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C H A P T E R

Administration
34
of Parenteral Essential Terms
ampule

Medications aqueous
aspirate
bolus
cannula
Chapter Outline cartridge unit
Administration of Parenteral Immunizations cubic centimeter (cc)
Medications Contraindications and Precautions diluent
Parenteral Equipment and Supplies in Vaccine Administrations extravasation
Preparing Medications Basics of Intravenous Therapy gauge
General Guidelines for Parenteral Equipment and Supplies Employed hypodermic
Medications in Intravenous Therapy infiltration
Routes of Administration Documentation of IV Therapy intra-articular
Intradermal Injections Risks, Complications, and Adverse intradermal
Reactions of IV Therapy intramuscular (IM)
Subcutaneous Injections
Discontinuation of Intravenous Luer-Lok
Intramuscular Injections
Infusion Therapy occlusion
Parenteral Complications
Intra-articular Injections parenteral
patency
phlebitis
precipitate
primary drug
secondary drug
continues

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836 ❖ CHAPTER 34

KEY COMPETENCIES CAAHEP ABHES


Withdraw Medication from a Vial III.C.3.b.4.g VI.A.1.a.4.m
Withdraw Medication from an Ampule III.C.3.b.4.g VI.A.1.a.4.m
Reconstitute a Powdered Base Medication with a Diluent III.C.3.b.4.g VI.A.1.a.4.m
Mix Two Medications into One Syringe III.C.3.b.4.g VI.A.1.a.4.m
Load a Cartridge or Injector Device III.C.3.b.4.g VI.A.1.a.4.m
Administer an Intradermal Injection III.C.3.b.4.g VI.A.1.a.4.m
Administer a Subcutaneous Injection III.C.3.b.4.g VI.A.1.a.4.m
Administer an Intramuscular Injection III.C.3.b.4.g VI.A.1.a.4.m
Administer a Z-Track Medication III.C.3.b.4.g VI.A.1.a.4.m

subcutaneous
Developmental Objectives
taut After completing this chapter, you should be able to:
thrombosis 1. Correctly spell and define the essential terms.
trocar 2. List six separate routes used for delivering parenteral medications.
vial
3. List four common parenteral routes by injection and list which ones are
viscosity routinely performed by the medical assistant.
wheal
4. Name and describe the components of a hypodermic needle and syringe.
5. Describe various designs of needle safety devices, and discuss the impor-
tance of using these devices.
6. Describe the importance of needle safety when administering injections.
7. Describe factors that help determine the size of the syringe, the length of
needle, and the gauge of needle to be used.
8. List complications that may occur when incorrect equipment is used or
the medication is administered using the wrong route.
9. Describe the role of the medical assistant in the administration of intrave-
nous medications.
10. List several complications that may occur when administering IV
medications.
11. List instances in which IV therapy should be discontinued.

Introduction
Medical assistants are often responsible for the administration of parenteral medi-
cations. The most common form of parenteral medication is injectables. In order
to successfully perform this task, the medical assistant must be able to select the
appropriate equipment, properly prepare the medication, select a suitable site,
and administer the medication using the correct technique. Both providers and
patients want to know that they can depend on the medical assistant to institute

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 837

safety checks along the way to ensure that the entire articular. Of those routes, only three are routinely used
procedure is performed with absolute accuracy. by the medical assistant: intradermal, subcutaneous,
Failure to institute safety measures can result in seri- and intramuscular. Some medical assistants are also
ous consequences for the patient and possible litigation responsible for administering intravenous medications;
for the office. This chapter will address the many duties however, this will vary according to the state’s medical
associated with parenteral drug administration and practice act and office policy.
provide useful tips that will aid in decreasing patient Parenteral medications are delivered into the blood
discomfort and anxiety. stream much more rapidly than oral medications, usu-
ally within minutes. The following list provides infor-
mation regarding the amount of time it takes for a
ADMINISTRATION OF medication to enter the bloodstream through selected
PARENTERAL MEDICATIONS parenteral routes:
The term parenteral means pertaining to outside ❖ Intravenous: Instantly to seconds
the intestines. When referring to parenteral medica- ❖ Intramuscular: 5 to 15 minutes, depending
tion, it means to deliver medication via a route other on the drug
than through the digestive tract. The most com- ❖ Subcutaneous: Several minutes
mon route used to deliver parenteral medications is
through injection; however, other parenteral routes Table 34-1 lists both the advantages and disadvan-
include intravenous (within the vein), transdermal tages of parenteral administration.
(through the skin), transmucosal (through the mucus
membrane), topical (on the skin), and inhalation Parenteral Equipment and Supplies
(through the respiratory tract). This chapter addresses There is a multitude of equipment and supplies available
parenteral medications delivered through the injec- for the delivery of parenteral medications. Syringes and
tion and intravenous routes; refer to Chapter 32 needles come in many sizes and are selected according
for all enteral and parenteral routes. to the route the medication is to be given, the patient’s
Common parenteral routes by injection include body size, the viscosity (or thickness) of the medica-
intradermal, subcutaneous, intramuscular, and intra- tion, and the amount of medication to be given.

TABLE 34-1 Advantages and Disadvantages of the Parenteral Route of Administration

ADVANTAGES DISADVANTAGES
Effective route when other routes would be difficult to Unsanitary equipment or mishandling of the equip-
use. For example, if the patient is unconscious or ment could cause microorganisms to be introduced
unresponsive. into the patient.
Medications administered by injection do not cause An allergic reaction to a parenteral drug may occur
irritation to the patient’s digestive system, nor are more rapidly and may be more severe than an allergic
they altered by gastric acids. reaction to an oral medication because of how
quickly it is absorbed into the bloodstream and the
amount that is given in one dose.
An exact dose can be administered to a direct site Improper injection procedures could cause damage to
by injection. the patient’s nerves, tissue, veins, and other vessels.
Effects of the medication take place much more Veins could be traumatized by an intravenous
rapidly than the oral route, so a patient that is in injection.
excessive pain would receive faster relief from a
parenteral pain reliever than an oral pain reliever.

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838 ❖ CHAPTER 34

Syringes
Syringes (Figure 34-1) used today are primarily made of
TOOL BOX
plastic and are completely disposable. Typical syringe
sizes range from 1 mL to 5 mL. Larger syringes (10 to FI E L D S M A RTS
60 mL) are used for irrigating wounds or body cavi- In order to prevent the medication from becoming
ties, drawing large amounts of blood, and for aspirat- contaminated, you must never touch the inside of
ing fluid from a patient’s joint or body cavity. Syringe the barrel of the syringe, the rubber stopper on
selection is primarily based on the amount of medica- the plunger, or the tip of the syringe that con-
tion to be administered. nects to the needle.
Syringes are packaged in hard plastic containers or
peel-apart packages and are sealed to ensure steril-
ity. If a syringe package appears to have already been
opened, the syringe should not be used and should be
disposed of properly.
The components of a syringe include the calibrated
barrel, plunger, flange, and tip (Figure 34-2). Table 34-2 FIGURE 34-2 The parts of a syringe
explains each component of a syringe.
Luer-Lok tip
Needles Tip
Barrel Rubber Rubber
Needles are available in various sizes and lengths and stopper stopper
come in disposable and nondisposable forms. Needle
selection is determined by the type of medication to be Plunger
administered, the route of administration, and the size
of the patient. Disposable needles are more commonly Plunger

used and are prepackaged in sterile plastic or paper


wrappers. Flange Flange
A needle’s gauge (G) refers to the diameter of the
needle. Gauge selection is determined by the viscosity 3 mL syringe
or thickness of the medication. Gauge sizes that are typ- separated
ically used in ambulatory care range from 20 to 27 G. 5 mL syringe separated
The larger the gauge, the smaller the diameter of the and together
needle (for example, a 22-G needle would be smaller in
diameter than a 20-G needle). Figure 34-3 shows the
different needle gauges and lengths available.

FIGURE 34-1 Syringes can range from 1 mL to 60 mL. FIGURE 34-3 Examples of different needle gauges and lengths

60 mL syringe

30 mL syringe

10 mL syringe

5 mL syringe

3 mL syringe

Tuberculin
Insulin syringe with needle

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 839

TABLE 34-2 Description of the Components of a Syringe

Barrel The cylinder that holds the medication and contains calibrations for precise measuring. The barrel
is typically calibrated in milliliters (mL) or cubic centimeters (cc) but may be also be calibrated in
minims (M). Some specialty syringes contain other calibrations such as
the insulin syringe, which is calibrated in Units.
Plunger A plastic rod with a rubber stopper on one end that seals the medication
within the syringe and flared edges on the other end for maneuvering
the plunger. This apparatus either draws medication in or pushes medi-
cation out of the barrel.
FIGURE 34-4 Slip-tip
Flange The flared plastic rim on the syringe used for guiding the plunger.
Tip The part of the syringe in which the needle is attached. Different types
of syringe tips include: the Slip-tip (Figure 34-4), a smooth tip in which
the needle is attached just by slipping it onto the syringe; and the
Luer-Lok tip (Figure 34-5), which has a threaded end in which the
needle can be locked by twisting. The tip of the syringe must remain
sterile throughout the entire procedure. FIGURE 34-5 Luer-Lok tip

Table 34-3 provides specific details for selecting the than a subcutaneous or intradermal injection because
appropriate gauge based on the route and the viscos- muscles are deeper than the other two types of tis-
ity of the medication. Note: General guidelines for needle sue. The location of the injection also plays a role in
gauges are provided later in the chapter under Routes of the selection of needle length. The deltoid and gluteal
Administration and should be used as guidelines for certifi- muscles are two common muscles that are used for
cation and registration testing. intramuscular injections, but each muscle is a different
The length of the needle is determined by the route size and at a different depth. The deltoid is smaller and
of administration, the site of the injection, and the more superficial than the gluteal muscle and, therefore,
amount of adipose tissue over the injection site. Intra- would take a shorter needle. Finally, the amount of
muscular (IM) injections will require a longer needle adipose tissue that the patient has in the area in which

TABLE 34-3 Common Gauge Sizes Based upon the Route of Administration and Viscosity of the Medication

GAUGE OF VISCOSITY OF
NEEDLE MEDICATION ROUTE EXAMPLES
19–20 Thicker or oil-based medications IM Hormones, steroids, penicillin, and certain
vitamin preparations
21–23 Aqueous- or water-based medications IM Immunizations and other water-based
medications
23–25 Aqueous-based medications Sub-Q Immunizations, allergy medications, etc.
26–27 Aqueous-based medications ID Allergy testing extracts and PPD extract
30 Aqueous-based medications Sub-Q Used when repeated injections are given,
(usually such as insulin
ultra-fine
point)

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840 ❖ CHAPTER 34

the injection is being administered will also play a role


in the length of the needle that is used. Patients with TOOL BOX
larger amounts of adipose tissue will require a lon-
ger needle to penetrate through the extra layers than FI E L D S M A RTS
patients with little adipose tissue. Many practices stock a limited variety of needle
Table 34-4 provides common needle lengths based gauges and lengths. This can be a real problem
upon the route of administration, the location of the when the patient does not meet the parameters of
injection, and the size of the patient. Note: General what is considered to be average. The smart med-
guidelines for needle lengths are provided later in the chap- ical assistant will stock a wide variety of needle
ter under Routes of Administration and should be used as gauges and lengths to accommodate patients of
guidelines for certification and registration testing. all sizes and medications of all viscosities.

Parts of the Needle Even though needles come in


disposable and nondisposable forms, they all have
The parts of a needle include the following:
similar components. Figure 34-6 shows different nee-
dles that are used for various routes and Figure 34-7 ❖ Point: The sharpened end of the needle, cut in a
shows the different parts of a needle. slanted edge called the bevel

TABLE 34-4 Common Needle Lengths Based upon the Route of Administration,
Location of the Injection, and Size of the Patient (Adult Chart)

INTRADERMAL INJECTIONS
Patients of all sizes 3 ⁄8⬙ to 1⁄2⬙

SUBCUTANEOUS INJECTIONS
Patients with little adipose tissue (muscular patients) 3 ⁄8⬙ to 1⁄2⬙
Patients with an average to large amount of adipose tissue 1 ⁄2⬙ to 5⁄8⬙

INTRAMUSCULAR INJECTIONS
Deltoid: Adult with an underdeveloped or atrophied deltoid muscle and very little adipose
tissue (i.e., frail adult) 5 ⁄8⬙
Deltoid: Adult with a well-developed deltoid muscle and an average amount of adipose tissue 1⬙
Deltoid: Adult with a well-developed deltoid and a large amount of adipose tissue 11⁄4⬙
Gluteal: Adult with very little adipose tissue 11⁄4⬙ to 11⁄2⬙
Gluteal: Adult with an average amount of adipose tissue 11⁄2⬙
Gluteal: Adult with a large amount of adipose tissue 2⬙ to 3⬙
Vastus lateralis (thigh): Adult with very little adipose tissue 1⬙
Vastus lateralis (thigh): Adult with an average amount of adipose tissue 11⁄4⬙
Vastus lateralis (thigh): Adult with a large amount of adipose tissue 11⁄2⬙ to 2⬙

Little adipose tissue: Can only pull up very little adipose tissue when lightly pinching the skin in the area
in which you are administering the injection (females or males less than 130 lb).
Average amount of adipose tissue: Can pull up an average amount of adipose tissue when lightly pinching the
skin in the area in which you are administering the injection (females 130 to 200 lb or males 130 to 260 lb).
Large amount of adipose tissue: Can pull up a large amount of adipose tissue when lightly pinching the skin in
the area in which you are administering the injection (females 200+ lb or males 260+ lb).

