MEDICATION ADMINISTRATION:
ADMINISTERING PARENTERAL MEDICATIONS
Parenteral medications are given through a route other than the alimentary canal; these routes are intradermal, subcutaneous, intramuscular, or intravenous. The angle of injection and the depth of penetration will indicate the type of injection. Many clients have broadly classified the parenteral route into one category: “injections” or “shots.” The nurse should provide the client with an explanation of the various routes used when administering parenteral drugs. To prepare and administer parenteral medications the nurse must have knowledge of the special equipment, use manual dexterity and sterile technique, and follow Standard Precautions. An injection is an invasive procedure because it breaks the skin barrier. As such, it must be performed using proper aseptic technique to prevent risk of infection.
EQUIPMENT
Nurses use special equipment such as syringes, needles, ampules, and vials when administering parenteral medications.
SYRINGES
A syringe has three basic parts: the hub, which connects with the needle; the barrel, or outside part, which contains measurement calibrations; and the plunger, which fits inside the barrel and has a rubber tip (Figure 29-10).
The nurse must ensure that the hub, inside of the barrel, and shaft and rubber plunger tip are kept sterile. When handling the syringe, the nurse should touch only the outside of the barrel and the plunger’s handle. Most syringes are disposable, made of plastic, and individually packaged for sterility. There are several types of syringes, such as the hypodermic, insulin, and tuberculin syringes (Figure 29-11A–C).
When a medication is incompatible with plastic, it is usually prefilled in a singledose glass syringe. Syringes are often prepackaged with the commonly used needle size and gauge and are referred to as disposable plastic syringes (Figure 29-11D). The hypodermic syringe comes in 2-, 2.5-, and 3-ml sizes.
The measurement calibrations (scales) are usually printed in milliliters and minims. Most syringes are marked in cubic centimeters (cc), and most drugs are ordered in milliters; these are equivalent measurements (1 cc = 1 ml). The hypodermic syringe is used most often when a medication is ordered in milliliters. When the order is written in minims, it is safer to prepare the drug in a tuberculin syringe.
The insulin syringe is designed specially for use with the ordered dose of insulin. For example, if the health care practitioner writes the order for 30 units of U-100 insulin, the nurse will use an insulin syringe that is calibrated on the 100-unit scale. Insulin syringes are calibrated on the U-100 (100-unit) scale, which is based on 100 units of insulin contained in 1 ml of solution. Insulin syringes come in sizes that hold 0.5 ml (50 units) to 1.0 ml (100 units). Insulin syringes that hold 0.5 ml are the easiest to read and are therefore used for low dosages.
There are other sizes of insulin syringes that complement the ordered dose, such as U-30 and U-50, although these dosages are seldom prescribed. The nurse should always compare the size of insulin syringe and the dose indicated on the insulin bottle with the health care practitioner’s order; all three unit doses must be the same.
The tuberculin syringe is a narrow syringe, calibrated in tenths and hundredths of a milliter (up to 1 ml) on one scale and in sixteenths of a minim (up to 1 minim) on the other scale. Originally this syringe was designed to administer the tuberculin drug, but it is commonly used today to administer small or precise doses, such as pediatric dosages. The tuberculin syringe should be used for doses 0.5 ml or less.
Prefilled single-dose syringes should not be confused with a unit dose. The nurse must be careful to check the prescribed dose against that in the prefilled syringe and discard excess medication. For example, if the health care practitioner orders diazepam (Valium) 5 mg IM as a preoperative sedative and the prefilled single-dose contains 10 mg/2 ml, the nurse must calculate dosage (5 mg/1 ml) and destroy 1 ml from the syringe before administration.
NEEDLES
Most needles are disposable, made of stainless steel, and individually packaged for sterility. Reusable needles are seldom used, except in certain areas such as surgery and special procedure rooms; reusable needles require frequent inspection to ensure that the needle is sharp, and resterilization is necessary between uses.
The needle has three basic parts: the hub, which fits onto the syringe; the cannula, or shaft, which is attached to the hub; and the bevel, which is the slanted part at the tip of the shaft. Needles come in various sizes, from 1/4 inch to
The gauge of the needle refers to the diameter of the shaft; the larger the gauge number, the smaller the diameter of the shaft. Large-gauge needles produce less trauma to the body’s tissue; however, the nurse has to consider the viscosity of a solution when selecting the gauge.
The shaft of the needle determines its length. The nurse selects the length of the needle on the basis of the client’s muscle development and weight and the type of injection, such as intradermal versus intramuscular.
The needle may have a short or long bevel. The length of bevel selected is based on the type of injection. Long bevels are sharp and produce less pain when injected into the subcutaneous or muscle tissues; however, a short-bevel needle must be used for intradermal and intravenous injections to prevent occlusion of the bevel either by the tissue or by a blood vessel wall. When the nurse removes a needle from its sterile wrapper, the hub of the needle should be immediately attached to the hub of the syringe to prevent contamination. Likewise, the protective cover should remain on the needle’s shaft until the nurse is ready to use the needle. After an injection, the nurse should not recap the needle; used needles should be disposed of in the proper receptacles, such as a sharps container, to prevent needle sticks. See Chapters 31 and 37 for details on how to prevent needle stick injuries. Most agencies have sharps containers in all client care areas.
AMPULES AND VIALS
Drugs for parenteral injections are sterile preparations. Drugs that deteriorate in solution are dispensed as tablets or powders and dissolved in a solution immediately before injection. Drugs that remain stable in a solution are dispensed in ampules and vials in an aqueous or oily solution or suspension.
Ampules are glass containers of single-dose drugs (Figure 29-13).
The glass container has a constriction in the stem to facilitate opening the ampule.
Because many drugs are irritating to the subcutaneous tissue, the nurse should change the needle on the syringe after withdrawing a drug from an ampule. The nurse should consider the use of a needle filter when withdrawing medication from an ampule or vial. Beyea and Nicoll (1996) suggest that the last few drops of the drug be left in an ampule or vial; some studies have found foreign substances, such as glass and rubber, in the containers that could be drawn into the syringe. Glass, single- or multiple-dose rubber-capped drug containers are called vials (Figure 29-16).
The vial is usually covered with a soft metal cap that can be easily removed.
The nurse should change the needle on the syringe after withdrawing a drug from a vial. Inserting the needle through the rubber cap of the vial can dull the needle or remove the needle coating that helps it glide through the skin (Beyea & Nicoll, 1996).
