCUMENT

2019 – Version 6

Striving for perfect care and a just culture


COMMUNITY SERVICES DIVISION CLINICAL POLICY DOCUMENT

CLINICAL GUIDELINE – ADMINISTRATION OF MEDICATION VIA AN INTRADERMAL /

SUBCUTANEOUS / INTRAMUSCULAR INJECTION

Further information about this document:

Document name CLINICAL GUIDELINE – ADMINISTRATION OF MEDICATION

VIA AN INTRADERMAL / SUBCUTANEOUS / INTRAMUSCULAR INJECTION (136)

Document summary To provide guidance for staff who administer medication by injection within Community Services Division

Author(s)

Contact(s) for further information about this document

Sue Roseboro - Practice Nurse Development Team Leader [email protected]

07770 347060

Published by

Copies of this document are available from the Author(s) and

via the trust’s website

Mersey Care NHS Foundation Trust V7 Building

Kings Business Park Prescot

Merseyside L34 1PJ

Trust’s Website www.merseycare.nhs.uk

To be read in conjunction with

038 Controlled Drugs Policy 032 Cold Chain Policy

SA50 Patient Group Directions Policy SA03 Incident Reporting Policy

IC01-Infection prevention and control IC02- Inoculation Injuries & impact assessment & BBV Injury

and Management Form SA36-Identification of Service Users

SA22-Waste Management

This document can be made available in a range of alternative formats including various languages, large print and braille etc

Copyright © Mersey Care NHS Trust, 2015. All Rights Reserved

Version Control:

Version History:

Version 6 Policy review undertaken – presented to / ratified by Clinical Standards Group Oct-19

Version 5

Transferred to Mersey Care NHS Foundation Trust Template, with reference to Liverpool Community

Health NHS Trust replaced with Mersey Care name and branding

20 Jun-19

http://www.merseycare.nhs.uk/


SUPPORTING STATEMENTS

this document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS

All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: • being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or

by professional judgement made as a result of information gathered about the child / adult; • knowing how to deal with a disclosure or allegation of child /adult abuse; • undertaking training as appropriate for their role and keeping themselves updated; • being aware of and following the local policies and procedures they need to follow if they have a child

/ adult concern; • ensuring appropriate advice and support is accessed either from managers, Safeguarding

Ambassadors or the trust’s safeguarding team; • participating in multi-agency working to safeguard the child or adult (if appropriate to your role); • ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to

Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

• ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTS

Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy


Contents

1. Purpose and Rationale 5

2. Outcome Focused Aims and Objectives 5

3. Scope 5

4. Definitions 5

5. Duties 6

6. Process 6

7. Consultation 12

8. Training and Support 12

9. Monitoring 12

10. Equality and Human Rights Analysis 13

11. Appendices 17

Section Page No


1. PURPOSE AND RATIONALE

1.1 The guideline is designed to ensure quality and consistency in the delivery of clinical care to people requiring intradermal, subcutaneous and intramuscular injection in the primary care setting and to provide guidance to practitioners who administer medication by those routes.

2. OUTCOME FOCUSED AIMS AND OBJECTIVES

2.1 Mersey Care Foundation Trust is committed to ensuring safe clinical practice in the administration of injections via the intradermal (ID), intramuscular (IM) and subcutaneous (SC) routes. This policy sets out the governance requirement for safe administration of injectable medicines.

3. SCOPE

3.1 This guideline applies to all staff for which the administration of injections is an agreed part of their role and who have been trained in the skill of injections; employed by Mersey Care Community Services Division. All staff for which the administration of injections is an agreed part of their role will be made aware of this guideline on commencement in post, as part of their local induction process.

4. DEFINITIONS

4.1 Table of Definitions

Injection A method of administering a substance such as a drug into the skin, subcutaneous tissue, muscle, blood vessels, or body cavities, usually by means of a needle

Intradermal The injection of a drug just under the

epidermis. Subcutaneous The injection of a drug into the subcutaneous

tissue.

Intramuscular The injection of a drug into muscle tissue,

where it is absorbed into the bloodstream, and the vascularity of the muscle aids the rapid absorption of the medication

Anaphylaxis An immediate and severe allergic

reaction to a substance (e.g. food or drugs). Symptoms of anaphylaxis include


breathing difficulty, loss of consciousness and a drop in blood pressure. This condition can be fatal and requires immediate medical attention

Safer sharps device A medical device that incorporates safety-

engineered protection mechanism 5. Duties

5.1 The Board of Directors, via the Chief Executive is responsible for ensuring the Trust has a policy to promote safe and best practice in relation to injections.

