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Preparation for Practice Injections

Workbook

© University of the West of England, Bristol 4 HB.24/5/12

This pack does not cover the administration of drugs intravenously or intradermally.


INJECTIONS Aim:

Staff will gain an understanding and appreciation of the role and responsibilities of the nurse and Assistant Practitioner in the administration of subcutaneous (SC) and intra-muscular injections (IM).

Learning Outcomes:

On completion of the workbook, and clinical skills session the staff will be able to:

Explain the reasons for giving medication via different routes. Identify the anatomical sites for giving injections. Recognise the Nursing and Midwifery Council (NMC) Code of Conduct (2008). Demonstrate the procedure for the safe administration of subcutaneous/

intramuscular injections.

Desirable reading for injections

Dougherty, L. & Lister, S. (2008) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 7th Edition, Blackwell science, Oxford (Ch 11, pp 224-231) Timby, B. (2005) Fundamental Nursing Skills and Concepts. 8th Edition, Lippincott, Williams & Wilkins, London. (Ch 34).


GLOSSARY

To assist your understanding of Nursing and Medical terminology, we have created a list of commonly used terms. A nurse’s dictionary can be a useful resource to refer to.

Medical Term DefinitionAddiction State of physical & mental dependence on a drug /

substance.

Adipose Fat or tissue containing fat cells

Air embolism Air entering the circulatory system (in the form of bubbles)

Allergen Substance that produces allergic immune response

Anaphylaxis Shock caused by an antigen/ antibody reaction

Dermis Below epidermis of the skin

Epidermis Non vascular outer layer of the skin

Immunization Artificial means by which state of immunity is increased

Injection Introduction of liquid into the body under pressure

Intradermally Between the layers of skin

Intramuscular Within a muscle

Inflammation Response of tissue to an injury

Lateral On the side

Skin Outer protective covering of the body (is the largest organ of the body)

Syringe Instrument for injection or aspirating fluid

Subcutaneous Beneath the skin


1. Give 4 reasons why drugs may be given by injection.

2. What standard precautions do you need to take before and after administering an injection?

3. What considerations may you want to think about when giving an injection in the community?

4. List 4 routes by which an injection may be administered and provide an example of a drug that is given in this way.


5. Label the routes shown in the diagram below:

A =

B =

C =

6. Injections cause anxiety to many patients. What measures could be used to reduce injection discomfort?


A

BC

Points to consider before giving an injection:

Think about the NMC’s Code of Professional Conduct & Guidelines for the Administration of Medicines, and reflect on what you’ve seen in practice.

7. Medication: What would you need to check and why?

8. Equipment: What would you require and why?

9. Patient: What would you need to clarify with the patient before administering the injection and why?

10.List 3 things you must ensure about your practice in your role.


11.Where can you as a healthcare professional find reference material and information regarding drugs and their administration?

12.Why are the following important to consider each time you give an injection?

The type of injection

Each patient as an individual

The drug and quantity

Previously used sites


13.There are a least 10 potential complications that can occur when giving an injection.

Explain why the following might occur and how they may be avoided.

Hitting a blood vessel

IM injection goes in subcutaneous tissue rather than IM.

Nurse gets a needle stick injury following giving the injection

Infection following an injection

Hitting the bone when giving an injection

Nerve damage

Muscle fibrosis and contracture

Septic and sterile abscess formation

Intramuscular haemorrhage

Lipodystrophy

Pain

Anaphylactic shock

Medication given to the wrong patient

Embolism


Adverse Reactions

14.How would you recognise that a patient is having an allergic reaction to a drug?

15.What are your priorities in the management of a person with anaphylaxis in the community?

16.What are your priorities in the management of a person with anaphylaxis in hospital?

Before you give any injection you should be able to answer the following questions. You may find a decision making framework for skills development helpful (see back of workbook).

What is the correct angle for the injection?

Is your injection technique right?

Do you aspirate?

Do you swab the site, before and after the procedure?

Do you know the correct way to dispose of sharps?

What do you do if a needle stick injury occurs?


Subcutaneous Injections


Subcutaneous Injections

1. From your practical experience, give 2 examples of drugs given via the subcutaneous route. For each of these drugs state the dose prescribed and any side effects you had to be aware of.

DRUG DOSE SIDE EFFECTS

A subcutaneous injection is administered beneath the epidermis and dermis, into the fat and connective tissue of the subcutaneous layer.

For subcutaneous injections the skin should be gently pinched to lift the subcutaneous tissue away from the underlying muscle.

2. Subcutaneous injections can be given at 45° or 90°. What factors would affect your choice of angle when administering a subcutaneous injection?


3. On the diagram below, mark the sites where subcutaneous injections could be administered.


4. What are the advantages and disadvantages of each subcutaneous injection site?

SITE ADVANTAGES DISADVANTAGESAbdomen

Thighs

Buttocks

Upper Arm

Scapulae


Intramuscular Injections


Intramuscular Injections

1. From your practical experience, here are two examples of drugs given via the intramuscular route. For each of these drugs, the recommended dose prescribed and any side effects you need to be aware of.

DRUG DOSE SIDE EFFECTS

Diamorphine

Hydroxocobalamin (vit b12)

2.5-10 mgs

1mg 3 times a week for 2 weeks, then 1mg every 3 months.

Respiratory depressionNausea & vomitingConstipationHypotensionHallucinationsDysphoria

NauseaHeadacheDizzinessFeverHypersensitivity and injection site reactions eg rashHypokalaemiaChromaturia

An intramuscular injection is administered through the epidermis, dermis and subcutaneous tissue into the muscle.