Compatible medications can be mixed in the same syringe. Refer to compatibility charts or check with the pharmacist to determine if the medications can be mixed. If medications are going to be mixed, care must be exercised not to contaminate one medication with the other in their respective vials. See Procedure 29-4 for mixing insulins in one syringe. The nurse must calculate and measure carefully to be sure the final dose is accurate.
ANGLE OF INJECTION
The angle of insertion depends on the type of injection. Figure 29-18 illustrates the angle of insertion for each type of parenteral injection.
INJECTION
Intradermal (ID) or intracutaneous injections are typically used to diagnose tuberculosis, identify allergens, and administer local anesthetics. The site below the epidermis is the location for administering ID injections; drugs are absorbed slowly from this site. The sites commonly used for ID injection are the inner aspect of the forearm (if it is not highly pigmented or covered with hair), upper chest, and upper back beneath the scapula (Figure 29-19). Only small amounts of water-soluble medication should be used for subcutaneous injections. The drug’s dosage for an ID injection is usually contained in a small quantity of solution (0.01 to 0.1 ml). A 1-ml tuberculin syringe with a short bevel, 25 to 27 gauge, 3/8- to 1/2-inch needle is used to provide accurate measurement. If repeated doses are ordered, the site should be rotated. ID injections are administered into the epidermis layer by angling the needle 10° to 15° to the skin. See Procedure 29-5 for administering intradermal injections.
SUBCUTANEOUS INJECTION
Subcutaneous (SC or SQ) injections are commonly used in the administration of medications such as insulin and heparin because these drugs are absorbed slowly, to produce a sustained effect. SC injections place the medication into the subcutaneous tissue, between the dermis and the muscle. Clients who administer frequent subcutaneous injections should rotate sites regularly. An administration chart can help them keep track of the sites used. The amount of medication given varies but should not exceed 1.0 ml; if repeated drug doses are given, rotate the sites. Subcutaneous tissues are sensitive to irritating medications. Hard painful lumps can develop beneath the skin if the sites are not rotated.
Common sites for SC injections are the abdomen, the lateral and anterior aspects of the upper arm or thigh, the scapular area on the back, and upper ventrodorsal gluteal areas (Figure 29-21).
The nurse should select a sterile 0.5-to 3-ml syringe with a 25- to 29-gauge, 3/8- to 1/2-inch needle. The medication is administered by angling the needle 45° or 90° to the skin. The client’s body weight will influence the angle used for injection. As a general rule, to reach subcutaneous tissue, if you can grasp
If only
The length of the needle may also vary with body weight. Normally for SC injections, a 25-gauge, 5/8-inch needle is used. A child will require a short needle, and an obese person may require a longer needle to ensure placing the medication in the subcutaneous tissue. The length of the needle should be approximately half the width of the pinched skinfold. See Procedure 29-6 for the technique used in administering an SC injection.
INTRAMUSCULAR INJECTION
Intramuscular (IM) injections are used to promote rapid drug absorption and to provide an alternate route when the drug is irritating to subcutaneous tissue. The IM route enhances the absorption rate because there are more blood vessels in the muscles than in subcutaneous tissue; however, the absorption rate may be affected by the client’s circulatory status.
Since the 1920s over 90 research studies related to IM injections have been reported in the literature (Beyea & Nicoll, 1995). Researchers have studied the medication volume and appropriate size of the syringe and needle for administering an IM injection to a particular site.
“Research on the maximum volume to be drawn up for a single injection is still inconclusive” (Beyea & Nicoll, 1996, p. 34).
The nurse should determine the maximum volume to inject on the basis of the site and the client’s muscle development:
• 4 ml for a large muscle (gluteus medius) in a welldeveloped adult
• 1 to 2 ml for less developed muscles in children, elderly, and thin clients
• 0.5 to 1.0 ml for the deltoid muscle
When more than 4 ml is ordered, the medication can be divided into two different sites.
There are four common sites for administrating IM injections (see the accompanying display). Injection sites are identified by using appropriate anatomic landmarks (Figure 29-22).
The primary site for administering an IM injection in clients over 7 months old is the ventrogluteal (VG) site. The gluteus medius is a well-developed muscle, free of major nerves and large blood vessels. Research shows that injuries—including fibrosis, nerve damage, abscess, tissue necrosis, muscle contraction, gangrene, and pain—have been associated with all the common sites (dorsogluteal, deltoid, and vastus lateralis, for example) except the VG site (Beyea & Nicoll, 1996, p. 35).
The nurse should avoid using the deltoid and dorsogluteal sites in infants and children. There is a risk of striking the sciatic nerve when using the dorsogluteal site. The deltoid muscle is not well developed in infants and children.
The nurse will need to decide on the gauge and length of the needle on the basis of the consistency of the solution, the site, and how far the needle must be injected to reach the muscle. A 21- to 23-gauge needle will accommodate the consistency of most drugs and will minimize tissue injury and subcutaneous leakage.
The needle’s length is determined by the site:
• 1 1 / 2-inch needle, VG site for average-sized adults
• 1-inch needle, VG site for children
• 1-inch needle, deltoid or vastus lateralis
An obese client usually requires a 2-inch needle to ensure that the needle will reach a large muscle such as the gluteal muscle. For example, for a client weighing
Z-TRACK INJECTION
The Z-track (zigzag) technique refers to a method used in administering IM injections (see Procedure 29-7). This technique was traditionally used when administering imferon, an iron preparation, which can cause permanent discoloration in the subcutaneous tissue. Today, the technique is used commonly when administering ventrogluteal and dorsogluteal injections.
When administering a Z-track injection, the nurse should place the client in the prone position (Figure 29-25A); then pull the skin to one side (Figure 29-25B), insert the needle at a 90° angle and administer the medication (Figure 29-
Parenteral Fluids
The nurse confirms the type and amount of IV solution by reading the health care practitioner’s prescription in the medical record. IV solutions are sterile and packaged in plastic bags or glass containers. Solutions that are incompatible with plastic are dispensed in glass containers. Plastic IV solution bags collapse under atmospheric pressure to allow the solution to enter the infusion set. Plastic solution bags are packaged with an outer plastic bag, which should remain intact until the nurse prepares the solution for administration. When the plastic solution bag is removed from its outer wrapper, the solution bag should be dry. If the solution bag is wet, the nurse should not use the solution. The moisture on the bag indicates that the integrity of the bag has been compromised and that the solution cannot be considered sterile. The bag should be returned to the dispensing department that issued the solution. Glass containers are discussed in the section on equipment. IV solutions are usually packaged in quantities ranging from 50 to 1,000 ml. The nurse should select a container that has the prescribed amount of solution or select several containers that together contain the prescribed volume. At no time should the nurse select a container
Implementation of IV Therapy
• Know why the therapy is prescribed.
