Fundamental Fundamental NursingNursing

Chapter 34Chapter 34

Parenteral Parenteral MedicationsMedications

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NeedlesNeedles The needle The needle gaugegauge (diameter) refers to its (diameter) refers to its

width. For most injections, 18- to 27-gauge width. For most injections, 18- to 27-gauge needles are used; the smaller the number, the needles are used; the smaller the number, the larger the diameter. For example, an 18-gauge larger the diameter. For example, an 18-gauge needle is wider than a 27-gauge needle. A needle is wider than a 27-gauge needle. A wider diameter provides a larger lumen, or wider diameter provides a larger lumen, or opening, through which drugs are opening, through which drugs are administered into the tissue.administered into the tissue.

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Injection Routes There are four injection routes for parenteral There are four injection routes for parenteral

administration: administration: intradermal injectionsintradermal injections (between the layers of the skin), (between the layers of the skin), subcutaneous subcutaneous injectionsinjections (beneath the skin but above the (beneath the skin but above the muscle), muscle), intramuscular injectionsintramuscular injections (in muscle (in muscle tissue), and tissue), and intravenous injectionsintravenous injections (instilled (instilled into veins; into veins; Fig. 34-8). ).

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Injection routes: intradermal (A ), subcutaneous (B ), intramuscular and subcutaneous in other than thin persons (C ), and intravenous (D ).

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Intradermal Injections

Intradermal injections are commonly used for Intradermal injections are commonly used for

diagnostic purposes. Examples include diagnostic purposes. Examples include

tuberculin tests and allergy testing. Small tuberculin tests and allergy testing. Small

volumes, usually 0.01 to 0.05 mL, are injected volumes, usually 0.01 to 0.05 mL, are injected

because of the small tissue space.because of the small tissue space.

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Injection Sites

A common site for an intradermal injection is A common site for an intradermal injection is

the inner aspect of the forearm. Other areas the inner aspect of the forearm. Other areas

that may be used are the back and upper chest.that may be used are the back and upper chest.

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Injection Equipment A A tuberculin syringetuberculin syringe holds 1 mL of fluid and holds 1 mL of fluid and

is calibrated in 0.01-mL increments (Fig. 34-is calibrated in 0.01-mL increments (Fig. 34-9). It is used to administer intradermal 9). It is used to administer intradermal injections. A 25- to 27-gauge needle injections. A 25- to 27-gauge needle measuring a half-inch in length commonly is measuring a half-inch in length commonly is used when administering an intradermal used when administering an intradermal injection.injection.

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Figure 34-9 • A tuberculin syringe.

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Injection Technique

When giving an intradermal injection, the When giving an intradermal injection, the

nurse instills the medication shallowly at a 10- nurse instills the medication shallowly at a 10-

to 15-degree angle of entry to 15-degree angle of entry

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Subcutaneous Injections

A subcutaneous injection is administered more deeply A subcutaneous injection is administered more deeply than an intradermal injection. Medication is instilled than an intradermal injection. Medication is instilled between the skin and muscle and absorbed fairly between the skin and muscle and absorbed fairly rapidly: the medication usually begins acting within rapidly: the medication usually begins acting within 15 to 30 minutes of administration. The volume of a 15 to 30 minutes of administration. The volume of a subcutaneous injection is usually up to 1 mL. The subcutaneous injection is usually up to 1 mL. The subcutaneous route commonly is used to administer subcutaneous route commonly is used to administer insulin and heparin.insulin and heparin.

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Injection Sites The preferred site for giving a subcutaneous The preferred site for giving a subcutaneous

injection of insulin and heparin is the injection of insulin and heparin is the abdomen.abdomen.

Additional or alternative injection sites for Additional or alternative injection sites for insulin are the outer back area of the upper insulin are the outer back area of the upper arm, where it is fleshier, and outer areas of the arm, where it is fleshier, and outer areas of the thigh and upper buttocksthigh and upper buttocks

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Injection Sites Rotating within one injection site, preferably Rotating within one injection site, preferably

the abdomen, is recommended rather than the abdomen, is recommended rather than rotating to a different area with each injection rotating to a different area with each injection

The rate of drug absorption at various The rate of drug absorption at various subcutaneous sites from fastest to slowest is subcutaneous sites from fastest to slowest is abdomen, arms, thighs, and buttocks. abdomen, arms, thighs, and buttocks.

