Anintroductiontothe

principlesandpracticeof
safeandeffective
administrationofinjections
 Introduction

Givinganinjectionsafelyisconsideredtobearoutine
nursingactivity.Howeveritrequiresknowledgeof
anatomyandphysiology,pharmacology,psychology,
communicationskillsandpracticalexpertise.

Todaywewillemphasisetheresearchbasedpractices
thatareknowntoencouragenursestoincorporate
bestpracticeintoaneverydayprocedure.
 IntendedLearningOutcomes

Recognisethefivereasonswhymedicationmaybegivenby
injection(parenteralroute)

Differentiatebetweenthestructuresinvolvedandusesofthe
intramuscular(IM)andsubcuctaneous(SC)

Outlinefactorsinfluencingchoiceofsyringesandneedles

Outlinesites,basicpreparationandadministrationtechniquesfor
theIMandSCroutes

Recognisetheimportanceofuniversalprecautionswhengiving
injections
 Considerations
Equipment
Route
Site
Technique
Safety
 Equipment

LuerLok
Forsecureconnections

EccentricLuerslip
Allowsonetogetcloser
totheskin

ConcentricLuerslip
Forallotherapplications
 Equipment
WhatneedleshouldIuseforIMinjections?

21Gor23G

Greenorbluehub

Lengthdependson
patientandsite
 Equipment
WhatneedleshouldIuseforSCinjections?

25gor26g

Orangeorbrown
hub

Lengthdependson
patientandsite
 Equipment
ParticleContamination

BluntFilter/FillNeedles
Filteroutsubvisibleparticlesofglass,rubber,
fibreandotherresidues.Theinfusionofthese
particleshasbeenlinkedwith
phlebitis,vascularocclusionandsubsequent
embolism,formationofgranulomasand
septicaemia.
Theyareforusewhenwithdrawingdrugs
fromvialsandglassampoules.
 Equipment

BluntFill
BluntFilter
 Injections
ReasonsforGivingMedicationbyInjection

Rapidactionrequired
Drugalteredbyintestinalsecretions
Drugnotabsorbedbyalimentarytract
Patientcannottakeoraldrug
Drugunavailableinoralform
 PreparationofPatient

Promotecomfortandrelaxation
Explainreasonforinjection
Describetheprocedure/obtaininformedconsent
Checkforanyallergies/historyofanaphylaxis
Checkprescription/drug/patientidentify
Checkexpirydatesandrecordlotnumbers
Avoidoverexposureofpatient
Positioningofpatient
 Injections
ProcedureforInjections

Selectsite
Selectcorrectneedlelengthandsyringe
Washhandsandapplygloves
Prepareinjectionsusingaseptictechnique
 Injections
ProcedureforInjections

Checkpatientidentity
Skinpreparation(localpolicy)
Injectslowlyandremoveneedle
Documentprocedure
Reviewtheindividualasappropriate
 Injections

PreparationofskinpriortoInjections

Littleevidencetosupporttheneedfordisinfection
oftheskinpriortosubcutaneousorintramuscular
injection
Ifsoiled,however,skinshouldbecleanedbysoap
andwaterorcanbedisinfectedbyanalcoholswab
(ifalcoholswabhasbeenusedallowthealcoholto
evaporatebeforeinjecting)
Refertolocalpolicy
 Injections
IntramuscularRoute

Howmanysitescanbeusedtogivean
I.M.injection?

1)TheDeltoid.
2)TheVentroglutealsite.
3)TheDorsogluteal
4)TheVastusLateralis.
 Injections
SitesforIMInjections

Deltoid

Ventrogluteal

Dorsogluteal

VastusLateralis
 Injections

Traditionallynurses
weretoldtodivide
thebuttocksinto
fourquadrants

INJECTINTO
THEUPPER
OUTER
QUADRANT
 Injections
IntramuscularInjection
Variabilityinsubcutaneoustissuethickness
Clinicalstudy Cockshott,etal.NewEngl.JMed,307(1982)

dorsoglutealinjectionsin213adults
1inch(or38mm)21ggreenneedle
localisationusingCTscans

Conclusions
Only5%ofwomen
Only15%ofmen
actuallyreceivedIMinjections,allotherinjectionswentinto
subcutaneoustissue
 Injections
IntramuscularInjections
MRIcloseupscanofthebuttocks
Thedistancefrom
skintomusclein
thispatient(line
marked1)is42mm

Aninjectiongiven
witha38mm
(11/2)needle
stayedinthefatty
SCtissue
 Injections
ARecentAdaptationofthisApproach

TheDoubleCross
Dividethebuttockwithanimaginarycross
THENdividetheupperouterquadrantby
anotherimaginarycross
Injectintotheupperouterquadrantofthe
upperouterquadrant
 Injections

TheDoubleCross
 Injections

TheDoubleCross
 Injections

TheDoubleCross
 Injections
IntramuscularInjections
VastusLateralis
Bunchupinelderly,
emaciatedorinfants
Dividethighinto
thirds,injectinto
bottomoftop1/3
 Injections
IntramuscularInjections
Deltoid
IdentifytheGreater
Tuberosity