5.2 The Director of Nursing and Operations is responsible for overseeing the local control

of and the implementation of the injection Policy

5.3 The Learning and Development Team is responsible for provision of Trust training related to Medicines Management. The team is also responsible for maintaining the electronic staff record of training.

5.4 Service Managers and Team Leaders are responsible for ensuring that staff who

undertake IM and SC injections are appropriately trained and assessed as competent, and compliant with the policy.

5.5 All staff who administer IM or SC injections as part of their role, are required to maintain

their competence in this skill and to adhere to this policy. Staff must also complete the mandatory anaphylaxis training annually.

5.6 All staff who delegate IM or SC injections to unregistered practitioners are responsible

for appropriate assessment of the patient prior to delegation.

5.7 Clinical Pharmacists and Technicians are responsible for providing a clinical advisory and medicine management service.

6. PROCESS

6.1 The patient will receive safely and comfortably the correct dose of drug / drugs as per prescription into the correct site.

6.2 Equipment Required in Preparation:

a. Prescription or drug with pharmacy dispensary label with all relevant

information about dosage, frequency, route etc. b. Trust documentation for recording the administration of the drug. c. 1 appropriate sized sterile syringe. d. 1 sterile safer sharp needle for drawing up of drug. e. 1 sterile safer sharp needle of appropriate size for administration. f. Prescribed drug. g. Sharps bin – this should be placed at point of care.


h. Anaphylaxis kit. i. Alcohol swab if indicated j. Disposable Apron and disposable non sterile gloves if indicated

Ste

Procedure Rationale

1

a) Verbally confirm patients date of birth and

full name b) Explain and discuss the procedure with the

patient. c) Obtain valid consent/best interest

assessment for the administration of the drug via injection and record consent/bests interest assessment in the patient’s electronic healthcare record where appropriate.

d) Under no circumstances should a staff

member undertake an intradermal/ subcutaneous/intramuscular injection unless they are competent to do so.

To ensure the patient understands the procedure and gives informed consent/best interest assessment

2

a) Verify the patients name and date of birth with

the prescription sheet/electronic record. Check the prescription sheet or pharmacy dispensary label for drug name, form, specific directions, time due, dosage, batch number and route of administration.

b) Check drug and dosage are appropriate to

the patient’s condition(s) / age / weight, if in doubt consult the British National Formulary and / or the prescriber.

c) Check that there are no contraindications to the

administration of the drug, including allergies

For Medication administered within emergency situations, please refer to appropriate SOP/ policy.

To ensure the medication is given safely to the correct patient, at the correct time, at the correct dose and route.

3

a) Check drug information leaflet to see if there

are any injection sites that are recommended or any that are to be avoided.

To ensure absorption of the drug.


4

a) In the case of unfamiliar medicines refer to the

package insert for manufacturer’s information or a current British National Formulary ( BNF)

b) If the dose is not within usage ranges contact

the prescriber or pharmacist for advice

To reduce the possibility of medication error

To reduce medication errors

c) Read the patients care plan and know its current

contents and check that the medicine is due for administration at that time.

d) Ensure dose has not already been given by; • Checking the professionals contact

record sign in sheet within the patient’s paper light handheld folder.

• Checking previous entries in the patient’s electronic health record within EMIS.

To prevent patient from receiving duplicate dose

5 a) Hand hygiene to be performed as per Mersey Care guidance.

Select appropriate injection site, based on manufacturer’s information, understanding of the site where uptake is known to be enhanced for a particular drug. and individual patient assessment.

b) Consideration should be made to patient’s

comfort and dignity.

Maintain infection prevention and control standards. To ensure absorption of the drug. Maintain patient comfort and dignity.

Prevent pain and discomfort to the patient.

6 a)Select appropriate sized safer sharp needle for administration, based on selected injection site, route and individual patient assessment.

To ensure absorption of the drug. Prevent pain and discomfort for the patient.

7 a) Ensure all the equipment and the drug to be administered is within its expiry date and is sterile, including anaphylaxis kit.

To ensure no adverse reaction or infection.

8 a) Re-check prescription and carry out any calculations relating to dosage.

To prevent overdose of drug.


