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20| Chapter
Principles of drug administration: injection technique
Figure 20.4 Lifted skin folds – the subcutaneous tissue is lifted away from the muscle and held until the needle has been removed.
Skin
Subcutaneous tissue
Muscle
Correct Incorrect
ing that the full dose has been delivered. Rubbing the injec-tion site may cause bruising and so should be avoided.
In some instances the woman may be taught to self-administer medication by injection; insulin is commonly given in this way, as is low-molecular-weight heparin. Hicks (2012) suggests that many insulin-dependent diabetics have no recollection of being taught a good injection tech-nique, and so it is noted (Hicks et al 2011) that many use an incorrect one. The midwife has a responsibility for anyone who self-medicates with subcutaneous injection both in teaching a correct technique and in assessing that this continues.
INTRADERMAL INJECTION (I.D.)
A small amount of solution (up to 0.5 mL) is injected locally into the skin using a 25 g (orange) needle at a 10–15° angle (Workman 1999) (Fig. 20.3D). The bevel of the needle is inserted upwards so that a small weal forms and is seen on the skin. The commonest sites are the scapu-lae or the inner forearm, but frequently midwives inject intradermally prior to cannulation (Chapter 47) and there-fore inject over the site of the vein to be cannulated. Local anaesthetic is also injected intradermally when iniltrating for perineal repair (Chapter 34).
PROCEDURE: I.M. and S.C. injections in the adult
•
Undertake the thorough checking procedures as for any medication administration (see Chapter 18).•
Decontaminate hands, put on non-sterile gloves and clean a plastic tray with the locally approved tissue) is not considered necessary for an S.C. injection(Nicol et al 2004).
Speed of delivery
As before, all injections are more comfortable if injected slowly. Ogston-Tuck (2014b) recommends Enoxaparin should be injected over 30 seconds, the literature does not appear to cite a time scale for other S.C. injections but sug-gests ‘slowly’ (Ansell & Dougherty 2011). Slow delivery of the medication aids comfort and reduces bruising.
Speciic considerations for Enoxaparin (EMC 2014)
Enoxaparin sodium (POM) is available in dose related pre-prepared syringes. In pregnancy the dose is adjusted accord-ing to body weight. It is generally administered once a day.
It is administered by the midwife or the woman, with decontaminated hands, using an S.C. technique. The needle is inserted at 90° with the lifted skin folds technique (see above and Fig. 20.3B). Only when the injection is complete should the skin fold be released. It should be administered into the abdomen, for which site rotation is necessary for long-term use. That advocated by Gelder (2014) is with diabetes in mind but is eminently sensible. The site is rotated, e.g. right or left, and within that area the site moves by at least 1 cm each day. Gelder (2014) shows this as cir-cular pattern similar to a snail shell. The woman should be lying down. The abdomen remains a safe site during preg-nancy and postnatally.
The safety device itted to the needle is activated auto-matically when the plunger is depressed far enough. The air bubble remains in the syringe as a mechanism of
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20| Chapter
Principles of drug administration: injection technique
remove the needle and release the skin folds. Apply gentle pressure with cotton wool or gauze, activate the needle defence system, put the used sharps straight into the sharps box.
•
For I.M. injection: using the landmarks for the chosen injection site (ventrogluteal recommended), identify the speciic site for puncture. Remove hands (to prevent needle stick injury) but retain the site of entry in the ‘mind’s eye’. Using the non-dominant hand gently stretch the skin/subcutaneous tissue 2–3 cm sideways or downwards, then decisively inject at a 90° angle, holding the syringe like a dart and inserting the needle with approximately 1 cm of it still visible. Push on the plunger smoothly at a rate of 10 seconds/mL to inject the solution. Wait 10 seconds, remove the needle and release the skin at the same time. Press gently on the puncture site with the gauze or cotton wool; avoid massage which may cause irritation. Activate the needle defence system and place the used sharps straight into the sharps bin•
Assist the woman to a comfortable position, decontaminate hands.•
Dispose of remaining equipment correctly.•
Document administration and act accordingly;examine the site 2 hours later for any possible reactions.
alcohol wipes. Remove gloves and wash and dry hands.