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 841

TOOL BOX Intramuscular Subcutaneous

C R I T I C A L TH I N K I N G Intradermal

C H A LL E N G E
An elderly, frail patient comes into the practice
to obtain a flu vaccine, which is an aqueous or
water-based solution. The patient’s deltoid mus-
cle is not very prominent and the patient has very
little fat over the deltoid. The needles available
are 23 G 5⁄8⬙, 22 G 1⬙, and 20 G 11⁄2⬙.
Intracatheters
1. What needle would work best for this for intravenous
particular medication and patient? Give use Butterfly needle and tubing for
infusions of medications i.v.
the reason for your selection. over a period of time

FIGURE 34-6 Different needles used for various routes of


administration

TOOL BOX
Lumen Shaft

C R I T I C A L TH I N K I N G
C H A LL E N G E Point Bevel
Mrs. Sims in room 2 is waiting for an ACTH injec-
tion. ACTH is a very thick, oily hormone. Mrs.
Plastic sheath
Sims has a large amount of adipose tissue around
her hips and buttocks region and weighs 253
pounds. The needle sizes available include 27 G
3⁄ ⬙, 25 G 5⁄ ⬙, 22 G 1⬙, 21 G 11⁄ ⬙, and 20 G 2⬙.
8 8 2 Point Shaft Hub
1. Which needle would work best under Lumen Hilt
these conditions? List your reasons.

❖ Lumen: The bore of a hollow needle FIGURE 34-7 The parts of a needle
❖ Bevel: The flat, slanted edge of the needle that
helps to ease the insertion of the needle into the
tissue; there are finer cuts and different lengths of TOOL BOX
bevels, such as a fine tip bevel, which is used for
insulin syringe needles. The finer the cut of the FI E L D S M A RTS
bevel, the less pain felt by the patient and the less Even though most injection equipment looks very
trauma to the patient’s tissue. similar, you should refrain from mixing one man-
❖ Shaft: The hollow steel tube of the needle through ufacturer’s equipment with another manufactur-
which the medication passes into the patient er’s equipment. There may be slight variations in
❖ Hub: The component that facilitates the attach- the equipment’s locking mechanisms, preventing
ment of the needle to the syringe; the hub is the needle from firmly attaching to the syringe.
color-coded for easy recognition of the size and This may cause leakage of medication from the
must remain sterile when assembling the needle syringe and detachment of the needle during the
and syringe. procedure.
❖ Safety device: A mechanism to shield the needle
after use (see Figure 34-8)

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842 ❖ CHAPTER 34

Needle Safety when Using Parenteral Equipment


Needle safety is very important when working with
parenteral equipment. Each office should use safety
devices to help prevent accidental needlesticks from
contaminated needles. There are a variety of different
types of safety devices, including retractable needles
and plastic sheaths that slide down over the needle.
Figure 34-8 shows a couple of different types of safety
devices.
If a dirty needlestick occurs while performing an
injection, the medical assistant should wash the area
immediately with soap and water and report the inci-
dent to a supervisor. An incident report should be
completed and the employee should receive counsel-
ing regarding what lab testing should be performed
and possible treatment options. Refer to Chapter 10
for a review of needle safety guidelines and procedures (a) (b) (c)
to follow in the event of a needlestick.
FIGURE 34-9 Various medication containers: (a) ampule;
(b) cartridge unit; (c) vial
Preparing Medications
Medications for parenteral administration are stored in
a variety of different containers. Medications may be Measuring Medication in a Syringe
stored in a(n):
The type of syringe used will be based on the amount
❖ Ampule (Figure 34-9a): A glass container with a of medication to be administered and sometimes on
stem that holds a single dose of medication the type of medication (for example, insulin). Syringe
❖ Cartridge unit (Figure 34-9b): A disposable, sizes 3 cc and below are normally calibrated using two
prefilled, single-dose cartridge of medication that scales: minims and milliliters (mL). Larger syringes are
slips into a nondisposable injection device normally calibrated in mL only. To draw up the cor-
❖ Vial (Figure 34-9c): A glass or plastic container rect amount of medication, the medical assistant must
that may contain either a single dose or multiple be able to properly read the calibrations on the outside
doses of medication of the syringe. The shorter lines on a 1-cc tuberculin

FIGURE 34-8 Examples of safety needles that assist in preventing accidental needlesticks (Courtesy and © Becton,
Dickinson, and Company.)

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 843

syringe are measured in increments of hundredths. name and strength of the drug should be checked on
Each small line represents 0.01 cc, or 1⁄100 of a cubic the medication label a minimum of three times and
centimeter. The longer lines are measured in tenths— verified with the physician’s order. Always check the
each line represents 0.1 cc, or 1⁄10 of a cc, and range expiration date on the vial as well. This information is
from 0.1 to 1.0 cc. On a 3-cc syringe, the smaller cali- usually checked:
brations are measured in tenths and represent 0.1, or
1 ❖ When removing the medication vial from the shelf
⁄10 of a cc. The larger lines represent increments of 1⁄2,
❖ Right before preparing the medication
1, 11⁄2, 2, 21⁄2, and 3 cc. On a 5-cc syringe, the smaller
❖ Right after preparing the medication
calibrations are measured on a scale of 0.2, or 2⁄10 of a
cc, with the longer calibration lines representing 1, 2, A vial is packaged with a sterile cap that protects the
3, 4, and 5 cc. rubber stopper. The sterile cap will need to be removed
Some specialty syringes are measured in units. A in a manner that prevents the stopper from becoming
unit is the amount of a substance necessary to stimu- contaminated prior to removal of the medication. Care
late a biological effect. The biological effect that one must also be taken not to contaminate or damage the
unit of medication has upon body tissue is decided vial when preparing the medication.
upon by the International Conference for the Unifica- Medication in a vial must be aspirated, or pulled
tion of Formulas. Unit increments are commonly used into the syringe through a needle, by pulling back on
for substances such as insulin and particular vitamins the plunger of the syringe.
and are specific to the individual substance or medi- To prepare the syringe for use, remove it from the
cation being administered; therefore, insulin syringes wrapper and assemble the needle. Pull the plunger
may not be interchanged with other types of syringes.
To correctly fill a syringe, the plunger should be
pulled back so that the top of the rubber stopper is TOOL BOX
even with the calibration line on the outside of the
syringe, matching the amount of medication ordered FI E L D S M A RTS
by the physician (Figure 34-10). Always inspect the rubber stopper of the vial to
make certain that the rubber is completely intact.
Withdrawing Medication from a Vial
Check the medication in the vial to make sure
When medication is stored in a vial, it may be in a single- the there is no precipitate (pieces of solid mate-
dose vial (containing an individual dose of medication) rial or crystals) or unusual cloudiness. If anything
or a multiple-dose vial (containing several doses). The unusual does appear, do not use the medication
and check with a supervisor to see if it should be
FIGURE 34-10 Examples of syringes containing specific discarded. Always check to see how the medi-
amounts of medication: (a) 3 mL syringe filled to 1.5 mL; cation should be stored, both before and after
(b) standard U-100 insulin syringe filled with 70 U of U-100 opening.
insulin; (c) 1 mL syringe filled to 0.3 mL

TOOL BOX
(a) FI E L D S M A RTS
There is no need to clean the stopper on a medi-
cation vial immediately after removing the seal.
The stopper is sterile at this point unless you con-
(b) taminate it when removing the seal. Once the first
dose of medication has been removed, the stop-
per is no longer considered sterile and will need
to be cleansed with an alcohol wipe with each
subsequent use.

(c)

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844 ❖ CHAPTER 34

within the barrel back to the calibration line that


matches the amount of medication to be removed. For TOOL BOX
example, if removing 11⁄2 mL of medication from the
vial, 11⁄2 mL of air must be inserted into the vial before C R I T I C A L T H I N K ING
withdrawing the medication. C H A L L E N GE
There is an air pressure vacuum inside the vial that When withdrawing medication from a vial, you
makes it easier to pull up the medication. The purpose notice that it is very difficult to pull back on the
of forcing air into the vial is to equalize the pressure plunger.
within the vial after the medication has been removed. 1. What may be the cause of this problem?
If the proper amount of air is not inserted within the 2. What can you do to correct the problem?
vial, the pressure within the vial will drop, making it
very difficult to pull back on the plunger when filling
subsequent syringes. On the other hand, if too much
air is inserted within the vial, the pressure within the
vial will become very powerful, causing the medication Carefully pull back on the plunger until reaching the
to be involuntarily forced out through the stopper and desired amount of medication to be withdrawn. Gently
out into the syringe. pull the needle out of the vial and carefully place the
Once the vial is prepared and the plunger is cap on the needle following institutional policy. (Tiny
pulled back to the amount of medication being with- air bubbles in the syringe may need to be removed by
drawn, insert the needle into the vial. With the vial gently flicking the syringe prior to withdrawing the
still in an upright position, push the plunger for- needle from the vial.) Procedure 34-1 lists the proper
ward to expel the air within the syringe into the vial steps for performing this procedure.
(Figure 34-11). Pick up the vial and invert it with the
needle in it. Make certain that the needle is below Withdrawing Medication from an Ampule
the liquid line before pulling back on the plunger An ampule is made of sterile glass and contains one
(Figure 34-12). single dose of medication premeasured to the exact
volume or amount needed. Examples of single-dose
medications contained in an ampule include heparin

FIGURE 34-11 Expel an amount of air into the vial that is equal
to amount of medication to be withdrawn.
FIGURE 34-12 The needle must be below the liquid line in
the vial before withdrawing the medication.

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 845

paring the medication. The neck of the ampule should


TOOL BOX be placed in a sharps container.
A special needle that contains a small filter
F IEL D S M A R T S within the lumen can be used to remove any glass par-
It is not against OSHA policy to recap a sterile ticles that may have mixed with the medication when
needle. The Needle Stick Safety and Prevention the top was snapped from the body of the ampule. A
Act is in reference to contaminated needles, not membrane filter (Figure 34-15) may also be attached
sterile needles. to the syringe before attaching the needle to keep glass
out of the syringe. The filter needle is then removed
and replaced with a hypodermic needle before inject-
ing the patient. Refer to Procedure 34-2 for the proper
and morphine. The neck of the ampule is constricted steps to follow when withdrawing medication from an
and may cause medication to become trapped at the ampule.
top of the ampule (Figure 34-13). By flicking the
ampule with your wrist and hand, any trapped medi-
cation in the top will be forced down into the body of FIGURE 34-14 Cover the neck of the ampule with gauze and
snap the neck off away from you.
the ampule. The outer surface of the ampule should be
cleaned with an alcohol pad or other antiseptic prior
to opening.
The glass ampule is hermetically sealed, mean-
ing the dose is completely enclosed in glass, and the
neck is scored (indented), so it will break easily when
opened. The medical assistant should practice safety
procedures when separating the neck of the ampule
from the body of the ampule by covering the neck with
a gauze square and breaking it away from the body
(Figure 34-14). This will help prevent tiny particles of
glass from flying into the face or eyes of the person pre-

FIGURE 34-13 Force medication from the neck of the ampule


by a quick snap of the wrist.