9 a) Prepare syringe and needle for drawing up and the reconstitution of powder utilising sterile safer sharp needle and aseptic technique. A 23G (Blue) safer sharp needle should be used for drawing up from a glass ampoule, unless a needle is provided for drawing up from a glass ampoule by drug manufacturer

b) Draw up prescribed amount of the drug aseptically into the syringe

c) Remove the needle used for drawing up and

apply the attached safety cover. Dispose into a sharps container.

d) Replace with a new, safer sharp needle of the appropriate size for administration

To ensure that the drug remains aseptic, without glass fragments and to prevent contamination.

To prevent accidental sharps injury.

To ensure smooth insertion of needle and to minimise pain and discomfort.

of 44 Policy 136 – Administration of Medication via Injection V7 Oct 2019

e) A new needle should be used for administration as the needle may have become blunted by passing through rubber bung or by hitting the side/bottom of the ampoule.

f) If the drug for injection is supplied in a pre-filled

syringe with an integral needle, this should be the appropriate size and gauge for the individual client.

10 a) Leave the needle sheathed until it is used.

The needle remains sheathed to prevent needle stick injury and contamination.

11 a) Expel air from needle and syringe except when using pre-filled syringes.

To prevent introduction of air emboli but in pre-filled it helps absorption of the drug.

12 a) Place the patient in the most appropriate position for administration.

To ensure the patient is in the correct position for administration. Promote patient comfort.

13 a) Ensure that the site for injection is socially clean. If cleaning is required soap and water should be used, ensuring that the area is dried.

b) Deep intra muscular injection require that the

skin must be cleaned with a isopropyl alcohol swab using a circular motion and allowed to dry for thirty seconds

Do not use alcohol skin disinfection for administration of vaccinations (WHO)

To prevent infection.

14 a) For intramuscular injections route - Insert needle into patient, into site, as per manufacturers recommendations. See appendix one for guidance on administration technique and appendix three for guidance on administration sites. b) For intradermal route-see appendix One for

guidance on administration technique and appendix two for guidance on administration sites.

c) For subcutaneous route see appendix one for guidance on administration technique and appendix two for guidance on administration sites.

To ensure the needle is in the correct position to administer the medication.


15 a) Administer drug by depressing plunger, ensuring full dose is given. Withdraw the needle and syringe from the patient and apply the attached safety cover Dispose of needle and syringe as a single unit. Disassembly of sharp items increases risk of injury. It is essential that needles remain unsheathed prior to disposal to prevent needle stick injuries to staff. Leave patient feeling comfortable

To maintain the health and safety of patients and staff.

16 a) Monitor patient’s condition following the procedure and report any adverse effects as per Mersey Care policy, in the patient’s health record, and via the yellow card system.

To maintain the safety of the patient. To ensure adverse reactions are recorded.

17 a) Document the administration of the medication within the patient’s electronic healthcare records, ensuring that the entry is dated and timed, for which your electronic signature will be attached. If a colleague has administered the medication, which you have witnessed and are documenting within the patient’s records on your EMIS log in then your colleague must sign within the signature box and type their full name within the boxes provided at the bottom of the medication administration and stock control template.

b) Documentation should include the site of the

injection (with rationale for choice), drug administered, expiry date and batch number of the drug, and the dose administered.

To provide a complete record of the administration/care given to inform the patient’s ongoing care, avoid duplication of administration and in the case of adverse reaction.

Presentation of Medications for Injection

6.3 Single Dose Glass Ampoule a. Shake down any liquid from the top of the ampoule.


b. If the ampoule is not pre-stressed score neck with file. c. If drawing up the drug from a glass vial a safer sharp needle no larger

than a 23 gauge (Blue) should be used to prevent any small glass fragments from being drawn up.

6.4 Multi-dose Vial a. Clean rubber seal with alcohol based swab and allow to air dry, to ensure asepsis. b. To facilitate aspiration of solution inject air, equal to amount of

medication needed, into bottle before aspirating. c. Aspirate appropriate amount of solution into syringe.

6.5 Drugs in Powder Form a. Follow manufacturer’s instructions when reconstituting drugs in powder form.

6.6 Pre-filled Syringes a. Follow manufacturer’s instructions as to whether the air bubble should /

should not be expelled.

