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90° injections are...
Intramuscular or IM
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45° injections are called...
Subcutaneous or Sub-Q
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25° injections are called...
Intravenous or IV
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10°-15° injections, almost parallel with skin are called...
Intradermal or ID
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These injections inject into the muscular layer.
IM
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These injections inject into the subcutaneous tissue.
Sub-Q
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These injections inject into the dermis.
IV
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These injections hit right between the epidermis and dermis layer of the skin.
Intradermal or ID
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What is the principle behind rotating sites of injection?
Prevent tissue/muscle damage.
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How do we avoid changes in absorption of insulin?
We rotate within one area for several doses.
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When is there no need to aspirate the needle? Why?
- Sub-Q and ID injections.
- These sites are avascular.
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When do we aspirate the needle and why?
IM injections because the muscle is vascular.
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What does it mean to aspirate a needle?
Pull back on syringe to get air in needle.
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For peds pts and geriatric pts, what happens to the needle length and angle of injection?
Needle is shorter and angle of injection is 45°
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When we have an obese pt what do we need when giving IM injections?
For the deltoid muscle we use 1 1/2" inch needle. For larger muscles we use 2"-3" needle.
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What do we do first to the injection site?
Clean with alcohol starting in center going outward, and let it dry.
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How long do we wait to take out needle after injecting a Sub-Q and IM injection?
5-10 sec.
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When removing the needle we use__________, especially for a longer needle for IM.
Counter-tension
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What position do we NEVER give an injection?
Standing position
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What do we consider when giving injections to pediatric pts?
- 1. Can be traumatic and painful.
- 2. Do not lie to child, don't want to break trust.
- 3. CDC-ACIP is a resource for peds injections
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How can we decrease a child's painful injection experience?
Use ice or topical anesthetic agents.
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What adjustments might we have to make for a child's size?
Needle size and medication volume.
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What common meds given Sub-Q?
- 1. Heparin
- 2. Insulin
- 3. Morphine
- 4. vaccines (chicken pox)
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0.5-1mL is the usual volume for...
Sub-Q
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What do we know about insulin injections?
Insulin syringe is only used for insulin.
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How is insulin prepared?
Prepared from a vial or ampule or pre-filled syringe.
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What might you need (depending on policy) while preparing heparin and insulin?
A second RN to check dose.
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This injection has a slow, sustained absorption.
Sub-Q
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Why is Sub-Q good for giving morphine?
Even pain control, slow and sustained absorption.
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This injection is less painful because of fewer pain receptors in the tissue.
Sub-Q
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This syringe is 1-3mL and typically used for...
Sub-Q
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0.3mL, 0.5mL, 1mL and 2mL *usual 0.5-1mL* syringes for...
Insulin
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3/8-5/8* inch needle used often for...
Sub-Q
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1/2" needle for...
insulin or infants
-
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27-29 gauge for.....
insulin
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The finer the needle, then...
the less painful, great for multiple injections in one day.
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What is the technique for Sub-Q injections?
Pinch up tissue to insure injection goes into sub-Q tissue and not muscle.
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For Sub-Q in a normal wt adult what needle and angle do we usually use to inject?
5/8" needle at 45°
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5/8" needle and 90° angle in abdomen for...
Sub-Q low dose heparin and low molecular wt heparin
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What angle and needle length is insulin delivered in?
90° and 1/2" needle
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What do we NEVER do before and after a heparin or insulin injection?
Never aspirate before or massage after.
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Why don't we aspirate before heparin or insulin injection?
Can traumatize tissue more.
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Why don't we ever massage after heparin or insulin injection?
Can cause bruising.
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What do they recommend doing when preparing meds from a vial? Why?
Recommend changing to a new needle after preparation because needle gets dull after going into vial so many times, and med might be on outside of needle (ex. low dose heparin) can irritate tissue = larger bruise.
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Lateral and posterior upper arm below deltoid (below axilla). What injection is used here?
Sub-Q
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Abdomen, at least 2" away from umbilicus is a site for...