•
Gather equipment:■ 1 sterile ilter needle, 1 sterile needle with protection system, assessed to be the correct size for the type of injection and size of the client (see above)
■ 1 sterile syringe (an appropriate size, in date, undamaged and conirmed to be sterile)
■ portable sharps box
■ approved skin cleanser, often 70% alcohol wipe
■ cotton wool or gauze
■ ampoule (already checked thoroughly)
■ medicine administration chart.
•
Open the plunger end of the syringe packaging,‘prepare’ the syringe ensuring that the plunger moves within the barrel. Connect the ilter needle irmly, using a non-touch technique (Key-Parts are the syringe tip and needle hub). Place connected syringe and needle onto the tray. Drop the other needle from its packaging onto the tray also (with protection system if separate).
•
For a glass ampoule ensure all of the solution is in the ampoule (not retained in the top), snap off the top (protect ingers). For a plastic ampoule, snap off the top.•
Unsheath the needle and draw up the required amount of solution using a non touch technique (Key-Parts are the solution and the needle), remove the ampoule.•
Invert the syringe and examine it for air. If necessary tap it gently to encourage the air up to the top of the syringe; push the plunger to exclude the air from the syringe, ensuring none of the solution is lost and the dosage in the syringe is correct.•
Remove the needle, discard it into the sharps box, replace with the protected needle using a non touch technique, place onto the tray. Take the medicine administration chart, sharps box and tray to the woman, include the skin cleanser if required, cotton wool or gauze.•
Conirm her identity by asking her to state her name and date of birth, ensure privacy and expose the injection site, positioning the woman accordingly, (often left lateral for I.M. right ventrogluteal muscle).•
Decontaminate hands, if local policy suggests: clean the injection site (Key-Site) for 30 seconds, up and down, side to side, creating friction. Leave to dry for at least 30 seconds.•
For S.C. injection: identify the site, lift the skin folds (away from the muscle, Fig. 20.4) with the non-injecting hand, decisively inject at a 90° angle, continuing to hold the folds. Inject slowly until the injection is complete. Wait for 10 seconds thenROLE AND RESPONSIBILITIES OF THE MIDWIFE These can be summarized as:
• correct use of equipment and choice of site to facilitate a safe and comfortable injection technique
• knowledge and application of evidence based best practice
• education and support of the woman, particularly if anxious
• correct disposal of sharps
• correct contemporaneous record keeping.
SUMMARY
•
Injections require the midwife to choose an appropriate length of needle and correct angle of insertion to ensure that the medication is placed into the correct tissue.•
A number of factors determine which site is chosen, the ventrogluteal site is the one of choice for I.M.injections.
•
Whether the skin is cleansed or not prior to injection remains an unanswered question.•
Care is taken to avoid needlestick injury by using needle defence systems and sharps boxes at the point of care, and not resheathing needles.•
Aspiration is not necessary for S.C. injections, Malkin (2008) suggest that it is not necessary for I.M. either unless using the gluteus maximus site.SELF-ASSESSMENT EXERCISES
The answers to the following questions may be found in the text:
1. Cite examples of when injections may be necessary for a childbearing woman.
2. List the sites suitable for I.M. injection for both the woman and the baby.
3. List the considerations necessary for the safe administration of S.C. Enoxaparin.
4. Demonstrate an I.M. injection for a baby.
5. Compare and contrast the similarities and differences between an I.M. and a S.C. injection in the adult, in relation to the equipment, technique and site.
6. Describe how a Z-track injection is completed.
7. Summarize the role and responsibilities of the midwife when administering an injection.
REFERENCES
Anon., 2007. Intramuscular injection technique. Paediatr. Nurs. 19 (2), 37.
