Fundamental Fundamental NursingNursing

Chapter 34Chapter 34

Parenteral Parenteral

MedicationsMedicationsInst.: Dr. Ashraf El - JediInst.: Dr. Ashraf El - Jedi

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NeedlesNeedles

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

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Injection Routes

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

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

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Intradermal Injections

Intradermal injections are commonly used for Intradermal injections are commonly used for diagnostic purposes. Examples include diagnostic purposes. Examples include tuberculin tests and allergy testing. Small tuberculin tests and allergy testing. Small volumes, usually 0.01 to 0.05 mL, are injected volumes, usually 0.01 to 0.05 mL, are injected because of the small tissue space.because of the small tissue space.

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Injection Sites

A common site for an intradermal injection is A common site for an intradermal injection is the inner aspect of the forearm. Other areas the inner aspect of the forearm. Other areas that may be used are the back and upper chest.that may be used are the back and upper chest.

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Injection Equipment

A A tuberculin syringetuberculin syringe holds 1 mL of fluid and holds 1 mL of fluid and is calibrated in 0.01-mL increments (is calibrated in 0.01-mL increments (Fig. 34-9Fig. 34-9). It is used to administer intradermal ). It is used to administer intradermal injections. A 25- to 27-gauge needle injections. A 25- to 27-gauge needle measuring a half-inch in length commonly is measuring a half-inch in length commonly is used when administering an intradermal used when administering an intradermal injection.injection.

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Figure 34-9 • A tuberculin syringe.

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Injection Technique

When giving an intradermal injection, the When giving an intradermal injection, the nurse instills the medication shallowly at a 10- nurse instills the medication shallowly at a 10- to 15-degree angle of entry to 15-degree angle of entry

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Subcutaneous Injections

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

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Injection Sites

The preferred site for giving a subcutaneous The preferred site for giving a subcutaneous injection of insulin and heparin is the injection of insulin and heparin is the abdomen.abdomen.

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

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Injection Sites

Rotating within one injection site, preferably Rotating within one injection site, preferably the abdomen, is recommended rather than the abdomen, is recommended rather than rotating to a different area with each injection rotating to a different area with each injection

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

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Injection EquipmentInjection Equipment

Insulin is prepared in an insulin syringe A 25-Insulin is prepared in an insulin syringe A 25-gauge needle is used most often gauge needle is used most often

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Injection Technique

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

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

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

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Intramuscular Injections

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

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Injection Sites

The five common intramuscular injection sites The five common intramuscular injection sites are named for the muscles into which the are named for the muscles into which the medications are injected: dorsogluteal, medications are injected: dorsogluteal, ventrogluteal, vastus lateralis, rectus femoris, ventrogluteal, vastus lateralis, rectus femoris, and deltoid.and deltoid.

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Dorsogluteal SiteDorsogluteal Site

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

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

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Divide the buttock into four imaginary quadrantsDivide the buttock into four imaginary quadrants..

Palpate the posterior iliac spine and the greater Palpate the posterior iliac spine and the greater trochanter.trochanter.

Draw an imaginary diagonal line between the two Draw an imaginary diagonal line between the two landmarks.landmarks.

nsert the needle superiorly and laterally to the nsert the needle superiorly and laterally to the midpoint of the diagonal line.midpoint of the diagonal line.

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Ventrogluteal SiteVentrogluteal Site

The The ventrogluteal siteventrogluteal site uses the gluteus medius uses the gluteus medius and gluteus minimus muscles in the hip for and gluteus minimus muscles in the hip for injection.injection.

This site has several advantages over the This site has several advantages over the dorsogluteal sitedorsogluteal site: : it has no large nerves or it has no large nerves or blood vessels, and it is usually less fatty and blood vessels, and it is usually less fatty and cleaner because fecal contamination is rare at cleaner because fecal contamination is rare at this sitethis site. . The ventrogluteal site is also safe for The ventrogluteal site is also safe for use in childrenuse in children..

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

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

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

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

24Figure 34-14 • Dorsogluteal site.

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Figure 34-15 • Ventrogluteal site.

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Vastus Lateralis Site

The The vastus lateralis sitevastus lateralis site uses the vastus uses the vastus lateralis muscle, one of the muscles in the lateralis muscle, one of the muscles in the quadriceps group of the outer thigh. Large quadriceps group of the outer thigh. Large nerves and blood vessels usually are absent in nerves and blood vessels usually are absent in this area,this area,

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

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Figure 34-16 • Locating the vastus lateralis muscle.

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

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Rectus Femoris SiteRectus Femoris Site

The The rectus femoris siterectus femoris site is in the anterior is in the anterior aspect of the thigh. This site may be used for aspect of the thigh. This site may be used for infants. The nurse places an injection in this infants. The nurse places an injection in this site in the middle third of the thigh, with the site in the middle third of the thigh, with the client sitting or supine (Fig. 34-18).client sitting or supine (Fig. 34-18).

31Figure 34-18 • Location of rectus femoris injection site.

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Deltoid SiteDeltoid Site

The The deltoid sitedeltoid site in the lateral aspect of the in the lateral aspect of the upper arm (Fig. 34-19) is the least-used upper arm (Fig. 34-19) is the least-used intramuscular intramuscular

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

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Figure 34-19 • Deltoid site.

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There is a risk for damaging the radial nerve and There is a risk for damaging the radial nerve and artery if the deltoid site is not well identifiedartery if the deltoid site is not well identified. . To use To use this site safelythis site safely::

Have the client lie down, sit, or stand with the Have the client lie down, sit, or stand with the shoulder well exposed.shoulder well exposed.

Palpate the lower edge of the acromion process.Palpate the lower edge of the acromion process. Draw an imaginary line at the axilla.Draw an imaginary line at the axilla. Inject in the area between these two landmarks.Inject in the area between these two landmarks.

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Injection TechniqueInjection Technique

When administering intramuscular injections, When administering intramuscular injections, nurses use a 90-degree angle for piercing the nurses use a 90-degree angle for piercing the skin (Skill 34-3). skin (Skill 34-3).

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Reducing Injection Reducing Injection DiscomfortDiscomfort

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

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

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Nursing ImplicationsNursing Implications

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