Administration of Parenteral. Medications. Chapter Outline. Essential Terms

Transcription

1 C H A P T E R 34 Administration of Parenteral Medications Chapter Outline Administration of Parenteral Medications Parenteral Equipment and Supplies Preparing Medications General Guidelines for Parenteral Medications Routes of Administration Intradermal Injections Subcutaneous Injections Intramuscular Injections Parenteral Complications Immunizations Contraindications and Precautions in Vaccine Administrations Basics of Intravenous Therapy Equipment and Supplies Employed in Intravenous Therapy Documentation of IV Therapy Risks, Complications, and Adverse Reactions of IV Therapy Discontinuation of Intravenous Infusion Therapy Intra-articular Injections Essential Terms ampule aqueous aspirate bolus cannula cartridge unit cubic centimeter (cc) diluent extravasation gauge hypodermic infiltration intra-articular intradermal intramuscular (IM) Luer-Lok occlusion parenteral patency phlebitis precipitate primary drug secondary drug continues 27187_34_c34_p indd Sec1:835 9/4/08 6:50:28 PM

2 836 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 taut thrombosis trocar vial viscosity wheal Developmental Objectives After completing this chapter, you should be able to: 1. Correctly spell and define the essential terms. 2. List six separate routes used for delivering parenteral medications. 3. List four common parenteral routes by injection and list which ones are routinely performed by the medical assistant. 4. Name and describe the components of a hypodermic needle and syringe. 5. Describe various designs of needle safety devices, and discuss the importance 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 intravenous 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 medications. 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 27187_34_c34_p indd Sec1:836 9/4/08 6:50:33 PM

3 ADMINISTRATION OF PARENTERAL MEDICATIONS 837 safety checks along the way to ensure that the entire procedure is performed with absolute accuracy. Failure to institute safety measures can result in serious consequences for the patient and possible litigation for the office. This chapter will address the many duties associated with parenteral drug administration and provide useful tips that will aid in decreasing patient discomfort and anxiety. ADMINISTRATION OF PARENTERAL MEDICATIONS The term parenteral means pertaining to outside the intestines. When referring to parenteral medication, it means to deliver medication via a route other than through the digestive tract. The most common route used to deliver parenteral medications is through injection; however, other parenteral routes include intravenous (within the vein), transdermal (through the skin), transmucosal (through the mucus membrane), topical (on the skin), and inhalation (through the respiratory tract). This chapter addresses parenteral medications delivered through the injection and intravenous routes; refer to Chapter 32 for all enteral and parenteral routes. Common parenteral routes by injection include intradermal, subcutaneous, intramuscular, and intraarticular. Of those routes, only three are routinely used by the medical assistant: intradermal, subcutaneous, and intramuscular. Some medical assistants are also responsible for administering intravenous medications; however, this will vary according to the state s medical practice act and office policy. Parenteral medications are delivered into the blood stream much more rapidly than oral medications, usually within minutes. The following list provides information regarding the amount of time it takes for a medication to enter the bloodstream through selected parenteral routes: Intravenous: Instantly to seconds Intramuscular: 5 to 15 minutes, depending on the drug Subcutaneous: Several minutes Table 34-1 lists both the advantages and disadvantages of parenteral administration. Parenteral Equipment and Supplies There is a multitude of equipment and supplies available for the delivery of parenteral medications. Syringes and needles come in many sizes and are selected according to the route the medication is to be given, the patient s body size, the viscosity (or thickness) of the medication, and the amount of medication to be given. TABLE 34-1 Advantages and Disadvantages of the Parenteral Route of Administration ADVANTAGES Unsanitary equipment or mishandling of the equip- ment could cause microorganisms to be introduced into the patient. Effective route when other routes would be difficult to use. For example, if the patient is unconscious or unresponsive. Medications administered by injection do not cause irritation to the patient s digestive system, nor are they altered by gastric acids. An exact dose can be administered to a direct site by injection. Effects of the medication take place much more rapidly than the oral route, so a patient that is in excessive pain would receive faster relief from a parenteral pain reliever than an oral pain reliever. DISADVANTAGES An allergic reaction to a parenteral drug may occur more rapidly and may be more severe than an allergic reaction to an oral medication because of how quickly it is absorbed into the bloodstream and the amount that is given in one dose. Improper injection procedures could cause damage to the patient s nerves, tissue, veins, and other vessels. Veins could be traumatized by an intravenous injection _34_c34_p indd Sec1:837 9/4/08 6:50:38 PM