All IM injections are administered at a 90° angle.

After quickly plunging the needle into the skin, the plunger is pulled back slightly to see if any blood is aspirated. If no blood is aspirated, then the injection is given depressing the plunger approximately 1ml per 10 seconds.

If blood should appear when the plunger is pulled back then withdraw the needle and complete the process again explaining to the patient what has occurred.

The Z Track Technique is the preferred method of giving the IM injection.


Intramuscular Injection sites

Intramuscular injections may be given in one of the following sites, depending on the patient’s size, mobility, the volume and the drug to be given.

Ventrogluteal Place the heel of your hand on the patients greater trochanter. (This may be easier if their leg is bent at the hip.) Spread your index and middle fingers from the anterior superior iliac spine to as far along the iliac crest as you can reach. Insert the needle between the two fingers at the level of the knuckles. Remove your fingers before inserting the needle.

Dorsogluteal With the patient lying either on their side, or prone, draw an imaginary line from the cleft of the buttock to the greater trochanter. Then draw another line vertically through the centre of the first, and identify the outer quadrant. This quadrant is then divided into four, and you insert the needle into the upper, outer quadrant.


Rectus femoris With the patient lying on his/her back, identify the length of the thigh from greater trochanter to patella. Divide this length by 3, and insert the needle into the middle third, on the front of the thigh.

Vastus lateralis With the patient lying on his/her back or side, identify the length of the thigh from greater trochanter to patella. Divide this length by 3, and insert the needle into the middle third, on the outer aspect of the thigh.


Deltoid With the patients hand on their hip, feel for the acromial process (the bony bump on the outside of the shoulder). Draw an imaginary horizontal line at this level, and insert the needle 2.5-5cm below this line, on the outermost aspect of the arm.

3. At what angle would you administer an Intramuscular injection?

4. What are the advantages and disadvantages of each intramuscular injection site?

SITE ADVANTAGES DISADVANTAGESDeltoid

Upper arm

Vastus Lateralis

Outer thigh


Dorsogluteal

Top of buttock

Ventrogluteal

Outer hip

Rectus Femoris

Front of thigh

The Z Track Technique

For intramuscular injections the skin needs to be stretched using the Z track technique.

5. Why is the Z track technique recommended when giving an intramuscular injection?


References

Gabriel, J. Dailly, S. & Keyley, J. (2004) Needlestick and sharps injuries: avoiding the risk in clinical practice. Professional Nurse 20 (1) 25-28

Harris, C. (2001) Effects of injection duration on site-pain intensity and bruising associated with subcutaneous heparin. Nursing Standard 35 (6) Sept 882-892

Higgins, D. (2004) IM Injection Nursing Times 100 (45) 36-37

Hunter, J. (2008) Intramuscular injection techniques. Nursing Standard. 22(24) 35-40

Hunter, J. (2008) Subcutaneous injection technique. Nursing Standard. 22(21) 41-44 Little, K. (2000) Skin preparation for intramuscular injections. Nursing Times 96(46) 6-8

Nursing & Midwifery Council (2002) An NMC guide for students of nursing and midwifery.

Rodger, MA. & King, L. (2000) Drawing up and administering intramuscular injections: a review of the literature. Journal of Advanced Nursing. March 31 (3), 574-582

Royal College of Nursing (2002) Position statement on injection technique. RCN publication code 001753

Small, S. (2004) Preventing sciatic nerve injury from intramuscular injections: literature review. Journal of Advanced Nursing 47(3) 287-296.

Workman, B. (1999) Safe injection techniques. Nursing Standard 13(39) 47-52

Websites

www.needlestickforum.net www.nmc-uk.org www.nursing-standard.co.uk www.rcn.org.uk www.rpsgb.org.uk (Royal Pharmaceutical Society


http://www.rpsgb.org.uk/

http://www.rcn.org.uk/

http://www.nursing-standard.co.uk/

http://www.nmc-uk.org/

http://www.needlestickforum.net/

A decision making framework toward skill development

The purpose of this decision making tool is to provide a framework to assist you when learning about a new skill. It utilises a step-by-step approach to the areas you need to consider when developing and building your skill repertoire.

The primary aim of this tool is to aid you in developing your competencies in clinical skills that you can provide evidence for your portfolio. It will hopefully help you, with support from your mentor / supervisor and/or another qualified healthcare professional, in practice, in identifying the particular aspects of a skill that you need to consider prior to undertaking this for the first time in the practice setting. The framework can also act as a means by which you and your mentor can measure your progress in developing your knowledge and understanding around the implementation of a specific skill.

A crucial attribute is the ability to take responsibility for one’s own learning. Firstly you need to be able to recognise your own strengths and weaknesses and secondly to develop an action plan to address developmental needs. Using this framework will assist you and your mentor in undertaking an appraisal of your abilities with regards to certain skills and then an appropriate action plan to enable you to gain the knowledge and understanding required prior to undertaking the skill for the first time to be developed.

In order to practice a skill confidently and competently it needs to be undertaken many times. You have a responsibility to ensure that you continue to develop your knowledge, understanding and delivery of this skill, exploring the implementation of this skill within differing environments, contexts of care as well as across the age spectrum.

At all times your mentor / supervisor, or the appropriately qualified healthcare professional, supervising or delegating this skill to you is accountable. You remain accountable in your own rights and should only proceed to undertake this skill if deemed competent and confident to do so.


· web viewtimby, b. (2005) fundamental nursing skills and concepts. 8th edition, lippincott,...

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