Sub-Q
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Upper ventrogluteal (above buttocks) is site for...
Sub-Q
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Upper anterior thighs (fatty tissue) is a site for (list 2)....
Sub-Q for adults and pediatrics
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Over the scapulae is a site for...
Sub-Q and allergy testing mainly
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How do u hold a syringe given Sub-Q?
Like a dart.
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When preparing site to inject what do we do?
Use alcohol pad and start in center and work outward 2", and keep alcohol pad nearby for after to clean any blood.
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What is always the last step after removing needle from injection site?
Activate needle safety device and discard syringe and needle in sharps container.
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After removing Sub-Q injection what do we right away unless contraindicated?
Lightly massage with alcohol prep.
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Fat pads above the iliac crests are preferred sites for...
Pediatric Sub-Q
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Upper lateral arms are preferred sites for...
Pediatric Sub-Q
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Upper lateral arms are preferred sites for...
Pediatric Sub-Q
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Why would we do Pediatric Sub-Q injections?
To avoid IM injections in pediatric pts.
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How much volume do we use in deltoid?
0.5-1mL
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How much volume do we use for smaller muscles or people with less developed muscle?
1-2mL
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How much volume do we use in large muscles (gluteus maximus and medius)?
3mL
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What is the absorption like for IM? Why?
Rapid because muscles are very vascular.
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3mL syringe for...
Most adult IM
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What factors into choosing the right syringe for IM?
Volume of medication
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What factors in needle choice for IM?
- 1. Size of muscle
- 2. Type of solution to be injected
- 3. Amt of adipose tissue
- 4. Age of pt
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The greater the viscosity, then...
the larger the gauge.
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As gauge gets larger...
the smaller the diameter.
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As gauge gets smaller...
the larger the diameter.
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1"needle and 21-23 gauge
Adult IM deltoid
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5/8" needle 25 g
small adult or child IM deltoid
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Maximum volume of 1mL for...
deltoid IM
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Lateral upper arm site is also known as...
Deltoid
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How do we landmark the deltoid IM shot?
Place pinky finger on acromium process, and lay rest of fingers down the side of the arm, 4th finger is injection site.
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Gluteus medius muscle is also known as...
Ventrogluteal site.
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Which is the preferred site for IM injections? Why?
- Ventrogluteal site
- 1. No large blood vessels or nerves
- 2. Large muscle mass
- 3. Less Sub-Q fat so easier to access muscle
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1 1/2" needle and 21-22g for...
average adult Ventrogluteal IM
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Maximum volume of 3mL for...
Ventrogluteal IM
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Ventrogluteal IM angle of injection is...
90°
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Kids over 18 months old, what is a suitable IM site?
Ventrogluteal
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What is the best spot for high volume, repeated injections?
Ventrogluteal
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How do we position pt for ventrogluteal site?
Side-lying position with knee bent or supine
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What hand do we use for ventrogluteal?
Right hand for left hip and left hand for right hip.
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Where do we place our hand on the body for the ventrogluteal site?
Heel of hand on the greater trochanter, fingers pointed toward the pt's head
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How do we place our fingers for the ventrogluteal site to landmark it?
Form a "V", point index finger toward anterior superior iliac spine and stretch 2nd finger posteriorly toward the posterior iliac crest
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Once we've landmarked the ventrogluteal site, what do we do?
Mark with alcohol pad, aspirate and inject into middle of V
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This is the recommended site for newborns and infants.
Vastus Lateralis
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This is the most developed muscle in most adults.
Vastus Lateralis
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1" needle 21-23g...
small adult or elderly with smaller muscle Vastus Lateralis IM
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1 1/2" 21-22g needle for...
Average adult, vastus lateralis site for IM
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Maximum volume 1-2mL for... why?
Vastus Lateralis IM, can't put as much fluid into this muscle
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Angle of injection for Vastus Lateralis
90°
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On side of thigh between anterior and lateral, this site is...