• Document client understanding.
• Select the appropriate equipment in accordance to agency policy.
• Obtain the correct solution as prescribed.
• Assess the client for allergies: tape, iodine, ointment, or antibiotic preparations to be used for
skin preparation of the venipuncture site.
• Administer the fluid at the prescribed rate.
• Observe for signs of infiltration (the seepage of substances into the interstitial tissue that occurs as the results of accidental dislodgement of the needle from the vein) and other complications that are fluid-specific.
• Document implementation of prescribed IV therapy in the client’s medical record. whose volume is greater than that prescribed. For example, if the client is to receive 600 ml of normal (0.9%) saline, the nurse must not select a 1000 ml container, but rather two containers, 100 ml and 500 ml (containers are not prepared in volumes of 600 ml).
Crystalloids (electrolyte solutions with the potential to form crystals) are used to replace concurrent losses of water, carbohydrates, and electrolytes. Sodium chloride and Ringer’s lactate are commonly used crystalloid solutions. There are three types of parenteral fluids that are classified in accord with the tonicity of the fluid relative to normal blood plasma. As previously discussed, an osmolar solution can be hypotonic, isotonic, or hypertonic. The type of solution is prescribed on the basis of the client’s diagnosis and the goal of therapy. The normal osmolarity of blood is between 280 and 295 mOsm/L, so the desired effect of the tonicity of the fluid is determined as follows:
1. Hypotonic fluid (hypo-osmolar, less than 290 mOsm/L) lowers the osmotic pressure and causes fluid to move into the cells; if fluid is infused beyond the client’s tolerance, water intoxication may result.
2. Isotonic fluid (iso-osmolar, 290 mOsm/L) increases extracellular fluid volume; if fluid is infused beyond the client’s tolerance, cardiac overload may result.
3. Hypertonic fluid (hyperosmolar, greater than 290 mOsm/L) increases the osmotic pressure of the blood plasma, drawing fluid from the cells; if fluid is infused beyond the client’s tolerance, cellular dehydration may result (Bulechek & McCloskey, 1999). Table 37-5 discusses the common types of intravenous solutions in terms of their tonicity, contents, and clinical usage. Crystalloid solutions can be isotonic (equal to the sodium chloride concentration of blood, 0.9%); hypotonic (less than the sodium chloride concentration of blood); and hypertonic (greater than the sodium chloride concentration of blood) (Kee & Paulanka, 2000). Colloids (nondiffusable substances) function like plasma proteins in blood by exerting a colloidal pressure to replace intravascular volume only. Examples of colloidal solutions are albumin, dextran, Plasmanate, and hetastarch (artificial blood substitute). During the administration of these solutions, the nurse should monitor the client for hypotension and allergic reactions (Bulechek & McCloskey, 1999; Kee & Paulanka, 2000). Blood transfusions are discussed later in this chapter.
Equipment
IV equipment is sterile, disposable, and prepackaged with user instructions. The user instructions are usually placed on the outside of the package, with a schematic that labels the parts, allowing the user to read the package prior to opening. The following discussion regarding intravenous equipment, inclusive of the frequency when to change disposal intravenous therapy equipment, is based on the revised 2000 Infusion Nursing Standards of Practice developed by INS. All intravenous
equipment must be inspected by the nurse to determine the integrity of the IV product before, during, and after use. Product integrity refers to the sterility of the equipment. Products are assessed for integrity by visual examination of the product and checking the expiration date on the equipment. All products identified with a defect must be returned to the appropriate department within the agency with a written report identifying the defect. Since intravenous therapy provides a direct access into the vascular system, the nurse must understand the basic epidemiology principles and common organisms that may cause an infection and implement infection control measures to minimize the potential for infectious complications. The nurse uses aseptic technique and standard precautions when assembling and changing intravenous equipment. To decrease the risk of pathogen transmission, handwashing is required before and immediately after all IV procedures and upon removal of gloves. The frequency of changing sterile intravenous equipment not only reflects the national standards of practice but the agency’s established infection control policies. Infection control data may allow the agency to increase the time interval beyond the recommended standard provided the data verifies low infection rates. INS (2000) recommends that an organization that exhibits an increased rate of catheter-related bloodstream infection with the practice of 72-hour administration set changes should return to a 48-hour administration set change interval.
Administration Set
The administration set (infusion set) refers to the plastic disposal tubing that provides for the infusion of a solution. There are several types of infusion sets to accommodate the solution and the mode of administration: primary continuous; secondary; primary intermittent; and special tubing for certain solutions such as blood/blood components. There are several add-on devices, such as extension sets, filters, stopcocks, PRN adaptor, and needleless devices that are used in conjunction
with the administration set and changed whenever the set is changed. Administration sets are changed at established time intervals and immediately upon suspected contamination or when the integrity of the set has been compromised. The administration set contains an insertion spike with a protective cap, a drip chamber, tubing with a slide clamp and regulating (roller) clamp, a rubber injection port, and a protective cap over the needle adapter (Figure 37-10). The protective caps keep
both ends of the infusion set sterile and are removed only just before usage. The insertion spike is inserted into the port of the IV solution container. Infusion sets can be vented or nonvented. The nonvented type is used with plastic bags of IV solutions and vented bottles. The vented set is used for glass containers that are not vented (Figure 37-11). Glass containers require an air vent so that air can displace fluid from the container into the IV tubing.
Some glass bottles are vented with an inside tube that exits the bottle into a rubber stopper in the neck of the bottle; if the bottle is not vented, then the nurse needs to select a vented infusion set. The drip chamber is calibrated to allow a predictable amount of fluid to be delivered. There are two types of drip chambers: a macrodrip, which delivers 10 to 20 drops per milliliter of solution, and a microdrip, which delivers 60 drops per milliliter. The drip rate varies with the manufacturer as indicated on the package. The administration set has a manual flow-control device such as a slide clamp (Figure 37-10), a roller clamp, or a screw to regulate a prescribed infusion rate. Follow the manufacturer’s guidelines when using the manual flow-control device to regulate the prescribed infusion rate. The end of the IV tubing contains a needle adapter that attaches to the sterile device inserted in the client’s vein. Extension tubing may be used to lengthen the primary tubing. A primary continuous administration set is used to administer routine solutions prescribed to infuse continuously over a 24 hour period. The primary administration set, inclusive of the add-on devices, is changed every 48 to 72 hours in conjunction with the peripheral cannula change. A bag of intravenous solution should not hang longer than 24 hours. Secondary administration sets are often referred to as “piggyback” administration sets. The secondary tubing is connected into the primary tubing at an injection site (see Figure 37-11) and allows for the administration of a second solution such as medication. Secondary administration sets are also changed every 48 to 72 hours. Primary intermittent administration sets are used to deliver medications at prescribed intervals through an injection/access port and are changed every 48 to 72 hours; all add-on devices such as extension sets, filters, PRN adaptors, and stopcocks are changed with the intermittent administration set. A sterile needle/ needleless device should be aseptically attached to the intermittent administration set prior to administering the medication and removed immediately after each use.