Ansell, L., Dougherty, L., 2011. Medicines management. In: Doughty, L., Lister, S. (Eds.), The Royal Marsden Hospital Manual of Clinical Nursing Procedures, eighth ed. Wiley Blackwell, Chichester, pp. 956–961.
(Chapter 16).
Diggle, J., 2014. How to help patients achieve correct self-injection technique. Pract. Nurs. 25 (9), 451–454.
EMC (electronic medicines compendium), 2014. Clexane.
Available online: <www.medicines .org.uk/emc/medicine/24345/SPC/
Clexane+pre-illed+syringes/>
(accessed 29 January 2015).
Gelder, C., 2014. Best practice injection technique for children and young people with diabetes.
Nurs. Child. Young People 26 (7), 32–36.
Hall, A., 2015. Administering medications. In: Potter, P.A., Perry, A.G., Stockert, P.A., Hall, A. (Eds.), Essentials for Nursing Practice, eighth ed. Elsevier, St. Louis, pp. 377–462.
(Chapter 17).
Hemsworth, S., 2000. Intramuscular injection technique. Paediatr. Nurs.
12 (9), 17–20.
Hicks, D., 2012. Diabetes focus: teaching injection technique will improve quality of life. Nurs. Times 108 (10), 16.
Hicks, D., Kirkland, F., Pledger, J., et al., 2011. Helping people with diabetes to manage their injectable therapies. Primary Health Care 21 (1), 28–31.
Hunter, J., 2008. Intramuscular injection techniques. Nurs. Stand. 22 (24), 35–40.
Jamieson, E.M., McCall, J.M., Blythe, R., et al., 1997. Clinical Nursing Practices, third ed. Churchill Livingstone, Edinburgh.
Jordan, S., 2010. Administration of medicines. In: Jordan, S. (Ed.), Pharmacology for Midwives, second ed. Palgrave Macmillan, Basingstoke, pp. 42–44. (Chapter 2).
Malkin, B., 2008. Intramuscular injection technique: an evidence-based approach. Nurs. Times 104 (50/51), 48–51.
Nicol, M., Bavin, C., Bedford-Turner, S., et al., 2004. Essential Nursing Skills, second ed. Mosby, Edinburgh, p. 130.
Ogston-Tuck, S., 2014a. Intramuscular injection technique: an evidence based approach. Nurs. Stand. 29 (4), 52–59.
Ogston-Tuck, S., 2014b. Subcutaneous injection technique: an evidence based approach. Nurs. Stand. 29 (3), 53–58.
Peragallo-Dittko, V., 1997. Rethinking subcutaneous injection technique.
Am. J. Nurs. 97 (5), 71–72.
PHE (Public Health England), 2013.
Immunisation procedures: the green book, Chapter 4. In: Part of Immunisation Against Infectious Disease. PHE, London. Available online: <www.gov.uk> (accessed 29 January 2015).
Rodger, M., King, L., 2000. Drawing up and administering intramuscular injections: a review of the literature.
J. Adv. Nurs. 31 (3), 574–582.
Rowley, S., Clare, S., 2011. ANTT: a standard approach to aseptic technique. Nurs. Times 107 (36), 12–14.
WHO (World Health Organisation), 2010. WHO Best Practices for Injections and Related Procedures Toolkit. WHO, Geneva, p. 6.
Workman, B., 1999. Safe injection techniques. Nurs. Stand. 13 (39), 47–53.
Zaybak, A., Yapucu, U., Tamsel, S., et al., 2007. Does obesity prevent the needle from reaching muscle in
intramuscular injections? J. Adv. Nurs.
58 (6), 552–556.
Principles of drug administration: administration of medicines per vaginam
Chapter
infections, contraceptive use or systemic use, e.g. prostag-landins. This chapter considers the midwife’s role and responsibilities and the procedure for administration P.V., focusing largely on the administration of prostaglandin E2
(PGE2). This chapter should be read in conjunction with Chapters 18, 29, and 30.