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Injection EquipmentInjection Equipment

Insulin is prepared in an insulin syringe A 25-Insulin is prepared in an insulin syringe A 25-

gauge needle is used most often. gauge needle is used most often.

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Injection Technique To reach subcutaneous tissue in a normal-To reach subcutaneous tissue in a normal-

sized or obese person who has a 2-inch tissue sized or obese person who has a 2-inch tissue fold when it is bunched, the nurse inserts the fold when it is bunched, the nurse inserts the needle at a 90-degree angle.needle at a 90-degree angle.

The tissue usually is bunched between the The tissue usually is bunched between the thumb and fingers before administering the thumb and fingers before administering the injection to avoid instilling insulin within the injection to avoid instilling insulin within the muscle. muscle.

16Figure 34-11 • Angles and needle lengths for subcutaneous injections.

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Intramuscular Injections An intramuscular injection is the An intramuscular injection is the

administration of up to 3 mL of medication administration of up to 3 mL of medication into one muscle or muscle group. Because into one muscle or muscle group. Because deep muscles have few nerve endings, deep muscles have few nerve endings, irritating medications commonly are given irritating medications commonly are given intramuscularly. intramuscularly.

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Injection Sites The five common intramuscular injection sites The five common intramuscular injection sites

are named for the muscles into which the are named for the muscles into which the medications are injected: dorsogluteal, medications are injected: dorsogluteal, ventrogluteal, vastus lateralis, rectus femoris, ventrogluteal, vastus lateralis, rectus femoris, and deltoid.and deltoid.

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Dorsogluteal SiteDorsogluteal Site The The dorsogluteal sitedorsogluteal site is the upper outer is the upper outer

quadrant of the buttocks and is a common quadrant of the buttocks and is a common location for intramuscular injections. The location for intramuscular injections. The primary muscle in this site is the gluteus primary muscle in this site is the gluteus maximus, which is large and therefore can maximus, which is large and therefore can hold a fair amount of injected medication with hold a fair amount of injected medication with minimal postinjection discomfort. This site is minimal postinjection discomfort. This site is avoided in clients younger than 3 years avoided in clients younger than 3 years because their muscle is not sufficiently because their muscle is not sufficiently developed.developed.

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If the dorsogluteal site is not identified If the dorsogluteal site is not identified correctly, damage to the sciatic nerve with correctly, damage to the sciatic nerve with subsequent paralysis of the leg can result. subsequent paralysis of the leg can result.

To locate the appropriate landmarks: To locate the appropriate landmarks: • Divide the buttock into four imaginary quadrants.Divide the buttock into four imaginary quadrants.• Palpate the posterior iliac spine and the greater Palpate the posterior iliac spine and the greater

trochanter.trochanter.• Draw an imaginary diagonal line between the two Draw an imaginary diagonal line between the two

landmarks.landmarks.• Insert the needle superiorly and laterally to the Insert the needle superiorly and laterally to the

midpoint of the diagonal line.midpoint of the diagonal line.

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Ventrogluteal SiteVentrogluteal Site The The ventrogluteal siteventrogluteal site uses the gluteus medius uses the gluteus medius

and gluteus minimus muscles in the hip for and gluteus minimus muscles in the hip for injection.injection.

This site has several advantages over the This site has several advantages over the dorsogluteal site: dorsogluteal site:

• It has no large nerves or blood vessels. It has no large nerves or blood vessels. • It is usually less fatty. It is usually less fatty. • It is cleaner because fecal contamination is rare at this It is cleaner because fecal contamination is rare at this

site. site. • It is safe for use in children.It is safe for use in children.

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To locate the ventrogluteal site:To locate the ventrogluteal site:

Place the palm of the hand on the greater trochanter Place the palm of the hand on the greater trochanter and the index finger on the anterior-superior iliac and the index finger on the anterior-superior iliac spine (Fig. 34-15).spine (Fig. 34-15).