FIGURE 34-15 Various membrane filters that can be attached to


syringes of all sizes, in place of using a standard filter needle

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846 ❖ CHAPTER 34

Reconstituting Medications for Injection primary drug and which is the secondary drug. The
Certain medications are packaged in powdered (dry) primary drug is the first drug to be drawn up into the
form and must be reconstituted with a liquid in order syringe. When administering insulin, the primary drug
to be injected. Powder forms of medication have a lon- is the clear insulin and the secondary drug is the cloud-
ger shelf life than liquid forms. A diluent (liquid) is ier insulin. Always check with the physician when in
used to reconstitute the powder. Normally this solu- doubt. Procedure 34-4 lists step-by-step instructions
tion is sterile saline (NaCl), sterile water (H2O), or for mixing two medications in a single syringe.
lidocaine. The diluent may be supplied with the medi-
Using a Medication Cartridge or an Injector Device
cation or may need to be drawn up separately. The
medical assistant must always follow the manufactur- Some medications come in sealed, prefilled glass car-
er’s instructions when reconstituting a medication. tridges that hold a single dose of medication. Depo-
Once the diluent is removed from its original con- Provera, penicillin G benzathine, Phenergan, and
tainer, it is injected into the powdered drug vial and interferon are examples of medications that are avail-
gently mixed by rolling the solution between both hands able in cartridges. The prefilled cartridge–needle units
until the all of the powder particles are dissolved. require no mixing, no special calculations, and are eas-
Once the particles are completely dissolved, the ily administered to the patient.
medical assistant will draw up the freshly made dilu- The cartridge–needle units are designed to fit into a
tion (medication) following the physician’s orders. cartridge unit syringe, referred to as an injector device
Procedure 34-3 provides detailed instructions on the (Figure 34-16). Injector devices, such as Tubex® and
steps required for reconstituting powdered drugs. Carpuject® syringes, are usually nondisposable, made of
nonchrome-plated brass or plastic, and are interchange-
Mixing Two Medications in a Single Syringe able with many brands of cartridges. Procedure 34-5
When a physician orders two medications, it is some- lists steps that are performed when using a cartridge
times possible to combine the two drugs into one injector device.
syringe, thus making it possible to give one injection
instead of two separate injections. It is most important General Guidelines for Parenteral
to check with the physician or pharmacist to clarify if Medications
the two medications can be combined. Some medica- In most medical facilities, the medication is prepared
tions are not compatible and may cause problems if in a different room than the examination room and
combined. transferred to the exam room prior to injecting. Below
When combining two medications, the medical are guidelines to follow when preparing and adminis-
assistant must determine which medication is the tering all types of injections:

FIGURE 34-16 A cartridge–needle unit and a reusable injec-


TOOL BOX tor device

F IEL D S M A R T S
Changing the needle between the vial and patient
reduces complications during and following the
injection. Each time the needle is pushed through
the stopper of a vial, it becomes dulled, making it
difficult to puncture the skin and creating more Plunger rod Plunger
pain for the patient. In addition, irritating sub-
Rubber collar
stances such as allergy extracts may adhere to
the needle upon aspiration from the vial. As the
needle penetrates the skin, a small amount of the
medication may adhere to the outside of the skin, Disposable sterile
cartridge-needle
promoting a painful local reaction at the site of unit
the injection.

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 847

❖ Prepare only one order of medication at a time ❖ Engage the needle sheath or safety device on the
and for one patient at a time. If the patient is to syringe immediately following the injection and
be given multiple injections, prepare each one dispose of the unit in the sharps container.
separately and label syringes or syringe wrappers ❖ Patients should wait a minimum of 20 to
with a marking pen so that you can identify which 30 minutes following the injection to monitor
syringe holds what medication. for anaphylaxis.
❖ Follow standard safety precautions when dealing
with needles and syringes. Guidelines for Aspiration
❖ Ensure that contamination does not occur to the When administering intramuscular and subcutane-
equipment during preparation or transport. ous injections, the medical assistant should aspirate
❖ Never allow another health care worker to to make certain that the needle is not in a blood ves-
prepare a medication that you will administer, sel. Depositing drugs directly into the bloodstream that
nor should you prepare a medication for someone are meant for slower absorption may result in serious
else. The responsibility for a medication error complications to the patient. To aspirate, pull back
falls on the person who administers the slightly on the plunger and look for blood in the tip
medication. of the syringe. If this occurs, the needle–syringe unit
❖ Follow the seven rights (from Chapter 32) when must be removed and disposed of according to OSHA
administering all medications. guidelines.
❖ Use two patient identifiers before administering Some drug manufacturers discourage aspiration
any medications (part of the Patient Safety Act). when administering certain types of medications. Med-
❖ Check the patient’s drug allergy status, latex ical assistants should check the drug package insert
allergy status, and adhesive allergy status prior to when in doubt. Table 34-5 lists general guidelines for
administering any medication. aspiration.
❖ Wash your hands and wear gloves just prior to
administering any parenteral medications. The Guidelines for Massaging the
gloves are to protect you against possible bleeding Site Following the Injection
from the site. At the conclusion of subcutaneous and intramuscular
❖ Never allow a patient to stand while receiving an injections, gently massage the site with a cotton ball
injection. The patient’s blood pressure may drop or gauze pad to assist with the disbursement of the
and the patient may faint. medication. Massaging is contraindicated with particu-
❖ Sites should be free of scar tissue, wounds, lesions, lar types of medications, especially those that may be
rashes, moles, or any other disturbance in tissue irritating to the tissue or those that can stain the skin.
growth. Examples of medications in which massage is contra-
❖ Cleanse all sites with an approved skin antiseptic indicated include heparin, imferon, insulin, Fragmin,
using a circular motion prior to the injection. and Lovenox. Massaging after these injections can
❖ Stabilize your hand when holding the needle and damage tissue at the site or cause the medication to be
syringe. Hand movement may cause the needle to absorbed incorrectly.
move, nicking a blood vessel or nearby nerve. Massaging is contraindicated when performing all
❖ Follow the same track coming out of a site that intradermal injections due to the disbursement of the
you use going in. This will decrease injury to the extract into deeper tissue and when administering all
surrounding tissue. Z-track injections.

TABLE 34-5 General Guidelines for Aspiration

Intradermal Do not aspirate on any intradermal injections.


Subcutaneous General guidelines call for aspiration during subcutaneous injections; however, some
medications given through this route discourage aspiration, including Heparin, Lovo-
nox, and insulin. Always check the manufacturer’s insert for clarification.
Intramuscular (IM) General guidelines call for aspiration for IM injections; however, always check the drug
package insert for clarification.

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848 ❖ CHAPTER 34

Following the Procedure over the next few days. Document the procedure and
Patients should be monitored for anaphylaxis (life- the follow-up observations in the patient’s chart. Refer
threatening allergic reaction) for 20 to 30 minutes fol- to Chapter 4 for a complete procedure on document-
lowing the injection. Most anaphylactic reactions will ing medications. Medications such as immunizations
occur during this time period. Check the patient at the and narcotics should also be documented in designated
end of the monitoring period to make certain there are log. Figure 34-17 shows a hospital medication log.
no concerns. Observe the site where the injection was
administered and look for any local reactions including
redness, wheals, or swelling. Ask if the patient is expe- ROUTES OF ADMINISTRATION
riencing any breathing difficulties or any other unusual The route that is selected for parenteral delivery will be
symptoms. If the patient experiences anything out of primarily based on the manufacturer’s recommenda-
the ordinary, check with the provider before dismiss- tion and the intended use of the drug. Routes selected
ing the patient. Provide the patient with education on by the manufacturer are based on absorption properties
how to manage the injection site and what to expect of the drug and possible irritants or dyes in the drug

FIGURE 34-17 An example of


a hospital medication log used to
document all medications for a
specific patient

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 849

TOOL BOX
F IEL D S M A R T S
Patients will often tell you that they do not have
to wait following an injection because they are
not allergic to the medication. Remind patients
that they can develop an allergy at any time and
that office protocol requires the patient to wait.
Patients refusing to wait should sign a refusal
form that states the possible consequences of not
waiting. Place the refusal form in the patient’s
chart and document the refusal on the progress
note. Know your office’s protocol in the event a
patient does have a reaction. EpiPens or epineph-
rine should be stocked in any room where injec-
tions are administered.
FIGURE 34-18 The needle is inserted at a 10° to 15° angle for
an intradermal injection.

that may make it harmful to surrounding tissue. Alter- When the medication is slowly injected at this angle, a
ing any drug routes could cause harmful side effects for bubble of fluid called a wheal (Figure 34-19) should
the patient, such as tissue abscess and degeneration, appear on the outer surface of the skin.
tissue staining, and shock. The standard sites used for intradermal injections
are the inner lower forearm and the middle of the back
(Figure 34-20). These sites are used due to the lack of
Intradermal Injections hair found in these areas and the thinness of the skin.
The term intradermal means pertaining to within the Because of the location of the injection, aspiration is not
skin. The epidermis (outer layer of the skin) is the layer necessary when performing intradermal injections.
of skin that is used for intradermal injections. In order Common types of injections administered through
for the needle to stay within this layer, the needle should this route include allergy extract for testing purposes
be positioned at a 10° to 15° angle (Figure 34-18). and the PPD or tuberculin skin test. Intradermal injec-

FIGURE 34-19 A wheal should appear on the surface of the arm


following an intradermal injection.
TOOL BOX
E M R A P P L I C AT I O N
Many EMR software applications have a “Logs”
section integrated within the software. Medica-
tion logs can be easily accessed by clicking on
the “Logs” icon or equivalent name and clicking
on the appropriate medication log. Often, the
manufacturer’s name, lot number, and expiration
date will automatically appear from the previous
entry. Make certain that these items match the
current medication label. If they do not, change
these items to match the current label.

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850 ❖ CHAPTER 34

FIGURE 34-20 Sites for


an intradermal injection
include the inner forearm
and the upper portion of
the back.

tions should never be massaged because it will force Subcutaneous Injections


the liquid to be dispersed in deeper tissues, causing the The term subcutaneous is a medical term that means
wheal to disappear. pertaining to under the dermis (or true layer of the
Patients receiving intradermal injections will need skin). Subcutaneous tissue is made up of fatty and con-
to have the site evaluated within a prescribed time nective tissue. When administering a subcutaneous
frame. The provider will measure the site where the injection, the adipose tissue should be slightly pinched
wheal was induced. If the wheal extends over a specific between the finger and thumb to help differentiate the
parameter, it means that the test is positive. Table 34-6 adipose tissue from the muscle. The injection is placed
is a summary chart for key information regarding in the fatty tissue of the body, not the muscle. In order
intradermal injections. Refer to Procedure 34-6 for to reach this tissue, the medical assistant should posi-
a complete procedure on administering intradermal tion the needle at a 45° angle (Figure 34-21); however,
injections. Chapter 16 provides additional information a 90° angle may be appropriate for patients with lots of
on TB skin testing. adipose tissue or when using a shorter needle.

TABLE 34-6 Intradermal Injection Summary Chart

NEEDLE SIZE 26–27 G, 3⁄8⬙–5⁄8⬙


SYRINGE SIZE 1 mL
ANGLE OF INSERTION 10°–15°
ASPIRATE No
COMMON MEDICATIONS OR Allergy extract, TB extract
EXTRACTS GIVEN THIS ROUTE
MAXIMUM AMOUNT OF ML 0.1 mL
PER LOCATION
MASSAGE No

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 851

Intramuscular Subcutaneous Intravenous Intradermal

90-degree 45-degree 25-degree 10- to 15-


angle angle angle degree angle
Epidermis
Dermis
Subcutaneous
tissue
Muscle

FIGURE 34-21 Angles


for injection into the
Intramuscular Subcutaneous Intravenous Intradermal correct layer of skin or
(IM) (SC) (IV) (ID) muscle

Aspiration is recommended for many medications Intramuscular Injections


given subcutaneously, but is contraindicated in a select The term intramuscular (IM) means within the mus-
few. Sites commonly used for this route include the cle. Intramuscular injections are given with a longer
fatty outer portion of the upper arms, the lower abdo- needle and at a steeper angle of 90°. The needle must
men, the middle and lower back, and the thigh region be long enough to penetrate through the skin and sub-
(Figure 34-22). Table 34-7 lists important facts about cutaneous tissues and deep into the muscular tissue;
subcutaneous injections. Refer to Procedure 34-7 otherwise, the medication will seep into the subcuta-
for instructions on how to administer subcutaneous neous tissue and may cause a sterile abscess or malab-
injections. sorption of the medication.

FIGURE 34-22 Common sites for


a subcutaneous injection

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852 ❖ CHAPTER 34

TABLE 34-7 Subcutaneous Injection Summary Chart

NEEDLE SIZE 23–25 G, 1⁄2⬙–5⁄8⬙


SYRINGE SIZE 1–3 mL (use an insulin syringe when giving insulin)
ANGLE OF INSERTION 45°–90°
ASPIRATE The majority of drugs given through this route should be aspirated, but
aspiration is contraindicated in a select few drugs (refer to Table 34-5).
COMMON MEDICATIONS OR Allergy injections, insulin injections, heparin, Lovonox, MMR vaccine,
EXTRACTS GIVEN THIS ROUTE small pox vaccine, IPV vaccine, VAR vaccine
MAXIMUM AMOUNT OF ML 1 mL
PER LOCATION
MASSAGE Yes, except in a select few medications (read manufacturer’s instructions)

Body areas normally used for intramuscular injec-


tion sites are the musculature of the dorsogluteal and TOOL BOX
ventrogluteal regions, vastus lateralis, and the deltoid.
When administering an intramuscular injection, the FI E L D S M A RTS
tissue overlying the muscle should be held taut (a term Ask the patient to relax the muscle when giving
that means to pull or draw tight) to ascertain that the an IM injection. The relaxed muscle will help
medicine is deposited into the muscle and not the sub- with absorption of the medication and cause less
cutaneous tissue. Table 34-8 provides facts regarding pain for the patient.
IM injections. Procedure 34-8 lists specific steps for
administering IM injections.