Health Hazard
A Health Alert from Health Care Without Harm (HCWH) (1999) cautioned the public about the potential risks of exposure to diethylhexyl phthalates (DEHP) from medical products such as IV bags and tubing. More than 500 million IV bags are used in the United States every year to deliver blood, medication, and other essential solutions to clients (HCWH, 1999). Eighty percent of the IV bags are made with polyvinyl chloride (PVC), which requires a plasticizer to make the bags soft and flexible. DEHP is the softener used in PVC products. DEHP has been shown to leach from IV bags into the solutions they contain and directly into the client’s bloodstream. The Environmental Protection Agency has classified DEHP as a probable human carcinogen and HCWH claims that studies have shown that DEHP can damage the heart, liver, testes, and kidneys and interfere with sperm production. Certain drugs such as Taxol (used to treat breast cancer) and Taxotere (used to treat ovarian and breast cancer and AIDS-related Kaposi’s sarcoma) have been shown to increase the leaching of DEHP from PVC plastics into the solution (Stewart, 1999); see the accompanying display for additional drugs that can increase leaching of DEHP from PVC IV products. Although one leading producer of intravenous vinyl IV bags containing DEHP plans to develop an alternative to polyvinyl chloride or PVC for their products, no time frames were given to totally remove these products from the market. A second health hazard is inherent in the use of DEHP. The disposal of medical products containing DEHP releases highly toxic and endocrine-disrupting dioxins. According to the ANA (1999), PVC is the only plastic linked both to phthalate chemical leaching and to the production of dioxin.
Intravenous Filters
Intravenous filters prevent the passage of undesirable substances such as particulate matter and air from entering the vascular system. Particulate matter filters are utilized when preparing infusion medications for administration to prevent obstruction in the vascular/pulmonary systems, irritation and phlebitis (inflammation of a vein). Aireliminating filters are used for the delivery of infusion therapy to decrease the potential of air emboli; the filter should be located as close as possible to the cannula site. IV filters come in various sizes; the finer the filter, the greater is the degree of solution filtration. Although studies have shown that IV filters reduce the risk of bacteremia and phlebitis as much as 40%, some agencies do not use IV filters because of cost. Many IV catheters contain an in-line filter; if the catheter has an in-line filter, it is not necessary to add a filter to the tubing.
Needles and Venous
Peripheral-Short Catheters
Needles and peripheral-short catheters provide access to the venous system. A variety of devices are available in different sizes to complement the age of the client, the type and duration of the therapy, and to protect the user from injury (Figure 37-12). As with any gauge needle, the larger the number, the smaller the lumen. The nurse considers the client’s age, body size, and the type of solution to be administered when selecting the gauge of the needle or catheter:
• Infants and small children, 24 gauge
• Preschool through preteen, 24 or 22 gauge
DRUGS THAT INCREASE LEACHING
OF DEHP FROM PVC PLASTICS
• Chemotherapeutic agents: Etoposide (VePesid) and Teniposide (Vumon)
• Antianxiety agents: Chlordiazepoxide HCl (Librium)
• Antifungal agents: Miconazole (Monistat IV)
• Immunosuppressive agents: Cyclosporine (Sandimmune) and Tacrolimus (Prograf)
• Nutritional solutions: Fat emulsions and vitamin A
NURS I N G T I P
Age Considerations for Choosing IVs and Equipment
Neonates, infants, and children are at risk for Altered Fluid Balance: Overload, related to rehydration. IV tubing with a microdrip and special volume control chambers is used to regulate the amount of fluid to be administered over a specific time interval. Armboards and soft restraints are used to stabilize peripheral infusions by immobilizing the extremity to prevent accidental removal of infusion devices.
• Teenagers and adults, 22 or 20 gauge
• Geriatric, 22 or 24 gauge
Butterfly (scalp vein or wing-tipped) needles are short, beveled needles with plastic flaps attached to the shaft. The flaps (which are flexible) are held tightly together to facilitate ease of insertion and then flattened against the skin to prevent dislodgement during infusion. These needles are commonly used for short-term or intermittent therapy and for infants and children. There are several types of short catheters used to access peripheral veins. Short peripheral venous catheters vary in length from 3/4 to 1 1/4 inches. During insertion, some of these catheters are threaded over a needle, and others are threaded inside a needle. Intracath is a term used to refer to a plastic tube inserted into a vein. An angiocatheter is a type of intracath with a metal stylet to pierce the skin and vein, after which the plastic catheter is threaded into the vein and the metal stylet is removed, leaving only the plastic catheter in the vein. Short venous catheters can have safety devices to reduce the risk of accidental needlesticks. These devices are designed to allow for easy insertion of the catheter while providing a built-in safety feature for the user. As the catheter is threaded over the needle and advanced into the vein, the built-in needle guard advances forward toward the tip of the needle; when the catheter hub is removed from the device, the entire needle is encased within the needle guard.
Peripheral Intravenous (PI) and Heparin Locks
Peripheral intravenous (PI) and heparin locks are devices that establish a venous route as a precautionary measure for clients whose condition may change rapidly or who may require intermittent infusion therapy. A butterfly needle or peripheral catheter is inserted into a vein and the hub is capped with a lock port, also called a Luer lock (Figure 37-13).
Needle-Free System
Safety is a concern associated with IV therapy; refer to Chapter 31. Accidental needle-stick injuries and puncture wounds with contaminated devices increase the employee’s risk for infectious diseases such as AIDS, hepatitis (B and C), and other viral, rickettsial, bacterial, fungal, and parasitic infections. Most health care agencies now use totally needle-free IV systems (Figure 37-14) to decrease the risk of employee injuries.