Move the middle finger away from the index finger Move the middle finger away from the index finger as far as possible along the iliac crest.as far as possible along the iliac crest.

Inject into the center of the triangle formed by the Inject into the center of the triangle formed by the index finger, middle finger, and iliac crest.index finger, middle finger, and iliac crest.

23Figure 34-14 • Dorsogluteal site.

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Figure 34-15 • Ventrogluteal site.

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Vastus Lateralis Site The The vastus lateralis sitevastus lateralis site uses the vastus lateralis uses the vastus lateralis

muscle, one of the muscles in the quadriceps group muscle, one of the muscles in the quadriceps group of the outer thigh. Large nerves and blood vessels of the outer thigh. Large nerves and blood vessels usually are absent in this area.usually are absent in this area.

The nurse locates the vastus lateralis site by placing The nurse locates the vastus lateralis site by placing one hand above the knee and one hand just below one hand above the knee and one hand just below the greater trochanter at the top of the thigh (Fig. the greater trochanter at the top of the thigh (Fig. 34-16). He or she then inserts the needle into the 34-16). He or she then inserts the needle into the lateral area of the thigh (Fig. 34-17).lateral area of the thigh (Fig. 34-17).

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Figure 34-16 • Locating the vastus lateralis muscle.

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Figure 34-17 • Spreading the skin at the vastus lateralis site and darting the tissue

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Rectus Femoris SiteRectus Femoris Site

The The rectus femoris siterectus femoris site is in the anterior is in the anterior

aspect of the thigh. This site may be used for aspect of the thigh. This site may be used for

infants. The nurse places an injection in this infants. The nurse places an injection in this

site in the middle third of the thigh, with the site in the middle third of the thigh, with the

client sitting or supine (Fig. 34-18).client sitting or supine (Fig. 34-18).

29Figure 34-18 • Location of rectus femoris injection site.

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Deltoid SiteDeltoid Site The The deltoid sitedeltoid site in the lateral aspect of the upper in the lateral aspect of the upper

arm (Fig. 34-19) is the least-used intramuscular arm (Fig. 34-19) is the least-used intramuscular injection site because it is a smaller muscle than injection site because it is a smaller muscle than the others. the others.

It is used only for adults because the muscle is It is used only for adults because the muscle is not sufficiently developed in infants and not sufficiently developed in infants and children. Because of its small capacity, children. Because of its small capacity, intramuscular injections into this site are limited intramuscular injections into this site are limited to 1 mL of solution.to 1 mL of solution.

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Figure 34-19 • Deltoid site.

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There is a risk for damaging the radial nerve and There is a risk for damaging the radial nerve and artery if the deltoid site is not well identified. To use artery if the deltoid site is not well identified. To use this site safely:this site safely: Have the client lie down, sit, or stand with the Have the client lie down, sit, or stand with the

shoulder well exposed.shoulder well exposed.

Palpate the lower edge of the acromion process.Palpate the lower edge of the acromion process.

Draw an imaginary line at the axilla.Draw an imaginary line at the axilla.

Inject in the area between these two landmarks.Inject in the area between these two landmarks.

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Injection TechniqueInjection Technique

When administering intramuscular injections, When administering intramuscular injections,

nurses use a 90-degree angle for piercing the nurses use a 90-degree angle for piercing the

skin (Skill 34-3). skin (Skill 34-3).

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Reducing Injection Reducing Injection DiscomfortDiscomfort

Use the smallest-gauge needle that is appropriate.Use the smallest-gauge needle that is appropriate. Change the needle before administering a drug that is irritating Change the needle before administering a drug that is irritating

to tissue.to tissue. Select a site that is free of irritation.Select a site that is free of irritation. Rotate injection sites.Rotate injection sites. Numb the skin with an ice pack before the injection.Numb the skin with an ice pack before the injection. Insert and withdraw the needle without hesitation.Insert and withdraw the needle without hesitation. Instill the medication slowly and steadily.Instill the medication slowly and steadily. Use the Z-track method for intramuscular injections.Use the Z-track method for intramuscular injections. Apply pressure to the site during needle withdrawal.Apply pressure to the site during needle withdrawal. Massage the site afterward, if appropriate.Massage the site afterward, if appropriate.