Dorsogluteal when administering injections in this area to ensure


The dorsogluteal site is used to administer injections that damage does not occur to underlying structures,
in adults and older children. Viscid or thicker medi- bones, vessels, or nerves.
cations or medications greater than 1 mL are usually When locating the correct site for this injection,
injected into this muscle. Extreme caution is to be used first locate the greater trochanter of the femur. Next,

TABLE 34-8 Intramuscular Injection Summary Chart

NEEDLE SIZE 20–23 G, 1⬙–3⬙


SYRINGE SIZE 3–6 mL
ANGLE OF INSERTION 90°
ASPIRATE Yes
COMMON MEDICATIONS OR Most vaccines, analgesics, antibiotics, steroids, hormones
EXTRACTS GIVEN THIS ROUTE
MAXIMUM AMOUNT OF ML Deltoid: l mL; large muscles such as the dorsogluteal and vastus lateralis:
PER LOCATION 3 mL
MASSAGE Generally: yes; Z-Track: no

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 853

TOOL BOX TOOL BOX


F IEL D S M A R T S FI E L D S M A RTS
When a physician orders a medication that To assist with relaxation of the dorsogluteal mus-
exceeds the maximum number of mL that the site cle, place the patient in a prone position with the
can hold, inquire about dividing the dose into toes turned inward.
two even doses and giving it in two different loca-
tions. Always check with physician for approval
prior to dividing.
emaciated, thin, or elderly patients due to a lack of suf-
ficient muscle tissue.

locate the posterior iliac spine. Draw an imaginary line Ventrogluteal


between these two landmarks. Any place above and The ventrogluteal muscle can accommodate many of
outside of the imaginary line (Figure 34-23) is consid- the same medications injected into the dorsogluteal
ered acceptable for this site. muscle and may be used for patients of all ages. The
The danger involved with using this site is the acci- ventrogluteal area is free of major nerves and vessels so
dental penetration of or damage to the sciatic nerve, it is considered safer than the dorsogluteal site.
the superior gluteal artery or vein, or the iliac crest To locate the ventrogluteal site, the medical assis-
of the hip. Do not use the dorsogluteal site on infants tant should be positioned to face the lateral side of the
and use careful consideration with small children and patient’s hip. Center the top of the hand or fingers over
the patient’s gluteal medial muscle, just below the iliac
crest. If facing the patient’s right side, place the left
FIGURE 34-23a The dorsogluteal site palm over the greater trochanter of the femur, place the
Iliac crest
index finger of the left hand on the anterior superior
Gluteus medius
iliac spine, and spread the middle finger posteriorly
muscle as far as it will reach along the iliac crest. This should
Posterior superior create a “V.” Within the “V” is where the injection will
iliac spine
be administered (Figure 34-24).
Gluteus minimus
muscle
Vastus Lateralis
The vastus lateralis is part of the quadriceps group
Greater trochanter of the thigh and is the preferred site for administer-
of femur ing injections on infants and young children. This is
Sciatic nerve because it is larger and more developed than any of the
Gluteus maximus
muscle other large muscle groups at birth. The vastus lateralis
Iliotibial tract can also be used to administer IM injections to adults
and is relatively free of large vessels and major nerves.
Some adults may find it more painful to use this site
FIGURE 34-23b The landmark for dorsogluteal injections than the dorsogluteal or ventrogluteal sites. To find
the correct location of the vastus lateralis in adults, the

TOOL BOX
FI E L D S M A RTS
To assist with relaxing the vastus lateralis, have
the patient sit at the edge of the table with legs
dangling over the edge of the table.

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854 ❖ CHAPTER 34

Tubercle of Femoral
iliac crest nerve
Gluteus medius
muscle Anterior
Anterior superior superior
iliac spine iliac spine
Gluteus minimus Tensor
muscle fasciae
latae muscle
Tensor fasciae latae
muscle Femoral
artery and
Gluteus vein
maximus Greater trochanter
muscle of femur Sartorius
muscle

Vastus
lateralis
FIGURE 34-24a The ventrogluteal site muscle

Patella

FIGURE 34-25a The adult vastus lateralis site

FIGURE 34-24b The landmark for ventrogluteal injections

medical assistant should position the hand so that it is


at least one hand’s width below the proximal end of the
greater trochanter of the femur. Place the other hand so
that it is at least one hand’s width above the kneecap.
The injection may be placed anywhere between those
two landmarks along the lateral or outer portion of
the thigh (Figure 34-25). Sites for infant and pediatric
injections are found in Chapter 19.

Deltoid FIGURE 34-25b The landmark for vastus lateralis injections


The deltoid is a smaller muscle than the other intra-
muscular sites, but can be used for thinner, less viscid
medications with a limited volume, such as immuniza-
tions. No more than 1 mL of medication should be TOOL BOX
given in this location. The deltoid is not recommended
for infants and small children because the muscle is not FI E L D S M A RTS
yet fully developed. The deltoid can be located by plac- To assist with relaxation of the deltoid muscle,
ing two fingers on the acromion process and measur- have the patient drop the arm against the side of
ing 1 to 2 inches below it (Figure 34-26). The injection the body.
should be administered in the most prominent portion
of the muscle.

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 855

Acromion cutaneous tissue over the dorsogluteal tissue are dis-


Clavicle
placed or pulled laterally before the needle is inserted
by placing the palm of the nondominant hand on the
surface of skin, and pulling it several inches to the
Deltoid muscle side. This hand should not move until the end of the
Brachial artery procedure. The needle is inserted and the syringe is
and vein aspirated (one-handed technique) to make certain that
the needle is not in a blood vessel. Following aspira-
Cephalic vein tion, medication is slowly injected into the tissue. Wait
10 seconds before removing the needle to give the
Humerus
medication time to be absorbed. Immediately remove
the hand, holding the tissue to help create a seal
(Figure 34-27). The displaced tissue will return to its
FIGURE 34-26a The deltoid site original shape or location and stop the medication from
leaking out into the subcutaneous tissue. The pathway
of the needle is interrupted when using this technique
and is quite effective in preventing the loss of medica-
tion or discoloration of the skin from occurring. Do not
massage Z-track injections. Procedure 34-9 provides fur-
ther details on how to perform this procedure. Com-
mon medications given by the Z-track method include
iron preparations and medications that are irritating to
superficial tissue, such as Vistaril®.

FIGURE 34-27 Remove the hand holding the Z-track immedi-


ately after withdrawing the needle.

FIGURE 34-26b The landmark for deltoid injections

TOOL BOX
F IEL D S M A R T S
When administering an immunization in the
deltoid muscle, use the patient’s dominant arm.
Increased muscle use will promote better circula-
tion and will help to work out the soreness from
the injection much faster.

Skin pulled taut Skin released


Z-Track Method of Injection
The Z-track method is used when the medication may
cause irritation to the skin or cause discoloration of
the tissues. This method seals the medication deeply
within the muscle and allows no exit path back into
the subcutaneous tissue and skin. The skin and sub-

27187_34_c34_p835-882.indd Sec1:855 9/4/08 6:51:09 PM


856 ❖ CHAPTER 34

PARENTERAL COMPLICATIONS adults receive their fair share of immunizations as well.


Immunizations such as the hepatitis B series, DT immu-
To reduce the risks of parenteral complications, follow nizations, and flu and pneumonia vaccinations are just
the guidelines listed throughout the chapter. Table 34-9 a few of the common immunizations that are listed on
lists potential ramifications of performing injections the adult immunization schedule. There have been a
using incorrect techniques. few new immunizations introduced in recent years,
including the shingles vaccine and the HPV vaccine.
It is important to help patients stay up to date with
IMMUNIZATIONS immunizations and provide patients with education
When most people think about immunizations, often about the newest immunizations available and their
they just think about children (refer to Chapter 19 for benefits. Figure 34-28 lists the standard immuniza-
information about immunizations in children), but tions for adults.

TABLE 34-9 Possible Parenteral Complications

INCORRECT TECHNIQUE CONSEQUENCES EFFECTS


Failure to change the needle Tissue irritation or discoloration Local reaction to the skin or muscle
between the vial and patient Excess pain to the patient Discoloration of the skin
Increased amount of pain because of the
needle’s dullness
Using a needle that is too Medication will be deposited Medication will not be absorbed the
short into incorrect tissue way the manufacturer intended it to be
absorbed, thus changing the desired
effects of the medication
Abscess
Tissue degeneration
Using a needle that is too Medication will be deposited Medication will not be absorbed the
long into incorrect tissue way the manufacturer intended it to be
absorbed, thus changing the desired
effects of the medication
Could cause damage to the periosteum
resulting in infection and bone retardation
Needle could break off into the bone
Failing to aspirate on Deposition of medication Shock: Medication was not intended
medications that should directly into a vein or artery to go directly into the bloodstream.
be aspirated May cause patient’s heart to beat faster,
respiration rate to increase, blood pres-
sure to drop. Patient may become
unconscious.
Break in sterile technique The introduction of micro- Blood infection
organisms into the muscle, An abscess in the subcutaneous tissue,
subcutaneous tissue, or blood muscle tissue, or surrounding tissue
stream Tissue degeneration
Choosing a muscle that is May cause injury to the nearby Tingling
underdeveloped nerves Excruciating pain
Paralysis
Injecting a patient with a May cause injury to the Burning
small-gauge needle when surrounding tissue Tissue degeneration
administering a viscid Increased pain to the patient
solution

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 857

Recommended Adult Immunization Schedule


Note: Thes ons must be read with the footnotes that follow.

Figure 1. Recommended adult immunization schedule, by vaccine and age group


United States, October 2007 – September 2008
VACCINE AGE GROUP 19–49 years 50–64 years > 65 years

Tetanus, diphtheria, 1 dose Td booster every 10 yrs


pertussis (Td/Tdap)1,* Substitute
Substitute 11dose
doseofofTdap
Tdapforfor
TdTd
3 doses
Human papillomavirus (HPV)2,* females
(0, 2, 6 mos)

Measles, mumps, rubella (MMR) 3,* 1 or 2 doses 1 dose

Varicella 4,* 2 doses (0, 4– 8 wks)

In uenza 5,* 1 dose annually

Pneumococcal (polysaccharide) 6,7 1–2 doses 1 dose

Hepatitis A 8,* 2 doses (0, 6–12 mos or 0, 6–18 mos)

Hepatitis B 9,* 3 doses (0, 1–2, 4– 6 mos)

Meningococcal 10,* 1 or more doses

Zoster 11 1 dose

*Covered by the Vaccine Injury Compensation Program.


For all persons in this category who meet the age Recommended if some other risk factor is
requirements and who lack evidence of immunity present (e.g., on the basis of medical,
(e.g., lack documentation of vaccination or have occupational, lifestyle, or other indications)
no evidence of prior infection)

Report all clinically signi cant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on ling a VAERS report are available
www.vaers.hhs.gov
at or by
telephone, 800-822-7967.
Information on how to le a Vaccine Injury Compensation Program claim is availablewww.hrsa.gov/vaccinecompensation
at or by telephone, 800-338-2382. To le a claim for vaccine injury, contact the U.S. Court of
Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400.
Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available at
www.cdc.gov/vaccines or from the CDC-INFO Contact Center at
CS115143

800-CDC-INFO (800-232-4636) in English and Spanish, 24 hours a day, 7 days a week.


Use of trade names and commercial sources is for identi cation only and does not imply endorsement by the U.S. Department of Health and Human Services.

FIGURE 34-28 Recommended adult immunization schedule by vaccine and age group, updated annually and posted on the CDC’s Web
site, http://www.cdc.gov.

Contraindications and Precautions


TOOL BOX in Vaccine Administrations
There are many misconceptions regarding immuniza-
C R I T I C A L TH I N K I N G tions among the general population. It is important for
C H A LL E N G E medical offices to stock brochures that will assist in
You are performing a flu vaccine on a very frail answering these questions and in helping to calm the
senior adult. Upon insertion of the needle, the fears of patients and parents of pediatric patients about
needle suddenly comes to a stop and you feel like risks involved with immunizing.
you hit a brick wall. Some of the more common misconceptions are that
1. What probably just occurred? immunizations should not be given to women who
2. How can you correct this? are pregnant or breastfeeding. The only two vaccines
3. Should you tell the patient what just known to actually cause harm to a developing fetus are
happened? How about the provider? the MMR and Varicella due to the fact that they are live
4. How could this have been prevented? vaccines. Some of the newer vaccines, such as the HPV
vaccine, are still being experimented with to determine
if there are risks to the developing fetus.