6.7 Retractable needles a. Follow manufactures instructions on retractable devices and seek

training if unfamiliar with device 7. CONSULTATION

7.1 The following colleagues are consulted within the production and review of this document:

a. Head of Integrated Nursing Services; b. Clinical Operational Lead; c. Practice Development Team d. District Nursing Service; e. Governance Lead Nurse; f. Medicines Management Team; g. Palliative Care Team

8. TRAINING AND SUPPORT

8.1 All staff undertaking the skill of injection must have undertaken training in these procedures; for nursing and medical staff this is normally done as part of pre-registration training. All staff administering medication via injection should complete yearly mandatory training in basic life support and anaphylaxis.

8.2 Mersey Care NHS Trust Safer Sharps e-learning is available on the

intranet with guidance on the use of safer needle devices. Each video is to be viewed by the clinician then staff should download and complete the safer sharps register.


8.3 Immunisation and vaccination training is also necessary when staff are injecting for this purpose. Further information can be obtained from the Clinical Policy for Vaccine Administration within Mersey Care NHS Trust. Training can be accessed via the Learning and Development Bureau.

9. MONITORING

9.1 The monitoring of this guideline will be in accordance with local clinical audit plans. Audit of the guideline will be undertaken at the request of the clinical document authors or the Clinical Governance Team.

10. EQUALITY AND HUMAN RIGHTS ANALYSIS

EQUALITY AND HUMAN RIGHTS ANALYSIS

Title: Clinical Guideline- Administration of medication via Intradermal/ Subcutaneous/ Intramuscular Injection.

Area covered: Mersey Care Community Nursing Staff

What are the intended outcomes of this work? The principle aim of this policy is to ensure that there is clarity and service specific guidance on the safe administration of S/C, I/D and I/M. Who will be affected? Trust staff and patients to whom medicines administered via I/D, S/C, I/M Evidence

What evidence have you considered? National guidance and Mersey Care policies relating to medicines

Disability (including learning disability) There are no identified barriers. Sex There are no identified barriers. Race There are no identified barriers. Age There are no identified barriers as all processes have been developed with regard to safeguarding, consent in line with Mersey Care policies Gender reassignment (including transgender) There are no identified barriers Sexual orientation There are no identified barriers Religion or belief


There are no identified barriers Pregnancy and maternity There are no identified barriers Carers Consider and detail (including the source of any evidence) on part-time working, shift-patterns, general caring responsibilities. Other identified groups Consider and detail and include the source of any evidence on different socio-economic groups, area inequality, income, resident status (migrants) and other groups experiencing disadvantage and barriers to access. Cross Cutting There are no identified barriers in sex, race, religion or belief as all processes are carried out to maintain personal dignity and with consent gained or following a best interest assessment.

Human Rights Is there an impact? How this right could be protected?

Right to life (Article 2) Use supportive of Human Rights based approach

Right of freedom from inhuman and degrading treatment (Article 3)

Use supportive of Human Rights based approach

Right to liberty (Article 5) Use not engaged

Right to a fair trial (Article 6) Use not engaged

Right to private and family life (Article 8)


Right of freedom of religion or belief (Article 9)


Right to freedom of expression Note: this does not include insulting language such as racism (Article 10)


Right freedom from discrimination (Article 14)


Engagement and Involvement detail any engagement and involvement that was completed inputting this together.


This policy is supportive of a Human Rights based approach but is not applicable to the right to liberty or a fair trial as that is not within the realms of the service delivery and has no impact.


Summary of Analysis This highlights specific areas which indicate whether the whole of the document supports the trust to meet general duties of the Equality Act 2010 Eliminate discrimination, harassment and victimisation No negative impact identified Advance equality of opportunity No negative impact identified Promote good relations between groups No negative impact identified What is the overall impact? Safe delivery of a service which respects the individual rights of patients Addressing the impact on equalities This policy serves to protect the characteristics and vulnerable groups by ensuring there is no negative impact on equalities

Action planning for improvement

No challenges or priorities have been identified during the review of this policy that requires an action plan for improvement in place.

For the record Name of persons who carried out this assessment: Karina Woodyer-Smith

Date assessment completed: 25th October 2019 Name of responsible Director: Lynda Taylor Date assessment was signed: 25th October 2019


11. References .

Hunter J (2008) Intramuscular injection techniques, Nursing Standards 22 24 35-40. Cocaman A. Murray J (2010) Recognizing the evidence and changing practice on injection sites. British Journal of Nursing NO 18 Vol 19

Walsh L & Brophy K (2010) Staff Nurses sites of choice for administering intramuscular injections to adult patients in the acute care setting. Journal of Advanced Nursing

NMC (2015). The Code: Professional standards of practice and behaviour for nurses and midwives.