Vascular Access Devices
Vascular access devices (VAD) include various catheters, cannulas, and infusion ports that allow for long-term IV therapy or repeated access to the central venous system. The kind of VAD used depends on the client’s diagnosis and the type and length of treatment (see Table 37-6). Site selection and insertion of central catheters, other than peripherally inserted central catheters, is a medical act performed by a practitioner. Although there are many types of catheter materials, insertion techniques and kinds of central catheters, all central catheters must be radiopaque to allow for radiographic verification of placement of the catheter and its tip prior to the administration of any solution. Central catheters are usually inserted into the internal jugular and subclavian veins with the distal tip located in the superior vena cava to minimize vessel irritation and sclerosis. The femoral vein can be used for central venous access when there is thrombosis of the internal jugular or subclavian veins; correct tip location should be in the inferior vena cava. Insertion of a central catheter can be performed either percutaneously or surgically. Surgically, a central catheter is either placed
Nedle
. An implantable port is a device made of a radiopaque silicone catheter and a plastic or stainless steel injection port with a self-sealing silicone-rubber septum. The health care practitioner inserts the device into a subcutaneous pocket, usually over the third or fourth rib, lateral to the sternum. The distal tip of the catheter is surgically tunneled in the cephalic or external jugular vein, with the proximal end of the catheter tunneled through the subcutaneous tissue into the injection port of the device. Implanted ports and pumps are vascular access devices that provide for the delivery of prescribed parenteral therapies. Accessing these devices requires the use of aseptic technique. Noncoring needles such as a Huber needle are used to access an implanted port/pump and should be changed at least every 7 days. The smallest gauge noncoring needle that can deliver the prescribed therapy should be used when accessing the port/pump. Nurses caring for clients with implanted ports/pumps must have a thorough knowledge of the design features of the device, as explained in the manufacturer’s guidelines, to ensure correct access and administration techniques, maintenance, and potential complications. Implanted pumps have a reservoir designed to continuously infuse a specific volume of solution over a preset period of time; the pump must be routinely emptied and refilled at established intervals. Some pumps have an additional feature, a side port designed for administration of intermittent medication. The flow rate of some pumps is sensitive to changes in atmospheric pressure, body temperature, blood pressure and the viscosity
of the medications. Clients are instructed to report changes in their lifestyle and physical condition that may affect the pump’s flow rate. Only nurses who have been specially trained are allowed to access an implanted port/pump because of the risk of infiltration into the tissue if needle placement is incorrect. A peripherally inserted central catheter (PICC) is the generic name for 11 different devices. A PICC is a silicone or polyurethane catheter inserted into one of the major veins in the antecubital fossa. Although the length of the catheter varies, on an average a PICC is
Preparing an Intravenous Solution
To prepare an IV solution, read the agency’s protocol and gather the necessary equipment. Because IV equipment and solutions are sterile, check the expiration date on the package prior to usage. The solution can be prepared at the nurses’ work area or in the client’s room (Procedure 37-2). The nurse prepares and applies a time strip to the IV solution bag to facilitate monitoring of the infusion rate as prescribed by the health care practitioner (Figure 37- 19). The IV tubing is tagged with the date and time to indicate when the tubing replacement is necessary. IV tubing is changed every 48 to 72 hours in accord with the agency’s protocol. The nurse initials the time strip and IV tubing tag.
NURSING ALERT
Marking an IV Bag
Do not use a felt-tip pen to mark an IV bag; the ink from the pen can leak through the plastic and contaminate the solution. Do not label bag with time strip made of adhesive/silk/paper tape, as the adhesive will leach into the bag. Use only labels appropriate for IV bags.
Initiating IV Therapy
When initiating IV therapy, the nurse should assess for a venipuncture site. Figure 37-20 presents the common peripheral sites for starting IV therapy in pediatric, adult, and geriatric clients (see Chapter 28, Procedure 28-1, Venipuncture). When assessing clients for potential sites, consider their age, body size, clinical status and impairments, and the skin condition (see the accompanying display for contraindications when selecting a site). Lowerextremity veins are used for IV therapy only when so prescribed by the health care practitioner; circulating
Figure 37-20 Peripheral Veins Used in Intravenous Therapy. A. Armand Forearm; B. Dorsum of the Hand; C. Dorsal Plexus of the Foot
blood in the lower extremities is likely to pool and clot, which may result in an embolism. Because contact with blood is likely, venipuncture requires the implementation of Standard Precautions. Refer to Chapter 31 for a complete discussion of Standard Precautions. Select a vein for puncture at its most distal end to maintain the integrity of the vein, because venous blood flows with an upward movement toward the heart. When a vein is punctured with an instrument, such as a needle, fluids can infiltrate (leak from the vein into the tissue at the site of puncture). If IV therapy has to be discontinued for any reason, such as infiltration, it can be restarted above the initial puncture site only.
Vein Finder
A vein finder is a device used to locate hard-to-find veins. It is helpful, for example, in working with obese clients whose superficial veins are difficult to locate. A Venoscope (Figure 37-21) is a type of vein finder with adjustable fiberoptic arms that reveal veins. The room is dimmed, and the disposable skids are placed flush against the skin. The nurse slowly moves the Venoscope along the extremity until a dark, shadowy line is seen between the fiberoptic arms. Once the vein is identified, it can also be checked to determine whether it is sclerotic. To assess for sclerotic veins, apply a downward pressure over the fiberoptic arms and observe the vein when pressure is applied then released. A nonsclerotic vein will disappear with pressure and reappear when pressure is released.
Administering IV Therapy
Once the solution is prepared for administration, the nurse calculates the rate and explains the procedure to the client (see Procedure 37-3 for the administration of IV therapy). There are three ways to administer solutions:
1. Initiate the infusion by performing a venipuncture.
2. Use an existing IV system: catheter, heparin or PI lock, central line, or implanted port.
3. Add a solution to a continuous-infusion line.
Fluid administration can be continuous, ongoing over a 24-hour period, or intermittent, 1000 ml ordered once in a 24-hour period. Although fluids may be continuous, the type of fluids can alternate over a 24-hour period; for example, an order might be add 40 mEq of KCl to first bag of 1000 ml of normal saline. IV medications may be piggybacked, added to an existing intravenous solution to infuse concurrently. IV solutions and medications that have been refrigerated should
Flushing
Flushing refers to the instillation of a solution into an intravenous cannula. Flushing is performed to assess and maintain cannula patency and prevent the mixing of incompatible medications and/or solutions, following the conversion of continuous IV therapy to intermittent IV therapy, and to maintain intermittent cannula patency following IV medication administration and blood sampling. The type of solution and frequency of flushing an intermittent intravenous cannula is determined by the agency’s policy/protocol. According to the INS (2000), flushing a cannula at established intervals with saline (0.9% sodium chloride injection) is the accepted solution to ensure and maintain patency of an intermittent PI cannula, while a heparin flush solution is the accepted solution to maintain patency of an intermittent central venous devices. The volume of flush is equal to the volume capacity of the cannula and add-on devices times two (INS, 2000). Consideration is also given to the volume and frequency of heparin flush in order to prevent an alteration in the client’s clotting factors. When flushing a cannula positive pressure within the lumen of the catheter must be maintained to prevent the reflex of blood into the cannula lumen. Use the manufacturer recommended maximum pressure limits (pounds per square inch) when selecting the size of the syringe to use for flushing since the smaller the syringe the greater the pressure generated; excessive internal pressures in the device increase the potential for cannula damage and/or progressive internal cannula weakening over the life of the device (INS, 2000). If resistance is met when flushing a cannula, do not exert pressure in an attempt to restore patency of an occluded cannula since this action may result in the dislodgement of a clot into the vascular system and/or rupture of the catheter.