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858 ❖ CHAPTER 34

Immune-compromised patients should explore the ply with federal and state laws regarding safe work
benefits and risks of immunizing and make an informed practices and for patient comfort. Containers for
decision on what is best for their particular situation. IV fluids have changed from glass containers to pli-
Some contraindications to vaccines include the able plastic bags (Figure 34-29) that are lightweight
addition of preservatives or stabilizers that may be and not at risk of becoming broken or damaged.
the cause of allergy sensitivity such as gelatin, eggs, IV fluid bags range in size from 50 to 2000 mL,
or other types of plant derivatives used in processing with the smaller bags often referred to as “piggyback”
the vaccines. Read the package inserts very carefully bags. When prescribed, the pharmacy will open the bag
and screen the patient before administering the immu- to add additional medications to the fluids and label
nizing agents to verify prior history of sensitivity or the bag with the specific prescription the physician has
allergic reaction. The CDC has a great deal more infor- ordered. If a bag is found with the opaque outer bag
mation regarding immunization contraindications on removed, do not use the solution because sterility and
their Web site at http://www.cdc.gov. viability of the product may be compromised.
The tamper-proof additive caps are removed when
additive drugs are mixed within the IV bag. Piggyback
BASICS OF INTRAVENOUS containers are used for reduced volume of fluid infu-
THERAPY sion and are filled with ready-to-use medications at the
Intravenous (IV) therapy is the administration of flu- time of manufacturing. The pharmacy will add addi-
ids or medications directly into a vein. The purpose of tional medications if prescribed, such as antibiotics.
administering fluids intravenously may be to replace Commonly used fluids contained within an IV bag
lost fluids or to introduce medication, solutions, or for infusion are normal saline (NaCl) or dextrose in
nutrients to a patient. IV injections are usually admin- water. Infusions are given to replace lost body fluids,
istered directly into the vein (bolus) or injected into restore fluid balance of cellular tonicity, or to provide
an access port on the IV line. Intravenous therapy is medications or nutrients to the body. Homeostasis of
preferred when the patient requires fast absorption and
can bring quick results because fluids enter the blood- FIGURE 34-29 Flexible IV solution containers (Courtesy of
stream immediately. IV therapy is drug specific, mean- Baxter Healthcare Corp.)
ing only certain drugs are administered by this route.
It is important to understand the difference between
intravenous injections and intravenous infusion. IV
injections consist of a relatively small amount of fluid
being introduced into the veins, while IV infusion is the
process of infusing fluid volumes of 50 mL to 500 mL
or more into the body.
Laws vary from state to state as to whether medi-
cal assistants can perform procedures directly related
to intravenous therapy. Health care facilities such as
ambulatory care clinics and urgent care centers have
started to delegate specific job duties to the medical
assistant including gathering the supplies, starting the
IV, monitoring the patient for adverse reactions, and
discontinuing the IV. A licensed physician is the one
who prescribes IV therapy. Whether or not the medical
assistant will be able to start IVs will be determined by
state law and office policy. The medical assistant must
be aware of the laws in the state in which she practices
so that the medical assitant does not go beyond the
scope of duty.

Equipment and Supplies Employed


in Intravenous Therapy
Equipment and supplies available for use in IV
therapy are continually being updated to com-

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TABLE 34-10 Common Fluids Used for IV Therapy

INFUSION INDICATIONS
5% Dextrose in water (D5W) Fluid replacement for rehydration
Normal saline (0.9% NaCl) Used to replace sodium losses
Dextrose in saline solutions Fluid replacement for burns, rehydration, maintenance infusion, circulatory
insufficiency, and in cases of shock
Ringer’s Solution Restores fluid and electrolyte balance, used when patients have lactose
Na 147 mEq/L, K 4 mEq/L, intolerance, may be used as a blood replacement for a short time
Cl 155 mEq/L

the body and its functions is the primary reason for Basic IV Administration Sets
infusion of fluids. The fluid choice is based on the Each IV administration set has similar components,
electrolyte balance and the patient’s needs at the time. including:
While there are numerous types of fluids used dur-
ing IV administration, some common products are ❖ Piercing pin (Figure 34-30): A hollow spike that is
included in Table 34-10. inserted into the administration port of the IV bag.
Infused fluids are introduced to the body through It is important this remains sterile when inserted.
administration sets, which is tubing that connects the ❖ Drip chamber (Figure 34-30): This is where the
IV bags to the IV cannula in the patient. Administra- solution flows prior to its entry into the tubing; it
tion sets come in a variety of styles, from the very basic acts as a pressurizing chamber for non-vented bags.
solution set to multiple administration tubing. All ❖ Roller clamp (Figure 34-31): This is used to regu-
IV tubing sets have common components including late the flow of fluids through the IV tubing.
clamps, a piercing pin, a drip chamber, and a cannula ❖ IV cannula or catheter (Figure 34-32): A flex-
adapter. ible tube that is used to insert medication within

FIGURE 34-30 An IV administration tubing set FIGURE 34-31 Tubing clamps

Piercing pin
Open
Flange
Open
Drip chamber Drop orifice
Close Open Close

Luer
slip Close

Close Open
Slide clamp
FIGURE 34-32 A catheter and needle

Injection port
Flow control
clamp Protective
Catheter cap
hub
Flashback
area
Catheter

Needle

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860 ❖ CHAPTER 34

a body cavity or blood vessel. It has a trocar (a of the IV set for occlusions is not necessary with the IV
sharp-pointed needle) attached to it that punc- pumps. The pump will sound an alarm if an occlusion
tures the skin to get the catheter within the vein. (blockage or closure) is detected or if the timing of the
❖ Slide clamp: This is used to restrict fluid flow and flow rate indicates the bag is almost empty. With the
act as a quick on/off control of the IV tubing. The pump, the fluid is forced with light pressure into the
tubing ends in a sterile-capped adapter, which is veins and lessens reflux, which is the backing up of
attached to the cannula. fluids into the veins and tissues. The pump can be set
for different lengths of time and rates of infusion. Some
Because of the legal issues involved with IV admin-
pumps can run multiple IV lines on the same patient.
istration, the medical assistant’s responsibilities for
IV therapy are usually to collect the equipment and
supplies and to assist with taping the IV in place (Fig- Documentation of IV Therapy
ure 34-33). The provider or nurse will usually be The health care professional that inserts and starts the
responsible for starting the IV. IV will be responsible for documenting the procedure.
The infusion of fluids can be achieved by either an Documentation in the patient’s chart should include
infusion pump (Figure 34-34) or by gravity flow. The the IV site location, number of attempts of insertion,
gravity method is controlled by the roller clamps on any complications of the procedure, the date and time
the IV tubing. The tighter the clamp, the less fluid that of insertions, the needle gauge and length, and the
flows through the tube. The drip chamber is used in person’s initials that inserted the catheter. Any adverse
calculating the drops per minute that flow into the IV reactions to the procedure such as redness, pain, swell-
tubing. ing, bruising, and other essential findings that are not
The IV pumps are more concise in delivery and more problematic at this point but could lead to complications
practical and safe for the patient. Constant monitoring at a later date and time should also be documented.

FIGURE 34-33 Proper taping of an IV site: (a) Place a foam pad under the cannula; (b) apply the dressing; (c) pinch to secure the dress-
ing to tubing; (d) secure with tape; (e) when removing, use alcohol to loosen tape. (Courtesy of ConMed Corp.)

(a) (b) (c)

(d) (e)

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Large Backlit Center Dual-Channel RS-232 Data Port


Display Delivery Enables communication
(Scratch Pad) Permits simultaneous with a variety of
Pressure History Facilitates programming. delivery of two separate information and
Graphically displays infusions at independent remote monitoring
pressure trend for rates. systems. Micro/Macro Infusion
last two hours. Capability
Delivers precise infusions
at rates from 0.1 to
99.9 mL/hr in 0.1 mL/hr
Rapid Rate, On-Line increments and from 1 to
Titration 999 mL/hr in 1 mL/hr
Facilitates rapid rate increments.
adjustments without
interrupting flow. Pump/Controller
Modes
Eliminates time-
consuming instrument
exchanges (based on
Programmable hospital infusion
Start Time protocols). Can switch
Can automatically start between pump and
multiple infusions at controller modes with
specified times. the press of a single
key.

All Fluids Air-In-Line


Detector
Significantly reduces Flo-Stop® Device
the chance of Provides disposable-
accidental administration based protection
of air. against accidental IV
free-flow.

Multi-Dosing Dual-Rate Volume/Time Automatic Drug


Enables the automatic Piggybacking Dosing Calculation
delivery of a series of Automatically switches Automatic calculation Calculates drug dose or
infusions, from the to primary parameters of rate by programming rate automatically for all
same IV container, at upon completion of volume and time. standard units of measure.
specified times. secondary (piggyback)
infusion.

FIGURE 34-34 An IV infusion pump (Courtesy of Alaris Medical Systems.)

Risks, Complications, and Adverse formation, venous spasm, vessel collapse, thrombosis
Reactions of IV Therapy (blood clot), and nerve, tendon, or ligament damage.
Intravenous therapy can have numerous inherent risks It is essential to communicate with the patient to
and complications associated with this type of medica- assess complications of IV therapy or patient intoler-
tion administration procedure. The medical assistant ance of the IV catheter. The medical assistant may be
must be knowledgeable in recognizing the complica- the health care professional that monitors the patient
tions, signs, and symptoms that may arise from the IV for complications and should know when the provider
infusion. The different complications can be classified or nurse should be alerted. Table 34-11 explains some
as local, systemic, or be a combination of the two. questions to ask a patient to clearly define the effective-
Local complications may consist of pain and irrita- ness of the therapy and patient tolerance.
tion at the insertion site, cannula dislodgement, cathe- Once the medical assistant has assessed the patient’s
ter or needle occlusion, and phlebitis (inflammation of pain, it is important to relay this information to the
the vein). Other complications may involve hematoma provider so a determination can be made for the most

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862 ❖ CHAPTER 34

TABLE 34-11 Guideline Questions for Patient appropriate intervention. Depending on the findings,
Pain Assessment the actions may include discontinuation of the therapy,
changing position of the extremity, adjusting the flow
1. Tell me about the pain you are having.
rate of infusion, re-taping the site, or applying a warm
or cool compress. Table 34-12 explains in further detail
2. Where does it hurt? more of the complications and risks of IV therapy.
3. When did it start? Systemic complications are much more danger-
ous and can be life threatening. The medical assistant
4. Is the pain in one spot, or does it radiate to should become familiar with symptoms that may indi-
other places? cate a systemic reaction. Table 34-13 provides details
5. What kind of pain is it? Aching? Gnawing? of systemic complications that may occur during IV
Burning? Stabbing or piercing? Dull? infusion therapy. If the medical assistant notices any of
Throbbing? the signs below, immediately alert the provider.
6. Are there any other symptoms of discomfort? Discontinuation of Intravenous
7. Rate the pain on a scale of 1 to 10, with 10 Infusion Therapy
being the worst pain. When the physician determines the patient no lon-
ger needs IV infusion, the IV must be discontinued.
The first step in discontinuing IV infusion is proper
aseptic technique and the application of gloves. Then
the IV tubing is clamped off and removed from the
adapter or extension set. Take care to not remove the

TABLE 34-12 Complications and Risks of Intravenous Therapy

COMPLICATIONS
AND RISKS DESCRIPTION SYMPTOMS
Infiltration or Medication fluid leaks from the Redness, severe swelling, hardness at the
extravasation cannula or from the vein into the site, pain, and edema
tissues surrounding the site.
Catheter and needle Redness
displacement
Occlusion The cannula becomes blocked and Blood in IV tubing
allows blood to back up into the
IV tubing.
Loss of patency Occurs when the vein wall has Blood in IV tubing
(the openness of been damaged
the vein)
Phlebitis Bacteria can form as a normal Vein may be hard, red streak along vein,
(inflammation of immune response due to the death inflammation, and swelling
the vein wall) of leukocytes and other tissue cells.
Thrombosis Blood clots form, causing slow or Slow or stopped infusion
stopped infusion. Fever and malaise may be present.
Hematoma Blood infiltrates into the tissues. Discoloration of the skin, discomfort, and
swelling
Cellulitis A bacterial infection that can spread Redness, red streak at the site of the needle
to surrounding tissues or nearby

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TABLE 34-13 Signs and Symptoms of Systemic Complications

SYSTEMS AFFECTED BY
SYSTEMIC COMPLICATIONS SIGNS AND SYMPTOMS
Cardiovascular system Facial edema, generalized edema, erythema along veins, palpitations,
hypotension, cardiac arrest
Gastrointestinal system Dysphagia, gastric cramping, intestinal cramping, nausea, vomiting
Integumentary system Flushing, red flare, rash, IV site edema, pruritus (itching), urticaria (hives)
Nervous system Agitation, anxiety, confusion, disorientation, headache, loss of sensation or
numbness, vertigo
Respiratory system Nasal congestion, runny nose, cough, sensation of tightness in throat,
mucous membrane edema, bronchospasm, respiratory arrest
Special senses Pruritus, watery eyes, scratchy throat, tinnitus (ringing in ears), buzzing
sound in ears, tingling or numbness in fingers or toes, vertigo

adapter—this will cause blood to leak profusely out of


the cannula hub. Remove the transparent dressing by FIGURE 34-35 Inspect the cannula following withdrawal from
the patient’s vein.
rubbing the patient’s skin with an alcohol pad, which
will loosen the adhesive in the dressing. This helps
patients who have a lot of hair on their arm or in cases
in which the adhesive dressing has adhered to skin and
is difficult to remove.
Once the transparent dressing is removed, the tape
securing the cannula hub should be removed. Take
care not to accidentally dislodge the hub from the
site during this process. When the tape is completely
removed, prepare a gauze pad and place above the
cannula site. Inform the patient to take a deep breath
and when the patient breathes in, remove the cannula
in one smooth continuous movement without press-
ing down on the cannula. Place the gauze over the site
and apply pressure for five minutes. Be sure to inspect
the cannula (Figure 34-35) to make sure it is in one
piece and has not broken off within the vein. Docu-
ment in the patient’s chart the state of the cannula for
its “intact” form (for example, “Cannula removed from
right anterior forearm. Cannula intact. Patient toler-
ated procedure well. No swelling, no bruising, or other
complications noted.”).
Intravenous therapy is a concise procedure and
should be performed only by specially trained individu-
als. If medical assistants are asked to perform duties that
exceed their training, life-threatening incidences may
occur to the patient. If unsure of what exactly is detailed
in the procedure, verify with the ordering physician to
ensure complete understanding of the expectations of
performance and completion of the administration of