NMC (2009). Guidelines for Records and Record Keeping for nurses and midwives.

NMC (2010) Standards for Medicines Management.

WHO best practices for injections and related procedures toolkit (2010)

Appendix 1: Guideline for the Administration of Medication via Injection Before undertaking intradermal/subcutaneous/intramuscular injection staff must be competent in the following areas:

• All staff administering medication via injection have a responsibility to be familiar with Mersey Care NHS Trust Administration of Medication prescription sheets which must be signed and dated by a Medical practitioner or Independent Prescriber. Some injections can be administered as part of Patient Group Directive.

• Identification of clinical need for intradermal/subcutaneous/intramuscular injection. • Understanding of NMC Guidelines for the Administration of Medication (2010),

or guidelines issued by your appropriate regulatory body. • Exclusions and contra-indications for administration of medication via


intradermal/subcutaneous/intramuscular injection. • All staff undertaking any form of injection or medication administration must have

completed mandatory training in basic life support and anaphylaxis. • If the injection is an immunisation or vaccination, the appropriate immunisation and

vaccination training must also have been undertaken. Training can be accessed through the Learning and Development Bureau.

Standard UK Needle Gauge and Length

Orange 25 gauge 16mm (5/8 inch)

long Pre term or very small infants

Orange 25 gauge 25mm (1 inch) Long

Blue 23 gauge 25mm (1 inch) long

Green 21 gauge 38mm (1 ½ inches) long

The higher the number referring to the gauge, the narrower the lumen of the needle.


The Intradermal Route

This provides a local effect and is primarily used for diagnostic purposes such as allergy testing or for local anesthetics. It is sometimes used in the administration of vaccines and immunisations. To give an intradermal injection a 25 gauge (orange), 10mm length needle is inserted at a 5 -15 degree angle, bevel up, just under the epidermis, virtually parallel, for approximately 3mm. Up to 0.5 ml of drug/fluid is injected until a bleb/wheal appears on the skin surface. The sites suitable for intradermal injection are similar to those for subcutaneous injections (see appendix 2) but also include the inner forearm and shoulder blades (Workman 1999).

Figure1. Skin W heal Caused by Intradermal Injection.

The Subcutaneous Route The Subcutaneous route is used for a slow, sustained absorption of medication. Up to 1-2 ml of drug/fluid is injected, slowly, into the subcutaneous tissue using a 25 gauge (orange) needle inserted at a 45 degree angle into a raised skin fold in order to lift adipose tissue from underlying muscle (Workman 1994). Aspiration following needle insertion is not required as risk of puncturing blood vessels is negligible.

For sites suitable for subcutaneous injection, please see appendix 1.

sue

tissue

Figure 2. Subcutaneous Injection Technique.


Figure 3. Subcutaneous Injection Technique.

Insulin Administration The introduction of shorter insulin needles means that it is now recommended that the angle for insulin injections is 90 degrees (Burden 1994).

Following administration of a medication subcutaneously, the site should not be massaged or rubbed as this can cause trauma to the injection site.

Safer Administration of Insulin as per NPSA advice http://www.nrls.npsa .nhs .uk/resources/type /alerts/?e ntryid45=74287

Errors in the administration of insulin by clinical staff are common. In certain cases they may be severe and can cause death. Two common errors have been identified:

• The inappropriate use of non-insulin (IV) syringes, which are marked in ml and

not in insulin units;

• The use of abbreviations such as ‘U’ or ‘IU’ for units. When abbreviations are added to the intended dose, the dose may be misread, e.g. 10U is read as 100.

Staff should ensure that:

All regular and single insulin (bolus) doses are measured and administered using an insulin syringe or commercial insulin pen device. Intravenous syringes must never be used for insulin administration. The term ‘units’ is used in all contexts. Abbreviations, such as ‘U’ or ‘IU’, are never used. All clinical areas and community staff treating patients with insulin must have adequate supplies of insulin syringes and subcutaneous safer sharp needles. An insulin syringe must always be used to measure and prepare insulin for an Intravenous infusion

http://www.nrls.npsa/

10

The Intramuscular Route The intramuscular route delivers medication into well-perfused muscle. The vascularity of the muscle tissue aids the rapid absorption of medication (Dougherty and Lister 2011). This provides a rapid systemic action. It is possible to inject between 1ml (in the deltoid) to 5ml in other intramuscular sites. These volumes should be halved for children (Workman 1994).