Regulating IV Solution Flow Rates
Infusion sets with macrodrip chambers are often used for adult clients, whereas microdrip chambers are used for volume-sensitive clients, such as geriatric or pediatric clients. Pediatric and geriatric clients usually require some type of device to regulate the fluids as a safety factor to prevent overload. Devices such as controllers and pumps are commonly used to regulate the rate of infusion.
Calculation of Flow Rate
The flow rate is the volume of fluid to infuse over a set period of time as prescribed by the health care practitioner. The health care practitioner will identify either the amount to infuse per hour (such as 125 ml per hour or 1000 ml over an 8-hour period). Calculate the hourly infusion rate as follows: For example, if 1000 ml is to infuse over 8 hours: Calculate the actual infusion rate (drops per minute) as follows: For example, if 1000 ml is to infuse over 8 hours with a tubing drop factor of 10 drops per milliliter: Another way to calculate the actual infusion rate is to use the hourly infusion rate; for the example just given:
Flow-Control Devices
Flow-control devices are used to regulate the infusion at the prescribed administration rate. Safety factors such as the client’s age and condition, prescribed therapy, and setting are considered when selecting a flow-control device. There are two basic types of flow-control devices: manual flow-control devices and electronic infusion devices. Manual flow-control devices include roller, screw, and slide clamps and may include volume control devices such as Buretrol. These devices are used routinely to regulate the accurate delivery of most prescribed IV therapy. Electronic infusion devices are operated either by electricity or battery and are used to administer IV fluids and medications and should be considered on all central access devices (INS, 2000). Electronic infusion pumps have audible alarms that sound when the solution has infused, the infusion tubing contains air or is kinked, or the cannula is clotted. There are two types of electronic infusion devices: controllers and pumps. Controller infusion devices generate flow by gravity and are capable of maintaining a constant preset flow rate either by drop counting or volumetric delivery. The nurse sets the flow rate, and the specific gravity of the solution and the height of the bag determine the maximum delivery pressure. Fluids with low-viscosity are usually infused by electronic controllers. Infusion pumps maintain the flow rate under positive pressure. Pumps counter the effects of resistance in the delivery system and pressure fluctuations at the infusion site (McConnell, 1999). Positive pressure infusion
devices are classified as either volumetric or syringe pumps, and are used to deliver viscous fluids or large volumes of fluids. Volumetric pumps use either a peristaltic pumping action or a pumping cassette or chamber to delivery a fixed volume over a specified period of time. Syringe infusion pumps rely on a syringe or cartridge to deliver the fluid at a specific set rate.
Managing IV Therapy
IV therapy requires frequent client monitoring by the nurse to ensure an accurate flow rate and other critical nursing actions; refer to Procedure 37-4. These other actions include ensuring client comfort and positioning; checking IV solution for correct solution, amount, and timing; monitoring expiration dates of the IV system (tubing, venipuncture site, dressing) and changing as necessary; and being aware of safety factors. Coordinate client care with the maintenance of IV lines. Clients with IV therapy usually require assistance with hygienic measures, such as changing a gown (see Procedure 37-4). Change IV tubing when doing site care to decrease the number of times the access device is manipulated, thereby decreasing the risk for infiltration and phlebitis. PI devices are changed every 72 hours as directed by the Centers for Disease Control and
Prevention (CDC) guidelines.
Hypervolemia
Hypervolemia (increased circulating fluid volume) may result from rapid IV infusion of solutions. This causes cardiac overload, which may lead to pulmonary edema and cardiac failure. Monitor the infusion rate hourly and refer to the Nursing Care Plan, Client with Fluid Volume Excess, for the assessment and interventions for a client experiencing fluid volume excess. Total volume
Number of hours to infuse = ml/hour
infusion rate 1000 8 = 125 ml/hour
Total fluid volume
Total time (minutes) drop factor = drops per minute
1000 ml
8(60) min10 drops/ml =
10,000 drops
480 min = 20.8 or 21
drops/min
125 ml 10 drops/ml
60 min
= 20.8 or 21 drops/min
NURSING ALERT
Catheter Sepsis
If client complains of chills and fever, check length of time that this IV solution has been hanging and the needle or catheter has been in place; assess client’s vital signs, and assess for other symptoms of pyrogenic reactions, such as backache, headache, malaise, nausea, and vomiting. Unexplained fever may be related to catheter sepsis. Pulse rate increases and temperature is usually above
If a solution infuses at a rate greater than prescribed, decrease the rate to keep vein open (KVO) and immediately notify the health care practitioner. Report the amount and type of solution that infused over the exact time period and the client’s response.
Infiltration
Infiltration may be caused by inserting the wrong type of device, using the wrong-gauge needle, or dislodgement of the device from the vein. When a drug or solution is administered under high pressure by a pump, it may also cause infiltration or vein irritation. Infiltration results in the leaking of fluids or medications into the surrounding tissue. The client usually complains of discomfort at the IV site. Inspect the site by palpating for swelling, and feel the temperature of the skin (coolness and paleness of skin are indications of infiltration). The nurse confirms that the needle is still in the vein by pinching the IV tubing; this action should cause a flashback (blood should rush into the tubing if the needle is still in the vein). If a flashback does not occur, aspirate the injection port nearest the device as explained in Procedure 37-4. Discontinue the needle or catheter if it cannot be aspirated and apply a sterile dressing to the puncture site. After the IV has been removed, the puncture site may ooze or bleed (especially in clients receiving anticoagulants). If oozing or bleeding occurs, apply pressure and reapply a sterile dressing until it stops. Accurately assess and document the degree of edema. Clients may be injured by infiltration. If the IV site becomes grossly infiltrated, the edema in the soft tissue may cause a nerve compression injury with permanent loss of function to the extremity. If a vesicant (medication that causes blistering and tissue injury when it escapes into surrounding tissue) infiltrates, it may cause significant tissue loss with permanent disfigurement and loss of function.