4 838 CHAPTER 34 Syringes Syringes (Figure 34-1) used today are primarily made of plastic and are completely disposable. Typical syringe sizes range from 1 ml to 5 ml. Larger syringes (10 to 60 ml) are used for irrigating wounds or body cavities, drawing large amounts of blood, and for aspirating fluid from a patient s joint or body cavity. Syringe selection is primarily based on the amount of medication to be administered. Syringes are packaged in hard plastic containers or peel-apart packages and are sealed to ensure sterility. 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 explains each component of a syringe. Needles Needles are available in various sizes and lengths and come in disposable and nondisposable forms. Needle selection is determined by the type of medication to be administered, the route of administration, and the size of the patient. Disposable needles are more commonly used and are prepackaged in sterile plastic or paper wrappers. A needle s gauge (G) refers to the diameter of the needle. Gauge selection is determined by the viscosity or thickness of the medication. Gauge sizes that are typically used in ambulatory care range from 20 to 27 G. The larger the gauge, the smaller the diameter of the 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. Flange TOOL BOX FIELD SMARTS In order to prevent the medication from becoming contaminated, you must never touch the inside of the barrel of the syringe, the rubber stopper on the plunger, or the tip of the syringe that connects to the needle. FIGURE 34-2 The parts of a syringe Luer-Lok tip Barrel Rubber stopper Plunger 5 ml syringe separated and together Flange Tip 3 ml syringe separated Rubber stopper Plunger 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 27187_34_c34_p indd Sec1:838 9/4/08 6:50:41 PM

5 ADMINISTRATION OF PARENTERAL MEDICATIONS 839 TABLE 34-2 Description of the Components of a Syringe Barrel Plunger Flange Tip 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. 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 medication out of the barrel. The flared plastic rim on the syringe used for guiding the plunger. 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 34-4 Slip-tip FIGURE 34-5 Luer-Lok tip Table 34-3 provides specific details for selecting the appropriate gauge based on the route and the viscosity of the medication. Note: General guidelines for needle gauges are provided later in the chapter under Routes of Administration and should be used as guidelines for certification and registration testing. The length of the needle is determined by the route of administration, the site of the injection, and the amount of adipose tissue over the injection site. Intramuscular (IM) injections will require a longer needle than a subcutaneous or intradermal injection because muscles are deeper than the other two types of tissue. The location of the injection also plays a role in the selection of needle length. The deltoid and gluteal muscles are two common muscles that are used for intramuscular injections, but each muscle is a different size and at a different depth. The deltoid is smaller and more superficial than the gluteal muscle and, therefore, would take a shorter needle. Finally, the amount of 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 Thicker or oil-based medications IM Hormones, steroids, penicillin, and certain vitamin preparations Aqueous- or water-based medications IM Immunizations and other water-based medications Aqueous-based medications Sub-Q Immunizations, allergy medications, etc 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) 27187_34_c34_p indd Sec1:839 9/4/08 6:50:43 PM

6 840 CHAPTER 34 the injection is being administered will also play a role in the length of the needle that is used. Patients with larger amounts of adipose tissue will require a longer needle to penetrate through the extra layers than patients with little adipose tissue. Table 34-4 provides common needle lengths based upon the route of administration, the location of the injection, and the size of the patient. Note: General guidelines for needle lengths are provided later in the chapter under Routes of Administration and should be used as guidelines for certification and registration testing. Parts of the Needle Even though needles come in disposable and nondisposable forms, they all have similar components. Figure 34-6 shows different needles that are used for various routes and Figure 34-7 shows the different parts of a needle. TOOL BOX FIELD SMARTS Many practices stock a limited variety of needle gauges and lengths. This can be a real problem when the patient does not meet the parameters of what is considered to be average. The smart medical assistant will stock a wide variety of needle gauges and lengths to accommodate patients of all sizes and medications of all viscosities. The parts of a needle include the following: Point: The sharpened end of the needle, cut in a 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 Deltoid: Adult with a well-developed deltoid and a large amount of adipose tissue Gluteal: Adult with very little adipose tissue to Gluteal: Adult with an average amount of adipose tissue Gluteal: Adult with a large amount of adipose tissue Vastus lateralis (thigh): Adult with very little adipose tissue Vastus lateralis (thigh): Adult with an average amount of adipose tissue Vastus lateralis (thigh): Adult with a large amount of adipose tissue 1 2 to 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) _34_c34_p indd Sec1:840 9/4/08 6:50:45 PM