For diagrams of sites suitable for use for intramuscular injections, please see appendix 2.

Older and emaciated patients may have less muscle mass than younger or more active patients. Proposed sites for intramuscular injection should be assessed for sufficient muscle mass. If the patient has reduced muscle mass it is helpful to “bunch up” the muscle before injection. Needles should be long enough to penetrate the muscle and still allow a quarter of the needle to remain external to the skin. For intramuscular injections the most common sizes used in adults and older children are 21 gauge (green) and 23 gauge (blue) with a length of 25mm (1 inch) or 38mm (1½ inches) long, length used should be based on an individual patient assessment. If a patient has a lot of adipose tissue, a longer needle should be used.

In infants a 23G (blue) or 25G (orange needle should be used). A 25mm (1 inch) needle is suitable for children of all ages. Only in pre-term or very small infants should a shorter, 16mm length needle be used. Intramuscular injections should to given at a 90 degree angle to ensure the needle enters into the muscle and reduces pain. Following insertion of the needle, aspiration should be performed to ensure a blood vessel is not being penetrated. In the event of blood being aspirated the procedure should be started again with a new safer sharp needle.

ssue

e tissue

Figure 4. Intramuscular Injection Technique.

22

Figure 5. Intramuscular Injection in to the Deltoid Muscle.

Figure 6. Bunching up of Muscle in Emaciated Patient.

The Z Track Technique for Giving IM Injections.

This technique is recommended for the full range of intramuscular medications. It is believed to reduce pain and the incidence of post injection leakage. The skin at the chosen site is pulled to one side or downwards, this moves the cutaneous and subcutaneous tissues by approximately 1-2cm. It is therefore important that you are able to visualise the underlying muscle and aim for that location rather than a distinguishing mark on the skin. The needle is inserted at a 90 degree angle and the injection is given. 10 seconds should be allowed to elapse before the needle is removed. This allows the medication to be diffused into the muscle before removal. On removal the retracted skin is released.

23

Figure 7. The Z Track Technique Injections in Children.

Intramuscular and deep subcutaneous injections, as are often required for immunisations and vaccinations, should be given in the anterolateral thigh or deltoid site. The anterolateral thigh should be used in infants under the age of one year and the deltoid site in older children. A needle length of 16mm (5/8th inch) is the minimum for all intramuscular or deep subcutaneous injections in children. A longer 25mm (1 inch) needle should be used, in all but pre-term or very small infants.

Appendix 2 Sites for Intradermal and Subcutaneous Injection

18

1

Appendix 3 Sites for Intramuscular Injection For older children and adults the deltoid muscle is the preferred site. The deltoid muscle is easier to access in most patients and results in less embarrassment for older children and adults. The Deltoid Muscle The densest part of the muscle is found by identifying the achromial process and the point on the lateral arm in line with the axilla. The needle should be inserted about 2.5cm below the achromial process, avoiding the brachial artery and the radial nerve. Patients should be asked to place their hand on their hip to relax the muscle.

2

The Dorsogluteal Site Draw an imaginary horizontal line across from the natal cleft in the buttocks to the greater trochanter of the femur. Then draw a vertical line midway through the horizontal line. The needle should be inserted into the upper outer quadrant, into the gluteus maximus muscle. The patient should be asked, if possible to lie on their side with their knees slightly flexed, or lie prone with their toes pointing inwards to relax the muscle (Covington and Trattler 1997). Do not use the gluteal muscle for vaccination as it is highly unlikely that the vaccine will reach the muscle and this may result in poor immune response. In addition to this there is a risk of damage to underlying structures, such as the sciatic nerve and superior gluteal artery. The ventrogluteal site is advocated as first choice (Roger and king 2000)

21

The Ventrogluteal Site This site can be identified by placing the palm of your left hand on the greater trochanter of the patient’s right hip (or vice versa). Extend your index finger to touch the anterior superior iliac crest and stretch the middle finger to form a V as far as possible along the iliac crest as you can. If you have small hands, slide the palm of your hand up from the greater trochanter until you can reach the anterior superior iliac crest with your index finger (Covington and Trattler 1997).

22

The Vastus Lateralis Site In adults the vastus lateralis can be located by measuring a hand’s breadth laterally down from the greater trochanter, and a hand’s breadth up from the knee. The injection site is the middle third of the quadriceps muscle. The rectus femoris is in the middle third of the anterior thigh.