Vastus Lateralis
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How do we landmark the vastus lateralis?
1.Place one hand below greater trochanter, other hand above the lateral femoral condyle
2. Divide thigh into thirds, inject into middle third at 90°
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What position should pt be in for vastus lateralis IM injection?
Lying or sitting position
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This is a traditional site that most people think of with IM injections.
Dorsogluteal site
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Dorsogluteal site is also our
butt
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Which site is no longer recommended? Why?
Dorsogluteal site because EBP shows sciatic nerve site varies from person to person so permanent damage can be done to the sciatic nerve.
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In pediatrics this site is used for birth to 3 yrs old.
Vastus lateralis
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Children older than 18 months use this site...what is it best for?
Ventrogluteal and best for larger volumes.
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Toddlers 2 yrs old and older this site is used for infrequent injections (immunizations)...
Deltoid
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What is a new procedure that's evidence based and now recommended for all IMs?
Z-track method
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What are benefits of Z-track method?
- 1. Less painful
- 2. Prevents leakage of irritating and discoloring meds into Sub-Q tissues
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What is the technique for the Z-track method?
Use ulnar side of non-dominant hand to pull skin and tissues approximately 1" to side and hold needle like dart at 90°
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IM injection procedure (List 18 steps)
- 1. Wash hands
- 2. Prepare med: 3 checks + 6 rights
- 3. Identify pt and explain
- 4. provide privacy
- 5. Select site and position pt comfortably
- 6. Apply gloves
- 7. Prepare site with alcohol, keep handy for after
- 8. Hold syringe like dart
- 9. Insert needle 90° with quick darting motion
- 10. Transfer hold of syringe to non-dominant hand
- 11. With dominant hand aspirate by pulling back on plunger
- 12. If blood aspirated, withdraw and discard-Start over!
- 13. No blood- inject med slowly 1mL/10sec
- 14. Wait 10 sec before removing
- 15. Use counter-tension to remove needle
- 16. Use alcohol pad or gauze to apply pressure if bleeding happens
- 17. Activate needle safety device and discard to sharps
- 18. Remove gloves and wash hands.
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1mL syringe used for...
Intradermal injection
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25-27g, 1/4" to 5/8" needle for..
Intradermal
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Site can only hold a small amt of liquid, usually 0.1mL, what type of injection is this?
Intradermal
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Why is intradermal perfect for allergy testing and PPD?
slow absorption from dermis
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Common sites for ID
- 1. Inner aspect (ventral surface) of lower arm
- 2. Left arm common for TB
- 3. Upper chest and back below scapula
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How is ID needle going into skin?
Just below epidermis, med will produce a bleb or wheal (blood is invalid!)
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How soon is ID site checked again?
24-72 hours
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What is a positive reaction for ID look like?
Redness and induration (firm)
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What do we want to make sure to do when we do ID injection?
Bevel is up, see needle just below the skin, inject slowly lifting at same time until bleb forms.
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What is an invalid ID injection?
If no bleb appears or site bleeds after needle is withdrawn.
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After ID injection what do we make sure to not do and do?
Don't massage site. Circle injection site to read site later and document according to agency policy.
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For IM injections at what rate do we inject medication into the site?
10 sec/mL to allow fluid to absorb
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Before giving an IM injection, what can help with reducing pain of an injection?
apply pressure for 10 sec. before inserting needle
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What is ventrogluteal site strongly recommended for?
IM injections of more than 1mL in pts older than seven months
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If you use dorsogluteal site besides causing damage to sciatic nerve what other damage can be done to the pt?
- 1. skin and tissue trauma
- 2. muscle fibrosis
- 3. contracture
- 4. hematoma
- 5. nerve palsy
- 6. paralysis
- 7. infectious abscess and gangrene
- 8. damage to superior gluteal artery
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What are other names for dorsogluteal site?
Buttocks or upper outer quadrant
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When palpating for greater trochanter, what should it feel like?
A golf ball
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The common Sub Q sites are...
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