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864 ❖ CHAPTER 34

intravenous therapy. If medical assistants are allowed


to perform IVs in their state but feel uncomfortable TOOL BOX
performing the procedure, they should get assistance
from their superior or the provider. C R I T I C A L T H I N K ING
C H A L L E N GE
INTRA-ARTICULAR You work in an urgent care center and the phy-
sician instructs you to start an IV on a specified
INJECTIONS patient. You know that the Medical Practice Act
The term intra-articular means within a joint. Some in the state in which you work requires a licensed
injections are given within a joint to help reduce inflam- health care provider or registered nurse to per-
mation and pain. Patients that suffer with osteoarthritis form this procedure. All of the rest of the medi-
are usually good candidates for these types of injections. cal assistants in the facility start IVs. One of the
The knee is the most common joint in which these medical assistants tells you that she will assist you
injections are given but other joints can be injected as with your first IV.
well. Steroids to reduce inflammation are the common 1. How will you respond to the physician?
drug category used to treat osteoarthritis.
The medical assistant’s duty for these injections
would be to prepare the patient for the injection and
to have all of the equipment ready for the physician.
The medical assistant may need to help hold the joint
still during the injection procedure.

PROCEDURE 34-1 Withdraw Medication from a Vial


Objective:
To prepare medication from a vial for administration.

Equipment/Supplies:
❖ Vial of medication ❖ Gauze 2x2 sponges
❖ Antiseptic wipe ❖ Sharps container
❖ Needle and syringe appropriate for ❖ Medication tray
procedure

PROCEDURAL STEPS RATIONALE


1. Wash your hands and apply gloves. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area. Distractions and poor lighting may lead to medication
errors.
4. Select the correct medication from the storage This assists in making certain you have the correct
area and check the drug label (Medication medication.
Check #1).
5. Check the expiration date. Using a medication beyond the expiration date may
decrease the effectiveness of the drug.

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PROCEDURAL STEPS RATIONALE


6. Compare the medication with the physician’s This alleviates the possibility of
order (Medication Check #2). mistakes and wasting of valu-
able medication.
7. Calculate the correct dose to be given, if needed. Giving the correct dose helps to
Verify the correct calculations with the physician obtain the desired effects and
if necessary. avoid complications.
8. Open the syringe and attach the needle to the
syringe. FIGURE 34-36
Cleanse the stopper
9. Open the antiseptic wipe and clean the vial This prevents contamination of of the vial.
stopper (Figure 34-36). the vial and the needle when
preparing the injection.
10. Holding the syringe at eye level, pull back on the This keeps the pressure in the
plunger of syringe to draw an amount of air into vial at atmospheric pressure.
the syringe equal to the amount of medication to
be withdrawn from the vial.
11. Check to make sure the needle is firmly attached If the needle is not firmly
to the syringe and remove the cap from the needle. attached to the syringe, it may
become disconnected and cause
FIGURE 34-37
an injury to the person prepar- Insert the needle
ing the medication or to the through the rubber
patient during the procedure. stopper.
12. Insert the needle through the rubber stopper
(Figure 34-37) until it reaches the empty space
between the stopper and the fluid level.
13. Push forward on the plunger to inject air into the Forcing air into the medication
vial. Keep the needle above the fluid level. can cause the fluid to break
down or bubble, thus creating
more bubbles in the medication
vial.
14. Invert the vial while holding onto the syringe and This helps prevent microorgan- FIGURE 34-38
plunger. Hold the vial and syringe without con- isms from entering the vial and Hold the vial at
taminating the needle or hub of the syringe. These the patient from obtaining an eye level during
parts of the syringe must remain sterile. infection. withdrawal of the
medication.
15. Hold the syringe at eye level and withdraw the This ensures that you are
proper amount of medication (Figure 34-38). reading the calibration lines
correctly.
16. Keep the tip of needle below the fluid level. This prevents air microorgan-
isms from entering the vial
and from being drawn into the
syringe.
17. Remove any air bubbles in the syringe by tap- If there are air bubbles in the
ping or flicking the side of the syringe where the syringe, you may not have the
bubbles are located (Figure 34-39). correct amount of medication. FIGURE 34-39
Air bubbles can take up extra Flick the syringe
space. Air bubbles may also to remove any air
bubbles.
cause pain to the patient.
continues

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866 ❖ CHAPTER 34

continued

PROCEDURAL STEPS RATIONALE


18. Remove any air remaining in the tip of the syringe. Removing air bubbles and expelling any air could
Check to make certain that you still have the cor- change the volume of medication in the syringe.
rect amount of medication. If you do not, make
the appropriate adjustments to ascertain you have
the correct amount before removing the needle
from the vial.
19. Remove the needle from the rubber stopper of
the vial.
20. Replace the needle cap on the syringe Replacing the nee-
(Figure 34-40) or replace with a new needle dle unit reduces the
and cap setup. risk of a local reac-
tion if the needle
used to withdraw
the medication is
changed between
the vial and patient.
Pushing the needle
through the rub-
FIGURE 34-40 Replace the
ber stopper dulls needle cap.
the needle; a new
needle pierces the
skin much easier.
21. Read the medication label and replace the Three checks help to ensure you have the correct medi-
medication vial in the correct storage cabinet cation and prevents errors from occurring.
(Medication Check #3).
22. Place the syringe onto a clean tray with other items
necessary for the injection, including an alcohol
wipe, a cotton ball, and an adhesive bandage.

PROCEDURE 34-2 Withdraw Medication from an Ampule


Objective:
To prepare medication from an ampule for administration.

Equipment/Supplies:
❖ Ampule of medication ❖ Gauze 2x2 sponges
❖ Antiseptic wipes (2) ❖ Sharps container
❖ Needle and syringe appropriate for ❖ Medication tray
procedure
❖ Filter needle

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PROCEDURAL STEPS RATIONALE


1. Wash your hands and apply gloves. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area. Distractions and poor lighting may lead to medication
errors.
4. Select the correct medication from the storage This helps to ascertain you have the correct medication
area and check the drug label (Medication and prevents error from occurring.
Check #1).
5. Check the expiration date. No medication should be given if the drug has reached
the expiration date, as it may not be effective.
6. Compare the medication with the physician’s order This alleviates the possibility of mistakes and wasting
(Medication Check #2). of valuable medication.
7. Calculate the correct dose to be given, if needed. An incorrect dose could cause great harm to the
patient.
8. Open the syringe and filter needle and assemble, A filter needle filters out possible glass fragments that
if necessary. may be present from snapping the stem from the body
of the ampule.
9. Tap the stem of the ampule lightly, or snap the This forces the medication into the base of the ampule
wrist of the arm holding the ampule, to remove container.
any medication in the neck of the ampule.
10. Open the antiseptic wipe and clean the ampule This prevents contamination of the needle when pre-
container. Allow the ampule to dry completely. paring the injection.
11. Place a piece of gauze around the neck of the This protects the fingers when breaking open the neck
ampule. Hold the ampule firmly between the of the vial.
fingers and the thumbs of both hands.
12. Break off the stem by snapping it quickly and This keeps glass fragments from flying into the medical
firmly away from the body. Discard the top in assistant’s eyes or face.
a sharps container and carefully set the ampule
down on a flat, firm surface.
13. Check to make sure the filter needle is firmly If the needle is not firmly attached it may cause injury
attached to the syringe and remove the cap from to the person preparing the medication.
the needle.
14. Insert the needle into the ampule below the fluid Tilting the ampule facilitates
level. Hold the ampule at a slight angle while emptying the entire ampule.
advancing the needle within the glass body. Com-
pletely draw up all the medication into the syringe
(Figure 34-41).
15. Remove the needle from the ampule without This prevents contamination of
allowing the needle to touch the edges of the the needle.
ampule.
FIGURE 34-41
16. Dispose of the ampule into the sharps container. Hold the ampule
Immediately disposing of the at a slight angle
Check the medication label before discarding the ampule prevents injury to the when withdrawing
ampule (Medication Check #3). person preparing the medica- medication.
tion for injection.
continues

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868 ❖ CHAPTER 34

continued

PROCEDURAL STEPS RATIONALE


17. Remove any bubbles in the syringe. This helps to prevent little air bubbles from entering the
patient.
18. Pull back slightly on the plunger to draw the med- This removes any medication that remains within the
ication from the needle into the syringe, engage filter needle. Medication cannot be administered to the
the safety device, and remove the filter needle. patient with the filter needle.
19. Open a new needle for administering medication The filter needle may have glass fragments inside, so it
to the patient and attach it correctly to the syringe. is not used.
20. Remove the cap from the needle and push slightly This expels any air that is within the syringe tip and
forward on the plunger to remove air that is within shaft of the new needle to ensure that air is not being
the tip of the syringe and shaft of the needle. injected into the patient’s tissues.
21. Replace the needle cap on the syringe following
institutional policy.
22. Prepare the medication tray. Place a bandage, a
gauze pad or cotton ball, an antiseptic wipe, and
the syringe on a medication tray for transporting
to the exam room to administer the injection to
the patient.

PROCEDURE 34-3 Reconstitute a Powdered-Base Medication


with a Diluent
Objective:
To reconstitute a powdered-base medication for preparation of administering
an injection to a patient.

Equipment/Supplies:
❖ Vial of powdered medication ❖ Gauze 2x2 sponges
❖ Vial of diluent ❖ Sharps container
❖ Antiseptic wipe ❖ Medication tray
❖ Two needles and a syringe appropriate
for procedure
PROCEDURAL STEPS RATIONALE
1. Wash your hands and apply gloves. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area. Distractions and poor lighting may lead to medication
errors.
4. Select the correct medication and diluent from Having the wrong medication or diluent could cause
the storage area, and check both drug labels harm to the patient.
(Medication Check #1).

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PROCEDURAL STEPS RATIONALE


5. Check the expiration date on both labels. Medication should not be given if the drug has reached
the expiration date, because it may not be effective.
6. Compare the medication with the physician’s order This alleviates the possibility of mistakes and wasting
(Medication Check #2). of valuable medication.
7. Calculate the correct dose to be given, if needed. Giving the wrong dose could cause great harm to the
Verify the correct calculations with the provider if patient.
necessary.
8. Open the syringe and needle and assemble, if
necessary.
9. Clean both the powder vial and the reconstituting This prevents possible contami-
fluid vial stopper with alcohol before use nation to the medication vials
(Figure 34-42). or the patient.
10. Pull back on the plunger to fill the syringe with This equalizes the pressure
the amount of air equal to the amount of diluting within the vial.
liquid required for reconstitution from the vial
containing the diluent.
11. Check to make sure the needle is firmly attached If the needle is not firmly
to the syringe and remove the needle cap. attached to the syringe, it may FIGURE 34-42
become disconnected and cause Cleanse the rubber
an injury to the person prepar- stopper of both vials.
ing the medication.
12. Insert the needle into the diluent vial.
13. Push in the plunger, forcing the air from the This equalizes the amount of air
syringe into the vial of diluent (Figure 34-43). in the vial.
14. Invert the vial in the dominant hand, holding it
between the thumb and index finger.
15. Keep the needle immersed in the solution while If the needle tip is not inserted
drawing the solution into the barrel of the syringe. in the fluid, air will be drawn
into the syringe. FIGURE 34-43
Inject air into the
16. Check for air bubbles and determine that the exact diluent vial.
amount of diluent is withdrawn from the vial
before removing the needle from the vial.
17. Carefully remove the needle from the vial.
18. Insert the needle into the vial containing the
powdered medication (Figure 34-44).
19. Add the appropriate amount of reconstituting This allows the powder to be
liquid to the powdered drug, slowly rotating vial flushed with the fluids and
while injecting fluid into it. helps to minimize the forma-
tion of clumps within the
powder. FIGURE 34-44
Inject the diluent into
20. Replace the needle cap on the syringe following powdered medication
institutional policy. vial.

continues

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870 ❖ CHAPTER 34

continued

PROCEDURAL STEPS RATIONALE


21. Roll the vial between the hands to thoroughly mix This allows all of the
the medication (Figure 34-45). particles to be sus-
pended appropriately.
22. Record the new date of expiration on the label of Once the medication
the medication vial. has been prepared, it is
only good for a certain
amount of time.
23. Recheck the medication label before returning A third check helps in
the vial to the proper storage area (Medication ascertaining you have FIGURE 34-45 Gently roll
Check #3). the correct medication. the vial between the hands to
mix well.
24. Prepare to administer the medication to the
patient. Place a bandage, a gauze pad or cotton
ball, an antiseptic wipe, and the syringe on a
medication tray for transporting to the exam room
to administer the injection to the patient.