23

Appendix 4: COMPETENCY FRAMEWORK FOR ADMINISTRATION OF DRUGS VIA AN INJECTION

The following framework can be used for practitioners that have been identified as needing to revisit their skills and under pining knowledge around the administration of injections as part of their ongoing professional development.

24

Staff Name:…………………………

COMPETENCY FRAMEWORK FOR ADMINISTRATION OF DRUGS VIA AN INJECTION All staff will be able to demonstrate their competence against this framework.

1 Underpinning knowledge

PRACTICE OUTCOME/ SKILL

SUPPORTING EVIDENCE Assessor Signature

Nurse Signature

1.0 Has under taken initial training in the process of intradermal / subcutaneous / intramuscular injection.

Has evidence of up to date CPR and Anaphylaxis training.

DATE Observation

Competent

COMMENTS

1.1 Demonstrates the ability to recognise the indications for use of an intradermal / subcutaneous / intramuscular injection.

Assessor Signature

Nurse Signature

DATE Observation

Competent

25

COMMENTS

26

COMPETENCY FRAMEWORK FOR ADMINISTRATION OF DRUGS VIA AN INJECTION 1 Underpinning knowledge


SUPPORTING EVIDENCE Assessor Signatur

Nurse Signatur

1.2 Demonstrates knowledge of drugs, possible side effects and contraindications of the drug to be administered by the injection.

DATE -Observation

Competent COMMENTS

1.3 Demonstrates a clear understanding of the procedure used to report any adverse drug reactions (Mersey Care policy and yellow card system).

Assessor Signatur

Nurse Signatur

DATE Observation

Competent

COMMENTS

27

COMPETENCY FRAMEWORK FOR ADMINISTRATION OF DRUGS VIA AN INJECTION 1 Underpinning knowledge



Nurse Signatur

1.4 Demonstrates a clear understanding of the legal implications associated with the administration of drugs.

DATE Observation

-Competent

COMMENTS

28

COMPETENCYFRAMEWORK FOR ADMINISTRATION OF DRUGS VIA AN INJECTION

2. Preparation


SUPPORTING EVIDENCE Assessor Signature

Nurse Signature

2.0 Before any activity is undertaken, obtains the patient’s consent and documents this in the patient’s notes.

DATE Observation Competent COMMENTS

2.1 Explains the principles and procedure of injections in a manner appropriate to patient and / or carer.

Assessor Signatur

Nurse Signatur

DATE Observation

-Competent

COMMENTS

29

COMPETENCYFRAMEWORK FOR ADMINISTRATION OF DRUGS VIA AN INJECTION 2. Preparation



Nurse Signatur

2.2 Uses additional patient / carer information resources where appropriate and available for example leaflets.

DATE -Observation

-Competent

COMMENTS

2.3 Able to identify and assemble all appropriate equipment / supplies for the procedure, including anaphylaxis kit.

Assessor Signature

Nurse Signature

DATE Observation

-Competent

COMMENTS

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COMPETENCYFRAMEWORK FOR ADMINISTRATION OF DRUGS VIA AN INJECTION 2. Preparation



Nurse Signatur

2.4 Ensures all appropriate documentation is ready for use prior to activity.

DATE Observation

-Competent

COMMENTS

2.5 Ensures all drugs are prescribed by a suitable independent prescriber in accordance with guidelines.

Assessor Signature

Nurse Signature

DATE -Observation

-Competent

COMMENTS

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2.Preparation

PRACTICE OUTCOME/ SKILL SUPPORTING EVIDENCE Assessor

Signature Nurse Signature

2.6 Allows time for questions to be asked and answered in a manner and level appropriate to the patient / carer.

DATE -Observation

Competent COMMENTS

2.7 Identifies an appropriate administration site based on prescription, drug information leaflet and individual patient assessment.

Assessor Signatur

Nurse Signatur

DATE Observation

-Competent

COMMENTS

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COMPETENCY FRAMEWORK FOR ADMINISTRATION OF DRUGS VIA AN INJECTION 3.Procedure



Nurse Signatur

3.0 Draws up solution appropriate amount of drug aseptically using appropriate equipment.

Leaves needle cover in place as long as possible.

Ensures area for injection is socially clean.