Move5cms(12inches)
belowthesite

Rotatearmtoconfirmsite
 Injections
IntramuscularInjections
ZtrackingProcedure
Pullskin Removeneedle
tautthen andrelease
skin
Insert
needle
 Injections
IntramuscularInjections
ZtrackingProcedure
Pullskintaut
Keepingskintautwithheelofhandinsertneedleata90%angle
Aspirateplungerover510secondsnotinganyblood
Ifclearinject1mlevery10seconds
Wait10secondsbeforeremovingneedle(Beyea&Nicoll1995)
Keepskintautuntilneedleremoved
Dontmassagethesite
Checkpatientandsite(30minutes)
 Injections
IntramuscularInjections
ZtrackingProcedure
Pullskin Removeneedle
tautthen andrelease
skin
Insert
needle
 Injections
Recommendedmedicationvolumesper
musclesite
Ventrogluteal Upto4mlinawelldevelopedmuscle

Upto2mlinlessdevelopedmuscle

Vastuslateralis Upto4mlinawelldevelopedmuscle

Upto2mlinlessdevelopedmuscle

Deltoid Upto1mlinawelldevelopedmuscle

Upto0.5mlinlessdevelopedmuscle
 Injections
SubcutaneousRoute
 Injections
SpeedofAbsorptioninInjectionSites
 Injections
ProcedureforSubcutaneousInjections
Liftskinfold
Punctureskinat90degrees
Donotaspirate
Injectslowlyandremoveneedle
Releaseliftedskinfold
 Injections
Scan:ThinPatient Abdomen
Injectionsperformed
withan8mmneedle,

Withoutaliftedskin
fold(left)

Withaliftedskinfold
(right)
Thigh
 Injections
Noliftedskinfold Liftedskinfold
 Injections
Correctlyliftedskinfold IncorrectlyLiftedskinfold
 Injections

PotentialComplications

Infection

Incorrectlocationofinjectate

Pain

Anaphylaxis
 Injections

PotentialComplications

Longandshorttermnervedamage
Intramuscularhaemorrhage
Hittingabloodvessel
Sterileabscess
Lipodystrophy
 LegalandProfessional

Understandthelegal&professionalresponsibilities
whenadministeringaninjection.
 LegalandProfessional

Traininganddirectsupervisionwithmentor
CarryoutprocedureinaccordancewithTrustpolicy
Developcompetence
Practiceyourskillregularly
Donotproceedunlessconfident
Documentation
 SafetyIssues
Whogetsinjured?
35%areNursingStaff

Wheredoestheinjuryoccur?
37%inthepatientsroom/ward

Wasthesharpcontaminated?
78%Yes

36%NSIoccurduringuse
19%NSIoccurduringaninjection
(intramuscular/subcutaneous)
EPINetTM dataforNeedlesandSyringes2003
 Safety

IfIamstuckwithaninfectedneedle
whatistherisk?

HBV 1in3
HCV 1in30
HIV 1in300
 Safety
Costtopractitioner
Immeasurablestress
Lifestylechanges
Possibleprematuredeath

Costtoemployer
Coveringsickness
Treatmentcosts
Litigation
Recruitmentandretentionofstaff
 Safety
TheNationalAuditOffice(NAO2003)
Thereportstatedneedlestickandsharpsinjuriesaccounted
for17%ofaccidentstoNHSstaffandwerethesecondmost
commoncauseofinjury,behindmovingandhandlingat18%.

AtleastfourUKHCWsareknowntohavediedfollowing
occupationallyacquiredHIVinfection

Since1996,theHPAhasreceivedreportsofnineHCWswho
havebeeninfectedwithHCVbecauseofoccupational
exposure

With40,000reportedincidentsayearandatleastasmany
unreported,needlesticksandsharpsinjuriesareasignificant
issue.
Themanagementofhealth,safetyandwelfareissuesforNHSstaffNewedition2005
 Safety
StandardPrecautions
Skin
Cutsorabrasionsinanyareaofexposedskinshouldbecovered.
Gloves
Wellfittingcleanglovesmustbewornduringprocedureswheretheremaybe
contaminationofhandsbyblood/bodyfluids.
HandWashing
Theuseofglovesdoesnotprecludetheneedforthoroughhandwashingbetween
procedures.
Aprons
Wherethereisapossibilityofbloodspillage.
EyeProtection
Wherethereisadangerofflyingbloodsplashes.
SharpsContainer
Needlesarenottoberesheathedpriortodisposalintoapprovedsharpscontainer.
 Safety

SAFEDISPOSALOFSHARPS
Immediatelyafteruse
Neverresheathorbendneedles
Ifpossible,disposeofneedleandsyringeasa
singleunit
Dontoverfillsharpsboxes
Reportanyaccidents/incidentsinaccordance
withyourlocalhospitalpolicy
 ManagementofNeedlestick
injury
Bleedwoundunderrunningwater
Washwithsoapandwater
AttendOccupationalHealthdeptassessriskand
takeappropriateaction
Identifysourceofcontaminationegpatientdetails
DocumentandReportincident