PROCEDURE 34-4 Mix Two Medications into One Syringe


Objective:
To draw two medications into one single syringe for injection administration
to a patient.

Equipment/Supplies:
❖ Two vials of medication ❖ Gauze 2x2 sponges
❖ Antiseptic wipe ❖ Medication tray
❖ Two needles and a syringe appropriate ❖ Sharps container
for procedure

PROCEDURAL STEPS RATIONALE


1. Wash your hands and apply gloves. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area. Distractions and poor lighting may lead to medication
errors.
4. Select the correct medications from the storage Reading the label helps to acertain you have the correct
area and check their drug labels (Medication medication.
Check #1).
5. Check the expiration dates on both vials. No medication should be given if the drug has reached
the expiration date, as the medication may not be as
effective.

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 871

PROCEDURAL STEPS RATIONALE


6. Compare the medications with the physician’s This alleviates the possibility of mistakes and wasting of
order (Medication Check #2). valuable medication.
7. Calculate the correct doses to be given, if needed. Giving an incorrect dose could cause great harm to the
Verify the correct calculations with the provider if patient.
necessary.
8. Open the syringe and needle and remove them
from their packaging. Attach the needle to the
syringe.
9. Clean the rubber stopper of both vials with an This removes microbes that may be on the stoppers.
alcohol wipe.
10. Determine which medication is the primary medi- The primary medication is the first medication to be
cation vial. Do not do anything with the primary drawn up.
medicine at this point.
11. Draw up an amount of air into the syringe that is Air is injected into the second vial at this point because
equal to the amount of medication required from once the syringe is filled with medication from the first
the second vial. vial, it will no longer be possible to inject air into the vial.
12. Check to make sure the needle is firmly attached If the needle is not firmly attached it may become
to the syringe and remove the needle cap. detached from the syringe, causing harm to the preparer.
13. Insert the needle into the second vial and push Pushing the needle into the medication will contaminate
the air from the syringe into the vial to replace the needle, affecting the next vial.
the medication that will be taken out later. Do not
allow the needle to touch the liquid.
14. Carefully remove the needle from the vial.
15. Draw up an amount of air into the syringe that is This equalizes the pressure due to the fluid being
equal to the amount of medication required to be removed from the vial.
taken from the primary vial.
16. Insert the needle into the primary vial. Push Pushing air into the liquid could create bubbles in the
forward on the plunger, forcing air from the syringe and vial.
syringe into the primary vial without contacting
the medication.
17. Invert the vial in the dominant hand, holding it
between the thumb and index finger.
18. Keep the needle immersed in the solution while If the needle tip is not inserted in fluid, air will be drawn
drawing the solution into the barrel of the syringe. into the syringe.
19. Remove any air remaining in the tip of the syringe. This expels any remaining air within the syringe and the
If there is medication lacking in the syringe, pull needle and ascertains you have the correct amount of
back on the plunger so that the correct amount of medication.
medication is drawn into the syringe.
20. Remove the needle from the stopper of the first This reduces the risk of medication from the first vial
vial, engage the safety device, and discard into a carrying over to the second vial.
sharps container. Replace the needle with a new
needle.

continues

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872 ❖ CHAPTER 34

continued

PROCEDURAL STEPS RATIONALE


21. Smoothly insert the needle into the secondary vial.

22. Invert the vial and slowly withdraw the medica- If medication from the primary vial mixes with the
tion required from the vial. Do not allow any secondary vial it will contaminate the contents of the
medication from the first vial to be inadvertently second vial.
injected into the second vial. Pulling slowly to
avoid creating air bubbles, pull the plunger back
to the correct calibration mark on the syringe.
23. Remove the needle from the second vial.
24. Check for air bubbles and remove them from the
syringe.
25. Check again that the total amount of medication If the incorrect dosage is in the syringe, the patient may
in the syringe is the correct total to be adminis- not obtain the full effects of the medication.
tered.
26. Replace the needle cap on the syringe following Some facilities will allow recapping of clean needles,
institutional policy. while other facilities prefer the scoop method.
27. Recheck the medication labels of both vials before Checking the label three times helps to ascertain you
returning the vials to the proper storage area have the correct medication and prevents errors from
(Medication Check #3). occurring.
28. Prepare to administer the medication to the
patient. Place a bandage, a gauze pad or cotton
ball, an antiseptic wipe, and the syringe on a
medication tray for transporting to the exam
room to administer the injection to the patient.

PROCEDURE 34-5 Load a Cartridge or Injector Device


Objective:
To prepare medication from a prefilled cartridge for administration.

Equipment/Supplies:
❖ Prefilled cartridge of medication ❖ Gauze 2x2 sponges
❖ Cartridge holder ❖ Sharps container
❖ Antiseptic wipe ❖ Injection tray

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 873

PROCEDURAL STEPS RATIONALE


1. Wash your hands and apply gloves. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area. Distractions and poor lighting may lead to medication
errors.
4. Select the correct medication from the storage This ascertains that you have the correct medication.
area and check the drug label (Medication
Check #1).
5. Check the expiration date. No medication should be given
if the drug has reached the
expiration date, as it may not
be effective.
6. Compare the medication with the physician’s This alleviates the possibility of
instructions (Medication Check #2). mistakes and wasting of valu-
able medication.
7. Calculate the correct dose to be given, if needed. There may be instances in
which a patient does not need FIGURE 34-46
the entire dose within the Turn the ribbed collar
cartridge. to the open position.

8. Pick up the cartridge unit holder (the injector).


9. Turn the ribbed collar toward the open position This allows for the insertion of
until it stops (Figure 34-46). the cartridge into the holder.
10. Hold the injector with the open end up and fully
insert the sterile cartridge–needle unit.
11. Firmly tighten the ribbed collar of the unit at the
syringe base by turning the ribbed collar toward
the “close” arrow. (Hold the cartridge to prevent it
from swiveling inside the holder while tightening.) FIGURE 34-47
Thread the plunger
12. Thread the rod of the plunger into the cartridge If the cartridge is not tightened
onto the cartridge
unit until a slight resistance is felt (Figure 34-47). securely onto the holder, the unit.
needle unit may move during
the injection procedure.
13. Prepare the medication for injection into the Checking the label three times
patient at this time. Place a bandage, a gauze pad ascertains you have the correct
or cotton ball, an antiseptic wipe, and the syringe medication and prevents errors
on a medication tray for transporting to the exam from occurring.
room. Check the medication label one last time
(Medication Check #3).
14. After use, do not recap the needle.
15. Disengage the plunger rod from the cartridge This prevents the fingers from FIGURE 34-48
unit holder while holding the needle down and being in front of the needle. After the injection
away from the fingers or hands over a sharps unit is given, disengage
the plunger from the
(Figure 34-48).
cartridge unit.

continues

27187_34_c34_p835-882.indd Sec1:873 9/4/08 6:51:30 PM


874 ❖ CHAPTER 34

continued

PROCEDURAL STEPS RATIONALE


16. Unscrew the ribbed collar of the cartridge unit
holder.
17. Allow the needle cartridge unit to drop into the This helps to prevent an acci-
sharps container (Figure 34-49). dental needlestick.
18. Cleanse the cartridge holder with an antiseptic This prevents cross-
cleanser and allow to dry. contamination from occurring
to the next patient receiving
medication from a prefilled
cartridge. FIGURE 34-49
Allow the cartridge
19. Cleanse the work area and remove gloves and to drop freely into the
wash your hands. sharps container.

PROCEDURE 34-6 Administer an Intradermal Injection


Objective:
To administer an intradermal injection into a patient.

Equipment/Supplies:
❖ Appropriate sized needle and syringe ❖ Sharps container
unit with correct medication ❖ Disposable gloves
❖ Antiseptic wipe ❖ Medication tray
❖ Gauze 2x2 sponges

PROCEDURAL STEPS RATIONALE


1. Wash your hands. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment. Institute the Seven Instituting the seven rights helps to alleviate errors.
Rights of Drug Administration.
3. Identify the patient using two identifiers, identify Giving the medication to the wrong patient can cause
yourself, and explain the procedure serious problems for the patient.
4. Ask patient about drug allergies or latex allergies. Giving the patient a drug or using products that the
patient is allergic to can cause an anaphylactic reaction.
5. Select the proper injection site (anterior forearm or
middle of back).
6. Cleanse the site with antiseptic and allow to air This prevents the possible contamination of the injec-
dry completely. (Cleanse in a circular motion tion site and ensures the removal of microorganisms
working outward to an area of 2 to 3 inches.) from the injection site area. Wet alcohol may cause the
site to burn when you inject the medication.

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 875

PROCEDURAL STEPS RATIONALE


7. Prepare the equipment and apply gloves. Wearing gloves prevents contamination of bloodborne
pathogens during the procedure.
8. Remove the needle cap. Pull the cap straight off, Twisting may loosen the needle attached to the syringe.
never twist.
9. Stretch the skin taut at the site of administration. This allows the needle to be inserted easier and keeps
the tissue from moving during insertion.
10. Insert the needle at a 10° to 15° angle
with the bevel upward just under the skin
(Figure 34-50).
11. Inject the medication slowly and steadily. A wheal This allows the tissue
should form (Figure 34-51). to slowly displace and
provides space for the
fluid. If the needle is
too deep, a wheal will FIGURE 34-50 Insert the
not form and the injec- needle bevel up just below the
surface of the skin.
tion will have to be
repeated.
12. Remove the needle quickly at the same angle of This prevents injury to
insertion. the tissue.
13. Do not press on or massage the injection site. The medication will be
Do not apply a bandage to the site. dispersed into deeper
tissue if pressure is
applied to the area. A
bandage will absorb FIGURE 34-51 A wheal will
the medication. form if the procedure was
performed correctly.
14. Properly engage the safety device on the needle Engaging the safety
and dispose of the needle–syringe unit in the device will help to
sharps container. prevent an accidental needlestick.
15. Remove gloves and wash your hands. This prevents contamination and the spread of
infection.
16. Give proper patient education for caring for The 20 to 30 minute wait is to observe the patient for
the site and inform the patient to wait 20 to anaphylaxis.
30 minutes.
17. Perform post-injection observation and document Documentation illustrates that the procedure was
the procedure in the patient’s chart and the appro- performed.
priate logs.

DOCUMENTATION EXAMPLE:
05-22-XX Tubersol, 0.1 mL, ID , right lower forearm, per Dr. Jones. Manf – Kline Beecham, Lot number—K449, exp.
3:15 p.m. date – 12/XX. Pt. tolerated well, instructions given to return to clinic 48–72 hours for PPD reading.
– complications during post-injection observation. Sherri Jones, CMA (AAMA)

27187_34_c34_p835-882.indd Sec1:875 9/4/08 6:51:32 PM


876 ❖ CHAPTER 34

PROCEDURE 34-7 Administer a Subcutaneous Injection


Objective:
To administer an injection through the subcutaneous tissue.

Equipment/Supplies:
❖ Appropriate sized needle and ❖ Sharps container
syringe unit with correct medication ❖ Disposable gloves
❖ Antiseptic wipe ❖ Medication tray
❖ Gauze 2x2 sponges ❖ Adhesive bandage
PROCEDURAL STEPS RATIONALE
1. Wash your hands. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment. Institute the Seven Instituting the seven rights will help prevent errors
Rights of Drug Administration. from occurring.
3. Identify the patient using two identifiers, identify Giving the medication to the wrong patient can cause
yourself, and explain the procedure. serious problems for the patient.
4. Ask the patient about drug allergies, latex allergies, Giving the patient a drug or using products that the
or adhesive allergies. patient is allergic to can cause an anaphylactic reaction.
5. Select the proper injection site (fatty tissue of the
arms, thighs, or stomach).
6. Cleanse the site with antiseptic and allow to air This prevents the possible contamination of the injec-
dry completely. (Cleanse in a circular motion tion site and ensures the removal of microorganisms
working outward to an area of 2 to 3 inches.) from the injection site area. Wet alcohol may cause the
site to burn when you inject the medication.
7. Prepare the equipment and apply gloves. This prevents contamination by bloodborne pathogens
during the procedure.
8. Remove the needle cap. Pull the cap straight off, Twisting may loosen the needle attached to the syringe.
never twist.
9. Grasp or pinch the tissue lightly with one hand. This helps to determine
the subcutaneous layer of
tissue and helps with the
needle insertion.
10. Insert the needle at a 45° angle with the other
hand, using a quick and smooth motion
(Figure 34-52).
Unnecessary movement of FIGURE 34-52 The
11. Stabilize the needle within the tissue. proper angle of inser-
the syringe can cause tissue tion for a subcutaneous
damage and pain to the injection
patient.