DATE Observation Competent

COMMENTS

3.1 Changes the needle prior to injecting, expelling any air bubbles. Checks volume of drug prior to administration.

Monitors the condition of the patient throughout the procedure.

Assessor Signature

Nurse Signature

DATE -Observation

Competent COMMENTS

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COMPETENCYFRAMEWORK FOR ADMINISTRATION OF DRUGS VIA AN INJECTION 3.Procedure



Nurse Signatur

3.2 Demonstrates the ability to administer the prescribed medication using the appropriate technique, as per Mersey Care guideline and prescription sheet.

Administers the injection in the appropriate site.


COMMENTS

3.3 Demonstrates appropriate use of trust documentation in accordance with NMC and local guidelines.

Assessor Signatur

Nurse Signatur

DATE Observation

-Competent

COMMENTS

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COMPETENCYFRAMEWORK FOR ADMINISTRATION OF DRUGS VIA AN INJECTION 4.Infection control



Nurse Signatur

4.0 Cleanse hands effectively before and after the activity.


COMMENTS

4.1 Before carrying out the clinical procedure ensure yellow sharps box is placed in a safe area in close proximity to you.

Assessor Signatur

Nurse Signatur

DATE -Observation

Competent

COMMENTS

4.2 If a risk assessment identifies the need for PPE this would be used throughout the procedure i.e. the wearing of protective disposable apron and disposable gloves.

Assessor Signatur

Nurse Signatur


COMMENTS

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4. Infection control

4.3 Following completion of the clinical procedure ensure all waste materials are disposed of in an appropriate manner in accordance with local trust policy.

Assessor Signature

Nurse Signature

DATE -Observation

Competent COMMENTS

APPENDIX 5 Patient Details

NHS Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Forename . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date of Birth . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bed Based Unit

Care Plan Number: 16

CORE CARE PLAN – Administration of Injection v2

Actual Problem…………………………………………………………………………………………………………………………… ....................................................................................................... .............................................requires an intradermal/subcutaneous/intramuscular injection due to . . . . . . . Individual Baseline………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………

Long term- discharge planning Patient will be monitored as appropriate to ensure patient safety Patient will be referred for on-going administration on discharge as required.

Nursing Intervention

Goals agreed with patient, family and nurse Short term Drug will be administered safely as per current prescription sheet. Patient will have an understanding of the need for the administration of the medication.

1. Qualified Nurse to obtain valid consent prior to intervention, either written or verbally to ensure all proposed treatment and interventions are discussed and fully understood. If concern raised regarding …………….’s capacity to consent relating to this care plan attach and complete Reduced Capacity to Consent Care Plan.

2. Consider risk factors for infection and act in accordance with appropriate Trust policy 3. Qualified Nurse to explain the reason for the use of the medication and the need for

administration via injection involving Pharmacist as required. 4. Qualified Nurse to check prescription sheet for any changes, prior to any administration of the drug. 5. Qualified Nurse to check drug card and evaluation sheet to ensure correct time of

administration and that the administration of the drug has not already taken place. 6. Check drug name, expiry date, contra-indications and document. 7. Select appropriate site for injection based on drug information and individual patient

assessment, rotating sites if appropriate ensuring site of administration is socially clean. 8. Administer medication using appropriate needle gauge and site for type of injection as policy. 9. Record drug administration using the drug card. 10. Give post injection advice appropriate to the drug administered to the patient as

appropriate. 11. Monitor . . . . . . . . . . . . . . . . . . . . . for any adverse effects or complications post injection. 12. Report any problems, deteriorations to Qualified Nurse as appropriate.

Individual Patient Care: Specific monitoring required whilst the patient is receiving this medication via injection. (E.g. Blood pressure monitoring, blood tests, urine tests etc.); ...................................................................................................................................................................... ………………………………………………………………………………………………………………………… State frequency of monitoring, safe/acceptable parameter and action to be taken if monitoring not within safe/acceptable parameters;

Review date no later than:

Outcome of care plan review; (please tick) Provide rationale on evaluation sheet

Sign and date:

Continue □ Discontinue □ Continue □ Discontinue □ Continue □ Discontinue □

Care planned by: Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Signature…………………………………………………… Designation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Date

ReferencesGulanick M & Myers J (2007) Nursing Care Plans; Nursing diagnosis and Intervention 6th Edition St Louis, Mosby Elsevier.

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APPENDIX 6 District Nursing Administration of Injection Care Plan

clinical guideline – administration of medication via …€¦ · the administration of...

Documents