Phlebitis
Phlebitis may result from either mechanical or chemical trauma. Mechanical trauma may be caused by inserting a device with too large a gauge, using a vein that is too small or fragile, or leaving the device in place for too long. Chemical trauma may result from infusing too rapidly, or from an acidic solution, hypertonic solution, a solution that contains electrolytes (especially potassium and magnesium), or other medications. Phlebitis may be a precursor of sepsis. Listen for client complaints of tenderness, the first indication of an inflammation. Inspect the IV site for changes in skin color and temperature (a reddened area or pink or red stripe along the vein, warmth, and swelling are indications of phlebitis). If phlebitis is present, discontinue the IV infusion. Before removing and discarding the venous device, check the agency’s protocol to see whether the tip of the device needs to be cultured and sent to the laboratory for a culture and sensitivity. After removing the device, apply a sterile dressing to the site and wet warm compresses to the affected area. Document in the nurses’ notes the time, symptoms, and nursing interventions. Hypertonic solutions may cause irritatioecessitating frequent IV site changes. Observe site for symptoms of postinfusion phlebitis following IV removal. This may occur in response to either chemical or mechanical factors of the preexisting IV. Postinfusion phlebitis is treated with hot compresses to the site and elevation of the extremity.
Intravenous Dressing Change
IV dressing changes require the use of Standard Precautions and aseptic technique; refer to Procedure 37-4. Institutional protocol and the type of intravenous access device and dressing determine the frequency of care:
1. Nontransparent (gauze) dressing may be used for a PI. It is changed every 24 hours.
2. Transparent dressings (Bioclusive, OpSite, Tegaderm) allow visualization of the IV site; these dressings are changed every 48 hours. Persistent drainage at the IV site may require dressing changes more frequently or necessitate changing the IV site.
Discontinuation
of Intravenous Therapy
Intravenous therapy is discontinued on health care practitioner order as determined by the client’s need or response to therapy. The removal of a short peripheral catheter is a nursing intervention to minimize the complication risks related to infusion therapy or to implement the health care practitioner’s order. Peripheral catheters are removed every 48 hours and immediately upon suspected contamination or complications. Pressure and a dry sterile dressing are applied to the site upon removal of the catheter; refer to Procedure 37-4. The integrity of the catheter and insertion site should be assessed with observations and actions documented to the client’s medical record. The removal of a PICC is usually a simple procedure; however, research suggests that, in 7% to 12% of PICC removals, difficulties can arise (Macklin, 2000). Only nurses who have been trained in the insertion of a PICC line should remove the catheter. Since the catheter is completely inserted in the vascular system and invisible, the nurse must feel for resistance during removal. If resistance is felt, the nurse stops and assesses for certain complicating factors: venous spasm, vagal reaction, phlebitis, thrombosis, and knotting of the catheter. Prior to removal, the nurse must verify in the client’s medical record the type and the specific length of the inserted PICC.
PROCEDURE CHECKLIST
Mixing Medications in One Syringe, Using Two Vials
Check (ü) Yes or No
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PROCEDURE STEPS |
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COMMENTS |
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1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.” |
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2. Checks compatibility of medications. |
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3. Before beginning, determines total volume of all medications to be put in the syringe and whether that volume is appropriate for the administration site. |
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4. Recaps needles throughout, using a needle capping device or approved one-handed technique that has a low risk of contaminating the sterile needle (see Procedure Checklist Chapter 23: Recapping Needles Using One-Handed Technique). |
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5. Maintains sterility of needles and medication throughout the procedure. |
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6. Avoids contaminating a multi-dose vial with a second medication. |
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7. Cleanses tops of vials with alcohol prep pad (according to agency procedure). |
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8. Places needle cap on opened, sterile alcohol wipe. |
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9. Draws up same amount of air into syringe as the total medication doses for both vials (e.g., if the order is for 0.5 mL for Vial A and 1 mL for Vial B, draws up 1.5 mL of air). |
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10. Maintaining sterility, inserts needle or vial access cannula into vial without coring (or uses a filter needle): a.Places the tip of the needle or vial access cannula in the middle of the rubber top of the vial with the bevel up at a 45°–60° angle. b. While pushing the needle or vial cannula device into the rubber top, gradually brings the needle upright to a 90° angle. |
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11. Keeping the tip of the needle (or vial access device) above the medication, injects amount of air equal to the volume of drug to be withdrawn from the first vial (e.g., 0.5 mL for Vial A in step 9; then injects the rest of the air into the second vial. |
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NOTE: If one vial is a multi-dose vial, injects air into the multiple-dose vial first. |
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NOTE: If mixing two types of insulin, puts air into the regular insulin last. Refer to Technique 23- |
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12a. Without removing the needle (or access device) from the second vial, inverts the vial and withdraws the ordered amount of medication. |
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12b. Using correct technique expels any air bubbles and measures dose at eye level. (See Procedure Checklist Chapter 23: Preparing and Drawing Up Medications from Vials.) |
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12 c. Removes needle from vial and pulls back on the plunger enough to pull all medication out of the needle (or access device) into the syringe. |
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12d. Reads dose at eye level; holds syringe vertically to eject all air; tips syringe horizontally if any medication must be ejected. |
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13a. Inserts needle into first vial, inverts, and withdraws the exact ordered amount of medication, holding syringe vertical (when finished, the plunger should be at the line for the total/combined dose. |
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13b. Keeps index finger on the flange of the syringe to prevent it being forced back by pressure. Does not draw excess medication into the syringe. |
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13c. If excess medication is inadvertently drawn into syringe, recognizes error, discards the medication in the syringe, and starts over. (The “total” amount calculated initially should be in the syringe.) |
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14. If a filter needle or VAD was used, draws air into syringe to clear medication from needle and proceeds according to Technique 23- |
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15. Removes needle from vial and recaps needle, using needle capping device or approved one-handed scoop method. |
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16. Places a new sterile needle on the syringe to be used to give the injection. |
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17. Next holds syringe vertically and re-checks the dosage at eye level. |
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PROCEDURE CHECKLIST
Administering Intradermal Injections
Check (ü) Yes or No
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PROCEDURE STEPS |
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COMMENTS |
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1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.” |
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2. Selects and correctly locates site for injection. Usual sites are the ventral surface of the forearm and upper back. The upper chest may also be used. |
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3. Assists patient to comfortable position. If using forearm, has patient extend and supinate arm on a flat surface. If using upper back, has patient lie prone or lean forward over a table or the back of a chair. |
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4. Cleanses injection site with alcohol prep pad by circling from the center of the site outward. |
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5. Allows site to dry before administering the injection. |
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6. Dons procedure gloves. |
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7. Holds syringe between thumb and index finger of dominant hand parallel to skin; removes needle cap. |