Z-track techniqueZ-track technique It’s pretty simple.It’s pretty simple.

It reduces leakage of medication through It reduces leakage of medication through subcutaneous tissue and decreases skin lesions at subcutaneous tissue and decreases skin lesions at the injection site. So, the patient gets the full dose the injection site. So, the patient gets the full dose of medication. of medication.

It doesn’t hurt patients quite as much as a regular It doesn’t hurt patients quite as much as a regular I.M. injection. I.M. injection.

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How to do it? How to do it? Verify the drug order on the patient’s chart. Verify the drug order on the patient’s chart. Wash your hands. Wash your hands. Reconstitute the drug as needed. Check the drug’s Reconstitute the drug as needed. Check the drug’s

colour, clarity, and expiration date. colour, clarity, and expiration date. Draw the correct amount of drug into the syringe Draw the correct amount of drug into the syringe

using aseptic technique. using aseptic technique. After drawing up the dose, replace the original After drawing up the dose, replace the original

needle with a sterile needle of the appropriate needle with a sterile needle of the appropriate length for the patient’s size. length for the patient’s size.

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How to do it? ContHow to do it? Cont……

Put on gloves. Put on gloves. Confirm the patient’s identity using two Confirm the patient’s identity using two

identifiers. identifiers. Select an injection site: the ventrogluteal or Select an injection site: the ventrogluteal or

deltoid site in adults, the vastus lateralis site in deltoid site in adults, the vastus lateralis site in infants and toddlers, and the vastus lateralis or infants and toddlers, and the vastus lateralis or deltoid site in children. deltoid site in children.

Position the patient so that the muscle at the Position the patient so that the muscle at the injection site relaxes. injection site relaxes.

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How to do it? ContHow to do it? Cont……

Clean the site with an alcohol pad and let it Clean the site with an alcohol pad and let it thoroughly dry. thoroughly dry.

Use your non-dominant hand to pull the skin Use your non-dominant hand to pull the skin downward or laterally to displace the tissue downward or laterally to displace the tissue about 1 inch (2.54 cm).about 1 inch (2.54 cm).

With the needle at a 90-degree angle to the With the needle at a 90-degree angle to the site, pierce the skin using a smooth, steady site, pierce the skin using a smooth, steady motion.motion.

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How to do it? ContHow to do it? Cont……

Aspirate for 5 to 10 seconds to ensure that you Aspirate for 5 to 10 seconds to ensure that you haven’t hit a blood vessel. haven’t hit a blood vessel.

Inject the drug slowly at a rate of 10 seconds/mL Inject the drug slowly at a rate of 10 seconds/mL of medication. of medication.

Once the drug is completely instilled, wait 10 Once the drug is completely instilled, wait 10 seconds before withdrawing the needle. seconds before withdrawing the needle.

Withdraw the needle with a smooth, steady Withdraw the needle with a smooth, steady motion and release the skin to its original motion and release the skin to its original position. position.

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How to do it? ContHow to do it? Cont……

Use dry gauze to apply very gentle pressure to the Use dry gauze to apply very gentle pressure to the puncture site.puncture site.

Never massage a Z-track injection site. This may Never massage a Z-track injection site. This may cause irritation or force the drug into subcutaneous cause irritation or force the drug into subcutaneous tissue. tissue.

Assess the site immediately after administering the Assess the site immediately after administering the injection and again 2 to 4 hours later. injection and again 2 to 4 hours later.

Properly dispose of all used equipment and Properly dispose of all used equipment and supplies.supplies.

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Nursing ImplicationsNursing Implications Acute PainAcute Pain AnxietyAnxiety FearFear Risk for TraumaRisk for Trauma Deficient KnowledgeDeficient Knowledge Ineffective Therapeutic Regimen ManagementIneffective Therapeutic Regimen Management