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 877

PROCEDURAL STEPS RATIONALE


12. Aspirate to ensure the needle is not in a blood If the needle has inadvertently been inserted into a
vessel. vessel, there will be a bloody return into the syringe.
Do not inject, but remove the needle immediately.
Depositing medication into a blood vessel could cause
harm to the patient.
13. Inject the medication slowly and steadily. Injecting the medication too quickly can cause discom-
fort to the patient and not allow the medication to be
absorbed properly.
14. Remove the needle quickly at the same angle of This helps to prevent trauma to the tissue.
insertion.
15. Place a cotton ball or gauze sponge over the injec- This helps ease the discomfort caused from the injec-
tion site and gently massage the area, if applicable. tion and accelerates absorption of the medication
(unless massaging is contraindicated).
16. Properly engage the needle’s safety device and Engaging the safety device helps to reduce the possibil-
dispose of the needle and syringe into the sharps ity of a needlestick.
container. Apply a bandage to the site to prevent
the patient’s clothes from becoming contaminated
with blood.
17. Remove gloves and wash your hands. This prevents contamination and the spread of
infection.
18. Give proper patient educational materials and
waiting instructions.
19. Perform post-check of the patient and site 20 to Allergic reactions usually occur within 20 to 30 min-
30 minutes following the procedure. utes of the procedure.
20. Chart the procedure correctly on the progress note Documentation illustrates that the procedure was
and appropriate logs. performed.

DOCUMENTATION EXAMPLE:
05-22-XX Varivax #1, 0.5 mL, sub-q, right arm per Dr. Sullivan. Manf.–Kline Beecham, Lot number–K449, exp. date
3:15 p.m. – 12/XX. Pt. tolerated well, instructions given to pt. for site care and VIS sheet provided—consent form
signed and filed in chart.. Post injection follow-up, –complications. Sherri Jones, CMA (AAMA)

27187_34_c34_p835-882.indd Sec1:877 9/4/08 6:51:33 PM


878 ❖ CHAPTER 34

PROCEDURE 34-8 Administer an Intramuscular Injection


Objective:
To administer an injection within the muscular tissue.

Equipment/Supplies:
❖ Appropriate sized needle and ❖ Medication tray
syringe unit with correct medication ❖ Sharps container
❖ Antiseptic wipe ❖ Disposable gloves
❖ Gauze 2x2 sponges ❖ Adhesive bandage
PROCEDURAL STEPS RATIONALE
1. Wash your hands. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment. Institute the Seven Instituting the seven rights will help prevent errors
Rights of Drug Administration. from occurring.
3. Identify the patient using two identifiers, identify This prevents the wrong patient from receiving the
yourself, and explain the procedure. medication.
4. Ask the patient about drug allergies, latex allergies, Giving the patient a drug or using products that the
or adhesive allergies. patient is allergic to can cause an anaphylactic reaction.
5. Locate the proper injection site (deltoid, dorsoglu- The right site must be selected in order for the drug to
teal, ventrogluteal, or vastus lateralis). be absorbed properly.
6. Cleanse the site with antiseptic and allow to air This prevents the possible contamination of the injec-
dry completely. (Cleanse in a circular motion tion site and ensures the removal of microorganisms
working outward to an area of 2 to 3 inches.) from the injection site area. Wet alcohol may cause the
site to burn when you inject the medication.
7. Prepare the equipment and apply gloves. This prevents contamination by bloodborne pathogens
during the procedure.
8. Remove the needle cap. Pull the cap straight off, Twisting may loosen the needle attached to the syringe.
never twist.
9. Stretch the tissue to hold the skin taut with your
nondominant hand.
10. Using your dominant hand, insert the needle at This helps with the needle
a 90° angle using a quick and smooth motion insertion.
(Figure 34-53).
11. Stabilize the needle within the tissue. Unnecessary movement
of the hand holding the
syringe can cause tissue
damage and pain to the
patient.
12. Aspirate to ensure the needle is not in a blood Depositing the medication FIGURE 34-53 The
vessel. If blood enters the syringe, do not inject, into the bloodstream could proper angle of inser-
but remove the needle immediately. If there is no cause great harm to the tion for an intramuscular
bloody return into the needle, proceed with the patient. injection
injection process.

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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 879

PROCEDURAL STEPS RATIONALE


13. Inject the medication slowly and steadily. Injecting the medication too quickly can cause discom-
fort to the patient and not allow the medication to be
absorbed appropriately.
14. Remove the needle quickly at the same angle of This helps to prevent trauma to the tissue.
insertion.
15. Place a cotton ball or gauze sponge over the injec- Massaging the area helps to disburse the medication,
tion site and gently massage the area, if applicable. unless contraindicated.
16. Engage the safety device on the needle, and This protects you from an accidental needlestick from
dispose of the needle–syringe unit in the sharps a contaminated needle.
container.
17. Place an adhesive bandage over the site and This prevents contamination and the spread of infection.
remove gloves and wash your hands.
18. Give related patient educational materials and
proper waiting instructions.
19. Perform post-check of the patient and site 20 to Allergic reactions usually occur within 20 to 30 minutes
30 minutes following the procedure. of the procedure.
20. Chart the procedure correctly on the progress note Documentation illustrates that the procedure was
and appropriate logs. performed.

DOCUMENTATION EXAMPLE:
05-22-XX Hepivax 0.5 mL, IM, R. Deltoid per Dr. Jones. Manf. – Kline Beecham, Lot number–K449, exp. date – 12/XX.
3:15 p.m. Pt. tolerated well, instructions given to pt. for site care and VIS sheet provided and consent form signed
and filed. No problems during post check. Sherri Jones, CMA (AAMA)

PROCEDURE 34-9 Administer a Z-Track Medication


Objective:
To administer an injection by the Z-track method

Equipment/Supplies:
❖ Appropriate sized needle and syringe unit ❖ Medication tray
with correct medication ❖ Sharps container
❖ Antiseptic wipe ❖ Disposable gloves
❖ Gauze 2x2 sponges ❖ Adhesive bandage
PROCEDURAL STEPS RATIONALE
1. Wash your hands. This prevents the spread of infection and contamina-
tion during the procedure
2. Assemble the equipment. Perform the Seven
Rights of Drug Administration.
3. Identify the patient using two identifiers, identify This ensures that you do not give the wrong patient the
yourself, and explain the procedure. medication.

continues

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880 ❖ CHAPTER 34

continued

PROCEDURAL STEPS RATIONALE


4. Ask the patient about drug allergies, latex allergies, Giving the patient a drug or using products that the
or adhesive allergies. patient is allergic to can cause an anaphylactic reaction.
5. Locate the proper injection site (usually the dorso-
gluteal site).
6. Cleanse the site with antiseptic and allow to air Cleansing the site reduces microorganisms on the skin.
dry completely. (Cleanse in a circular motion Allowing the site to air dry helps to take away the sting
working outward to an area of 2 to 3 inches.) when inserting the needle.
7. Prepare the equipment and apply gloves. Gloves help to prevent contamination by bloodborne
pathogens during the procedure in the event the site
bleeds.
8. Remove the needle cap. Pull the cap straight off, Twisting may loosen the needle attached to the syringe.
never twist.
9. Using your nondominant hand, pull the tissue to This displaces the tissue so when the tissue is released,
be injected laterally 1 to 2 inches away from the the tissue will return to a normal position to prevent
injection site. the medication from leaking out of the site and into sur-
rounding tissue.
10. Using your dominant hand, insert the needle at a
90° angle with a quick and smooth motion.
11. Stabilize the needle within the tissue. Unnecessary movement of the hand holding the syringe
can cause tissue damage and pain.
12. Aspirate using the one-hand technique to ensure Using the one-hand technique when aspirating frees the
the needle is not in a blood vessel. If medication is other hand to keep the tissue retracted.
in a blood vessel, remove the needle and prepare a
new setup.
13. Inject the medication slowly and steadily. Injecting the medication too quickly can cause discom-
fort to the patient and not allow the medication to be
absorbed properly.
14. Wait 10 seconds before removing the needle. This allows the medication to settle in the tissue.
15. Remove the needle quickly at the same angle of
insertion.
16. Release the tissue after removing the needle from This allows the displaced tissue to return to a normal
the site. position and blocks the insertion path of the needle,
preventing the medication from leaking into the sur-
rounding tissues.
17. Place a cotton ball or gauze sponge over the Massaging could possibly cause malabsorption of the
injection site. Do not massage the site for a Z-track medication, discoloration to the tissue surrounding the
injection. site, or even leakage of the medication from the injec-
tion site.

18. Properly engage the safety device and dispose of Engaging the safety device keeps you from accidentally
the needle–syringe unit into the sharps container. getting stuck with a contaminated needle.
Apply a bandage to the site to prevent the patient’s
clothes from becoming contaminated with blood.
19. Remove gloves and wash your hands. This prevents contamination and the spread of
infection.

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PROCEDURAL STEPS RATIONALE


20. Give related patient educational materials and
waiting instructions.
21. Perform post-check of the patient and site 20 to Allergic reactions usually occur within 20 to 30 min-
30 minutes following the procedure. utes of the procedure.
22. Chart the procedure correctly in the progress note Documentation proves that you performed the
and appropriate logs. procedure.

DOCUMENTATION EXAMPLE:
05-22-XX Methylcobalamin, 1.0 mL, Deep IM (Z-Track), L. Dorsogluteal per Dr. Raymond. Manf. – Kline Beecham, Lot
3:15 p.m. number–K449, exp. date – 12/XX. Pt. tolerated well, –complications during post injection check. Sherri
Jones, CMA (AAMA)

Chapter Summary
By learning the information provided in this chapter and performing the competencies, medical assistants will come
to realize the importance of performing safe and competent invasive procedures for their patients’ health care needs.
The practice of performing invasive procedures must be methodical, focused, and performed with the utmost care,
not given light thought or compromising the quality of services provided. The standard of care demands a high level
of achievement and understanding, for the protection of the patient and the provider’s practice.

FIELD APPLICATION CHALLENGE


The physician asks you to administer a hormone 1. What are some possible causes for the difficulty
shot that is very viscid and oily. As you go to with- in pulling back the plunger?
draw the medication, you notice that you are having
2. What should you have done when the patient
a great deal of trouble pulling back on the plunger.
asked for the injection in the arm? What would
After preparing the medication, you go back to the
have been a better location?
patient’s room with the medication tray. You ask
the patient where he wants to have the medication 3. What would have been an appropriate sized
administered. The patient replies his arm and rolls needle to use for this injection based on the
up his sleeve. You start to administer the injection. new location of the injection and the viscosity
You notice that it is very difficult to push forward of the medication?
on the plunger as you inject the medication into the
4. Why do you suppose that the patient’s arm red-
patient’s deltoid. The patient appears to be experi-
dened and a knot appeared in the area where
encing a great deal of pain. Following the injection,
the injection was given?
the skin over the site is very reddened and a hard
knot now appears at the injection site.

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882 ❖ CHAPTER 34

Chapter Assessment Web Activity


1. What is the most important aspect of administra- 1. The Centers for Disease Control and Prevention
tion of medication to a patient? National Immunization Program provides infor-
a. Documentation of the procedure mation on the importance of vaccinations. Go to
b. Documentation of the medication administered http://www.cdc.gov and look up this important
to the patient information. Prepare a one-page summary that
c. Proper identification of the patient depicts why the benefits of immunizing far out-
d. Proper technique in administering the weighs the risks of immunizing.
medication
2. Tuberculin syringes come in what syringe size?
a. 1 mL syringes
b. 3 mL syringes
c. 5 mL syringes
CONNECTION
d. 10 mL syringes Using your StudyWARE CD-ROM:
3. The gauge of the needle indicates: ❖ Complete the Concentration activity for this
a. the size of the lumen. chapter.
b. the length of the needle. ❖ Complete the Quiz for this chapter in Test Mode.
c. the length of the hub.
d. the size of the syringe.
4. A subcutaneous injection is usually given at what
degree for angle of insertion?
THE DVD LINK
a. 10° On your StudyWARE CD-ROM,
b. 15° go to the DVD Challenge for
c. 45° this chapter. View the DVD clip
d. 90° and respond to the following
questions:
5. The two vaccines that are contraindicated for
pregnant women are: 1. Once you load the cartridge into the injector
a. hepatitis B and tetanus. device and lock it into place, what should
b. Varicella and MMR. you do with the medicine in the syringe to
c. PPD and hepatitis B. finalize the preparation of the syringe needle
d. small pox and hepatitis A. unit?

6. The gauge used for an injection is determined by: 2. After administering the injection, what steps
a. the viscosity of the medication. should you take to dispose of the cartridge
b. the site of the injection. unit?
c. the amount of fat the patient has.
d. all of the above.
7. Parenteral routes include all but which of the
following?
a. Intramuscular
b. Intravenous
c. Oral
d. Intra-articular

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