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8. With the nondominant hand, holds skin taut by one of the following methods: a. If using forearm, may be able to place hand under the arm and pull the skin tight with thumb and fingers. b. Stretching skin between thumb and index finger. c. Pulling the skin toward the wrist or down with one finger. |
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9. While holding the skin taut with the nondominant hand, holds syringe in dominant hand with the bevel up and parallel to the patient’s skin at a 5° to 15° angle. |
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10. Inserts the needle slowly and advances approximately 1/8 inch ( |
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11. Releases the taut skin and holds syringe stable with nondominant hand. Does not aspirate. |
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12. Slowly injects the solution. A pale wheal, about 6–10 mm (1/4 inch) in diameter should appear over the needle bevel. |
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13. Removes needle, engages safety needle device, and disposes in biohazard puncture-proof container. If there is no safety device, places uncapped syringe and needle directly in biohazard puncture-proof container. |
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14. Gently blots any blood with a dry gauze pad. Does not rub or cover with an adhesive bandage. |
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PROCEDURE CHECKLIST
Chapter 23: Preparing and Drawing Up Medications from Ampules
Check (ü) Yes or No
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PROCEDURE STEPS |
Yes |
No |
COMMENTS |
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1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.” |
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2. Recaps needles throughout, using a needle capping device or approved one-handed technique that has a low risk of contaminating the sterile needle (see Procedure Checklist Chapter 23: Recapping Needles Using One-Handed Technique). |
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3. Flicks or taps the top of the ampule to remove medication trapped in the top of the ampule. Alternatively, shakes the ampule by quickly turning and “snapping” the wrist. |
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4. Uses ampule snapper, or wraps 2×2 gauze pad or unwrapped alcohol wipe around neck of the ampule; using dominant hand, snaps off the top. |
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5. Breaks ampule top away from the body. |
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6. Attaches filter needle (or filter straw) to a syringe. If syringe has a needle in place, removes both the needle and the cap and places on a sterile surface (e.g., a newly unwrapped alcohol pad still in the open wrapper), then attaches filter needle. |
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7. Does not touch the neck of the ampule with the needle while withdrawing medication. |
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8. Uses one of the following techniques to withdraw medication: a. Inverts ampule, places needle tip in liquid, and withdraws all of medication. Does not insert needle through the medication into the air at the top of the inverted ampule. b. Alternatively, tips ampule, places needle in liquid, and withdraws all medication. Repositions ampule so that needle tip remains in the liquid. |
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9. Draws up exact amount of medication. |
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10. If necessary to eject medication after ejecting air, tips the syringe horizontal to do so. |
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11. Holds syringe vertically and draws 0.2 mL of air into the syringe. Measures exact medication dose (draws back plunger to the “dose + 0.2 mL” line). |
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12. Removes filter needle and reattaches the “saved” (or other sterile) needle for administration. |
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13. Ejects the 0.2 mL of air, and checks the dose again. |
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(If giving an irritating medication such as parenteral iron, omit this step.) |
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14. Disposes of top and bottom of ampule and filter needle in a sharps container. |
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ADMINISTERING INTRAMUSCULAR INJECTIONS
Procedure |
Yes |
No |
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1. Gather supplies: MAR, alcohol swabs, vial or ampule of medication, clean gloves and 3 ml syringe, #20 to #22 gauge 1″ to 1 1/2″ inch needle. |
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2. *Calculate the correct amount of medication to administer. |
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3. *Wash hands. |
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4. *Using five rights of medications check against MAR and note any allergies. |
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4. Withdraw correct medication from vial or ampule and recap using one-handed method. Use filter needle to withdraw medication from an ampule, replace with injectioeedle after drawing up medication. |
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5. Label syringe with the name of the drug using tape or preprinted medication labels. |
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6. *Identify client using two identifiers found on MAR and ID bracelet. Recheck medication against MAR. |
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7. Explain procedure and reason for medication to client. |
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8. Apply clean gloves and determine appropriate site. Use anatomical landmarks to locate exact injection site. |
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9. Cleanse injection site with alcohol swab in a circular motion starting at site and working away from area. |
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10. Using nondominant hand spread skin with thumb and forefinger. |
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11. Remove needle guard and hold syringe like a dart between thumb and forefinger. |
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12. Insert needle at a 90-degree angle to client’s skin surface. |
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13. Using nondominant hand stabilize syringe while using dominant hand to aspirate on plunger. If no blood appears slowly inject medication. If blood appears remove needle and prepare a new dose of medication. |
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14. Withdraw needle and use alcohol swab to apply pressure to site. Gently massage site. |
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15. Dispose of syringe and needle directly into sharps container. Do not recap. |
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16. *Wash hands
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ADMINISTERING SUBCUTANEOUS INJECTIONS
Procedure |
Yes |
No |
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1. Gather supplies: MAR (medication administration record), alcohol wipes, clean gloves, 1-3ml syringe, 3/8 – 5/8 inch and 25-27 guage needle, and medication to be administered. |
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2. *Wash hands. |
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3. *Calculate the correct amount of drug to be administered. |
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4. *Using the five rights and three checks prepare the correct dose of medication to be administered. |
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5. *identify client using two identifiers. Explain procedure and provide for privacy. |
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6. Apply clean gloves and select an injection site. |
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7. Cleanse site with alcohol swab in circular motion starting from center outward. Allow to dry. |
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8. Remove needle guard and hold syringe in dominant hand. Use nondominant hand to pinch subcutaneous tissue to be injected. |
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9. While holding syringe between thumb and forefinger inject in a dart like fashion at a 45-90 degree angle. |
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10. Release bunched skin and use nondominant hand to stabilize syringe while using dominant hand to aspirate gently on plunger. If blood appears in syringe withdraw needle and prepare new injection. Do not aspirate when injecting anticoagulants, (Ex: heparin, lovenox),or insulin. |
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11. Slowly inject medication and remove needle while applying pressure over site with alcohol swab. |
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12. Gently massage site with alcohol swab. Do not massage site when injecting anticoagulants as this may cause bleeding at the injection site. It is appropriate to massage following insulin injections. |
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13. Do not recap needle. Dispose of needle and syringe in sharps container. |
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14. *Wash hands. |
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15. Using the sixth right of medication administration document medication administration on MAR according to agency policy. |
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