7 ADMINISTRATION OF PARENTERAL MEDICATIONS 841 TOOL BOX CRITICAL THINKING CHALLENGE 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 muscle 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 What needle would work best for this particular medication and patient? Give the reason for your selection. Intramuscular Intracatheters for intravenous use Subcutaneous Intradermal Butterfly needle and tubing for infusions of medications i.v. over a period of time FIGURE 34-6 Different needles used for various routes of administration TOOL BOX CRITICAL THINKING CHALLENGE Mrs. Sims in room 2 is waiting for an ACTH injection. ACTH is a very thick, oily hormone. Mrs. 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 8, 25 G 5 8, 22 G 1, 21 G 1 1 2, and 20 G Which needle would work best under these conditions? List your reasons. Point Plastic sheath Lumen Bevel Point Lumen Shaft Shaft Hilt Hub Lumen: The bore of a hollow 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 bevels, such as a fine tip bevel, which is used for insulin syringe needles. The finer the cut of the bevel, the less pain felt by the patient and the less trauma to the patient s tissue. Shaft: The hollow steel tube of the needle through which the medication passes into the patient Hub: The component that facilitates the attachment of the needle to the syringe; the hub is color-coded for easy recognition of the size and must remain sterile when assembling the needle and syringe. Safety device: A mechanism to shield the needle after use (see Figure 34-8) FIGURE 34-7 The parts of a needle TOOL BOX FIELD SMARTS Even though most injection equipment looks very similar, you should refrain from mixing one manufacturer s equipment with another manufacturer s equipment. There may be slight variations in the equipment s locking mechanisms, preventing the needle from firmly attaching to the syringe. This may cause leakage of medication from the syringe and detachment of the needle during the procedure _34_c34_p indd Sec1:841 9/4/08 6:50:46 PM

8 842 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 incident to a supervisor. An incident report should be completed and the employee should receive counseling regarding what lab testing should be performed and possible treatment options. Refer to Chapter 10 for a review of needle safety guidelines and procedures to follow in the event of a needlestick. Preparing Medications Medications for parenteral administration are stored in a variety of different containers. Medications may be stored in a(n): Ampule (Figure 34-9a): A glass container with a stem that holds a single dose of medication Cartridge unit (Figure 34-9b): A disposable, prefilled, single-dose cartridge of medication that slips into a nondisposable injection device Vial (Figure 34-9c): A glass or plastic container that may contain either a single dose or multiple doses of medication (a) (b) (c) FIGURE 34-9 Various medication containers: (a) ampule; (b) cartridge unit; (c) vial Measuring Medication in a Syringe The type of syringe used will be based on the amount of medication to be administered and sometimes on the type of medication (for example, insulin). Syringe sizes 3 cc and below are normally calibrated using two scales: minims and milliliters (ml). Larger syringes are normally calibrated in ml only. To draw up the correct amount of medication, the medical assistant must be able to properly read the calibrations on the outside 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.) 27187_34_c34_p indd Sec1:842 9/4/08 6:50:49 PM

9 ADMINISTRATION OF PARENTERAL MEDICATIONS 843 syringe are measured in increments of hundredths. Each small line represents 0.01 cc, or of a cubic centimeter. The longer lines are measured in tenths each line represents 0.1 cc, or 1 10 of a cc, and range from 0.1 to 1.0 cc. On a 3-cc syringe, the smaller calibrations are measured in tenths and represent 0.1, or 1 10 of a cc. The larger lines represent increments of 1 2, 1, 1 1 2, 2, 2 1 2, and 3 cc. On a 5-cc syringe, the smaller calibrations are measured on a scale of 0.2, or 2 10 of a cc, with the longer calibration lines representing 1, 2, 3, 4, and 5 cc. Some specialty syringes are measured in units. A unit is the amount of a substance necessary to stimulate a biological effect. The biological effect that one unit of medication has upon body tissue is decided upon by the International Conference for the Unification of Formulas. Unit increments are commonly used for substances such as insulin and particular vitamins and are specific to the individual substance or medication being administered; therefore, insulin syringes 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 even with the calibration line on the outside of the syringe, matching the amount of medication ordered by the physician (Figure 34-10). Withdrawing Medication from a Vial When medication is stored in a vial, it may be in a singledose vial (containing an individual dose of medication) or a multiple-dose vial (containing several doses). The FIGURE Examples of syringes containing specific amounts of medication: (a) 3 ml syringe filled to 1.5 ml; (b) standard U-100 insulin syringe filled with 70 U of U-100 insulin; (c) 1 ml syringe filled to 0.3 ml name and strength of the drug should be checked on the medication label a minimum of three times and verified with the physician s order. Always check the expiration date on the vial as well. This information is usually checked: When removing the medication vial from the shelf Right before preparing the medication Right after preparing the medication A vial is packaged with a sterile cap that protects the rubber stopper. The sterile cap will need to be removed in a manner that prevents the stopper from becoming contaminated prior to removal of the medication. Care must also be taken not to contaminate or damage the vial when preparing the medication. Medication in a vial must be aspirated, or pulled into the syringe through a needle, by pulling back on the plunger of the syringe. To prepare the syringe for use, remove it from the wrapper and assemble the needle. Pull the plunger TOOL BOX FIELD SMARTS Always inspect the rubber stopper of the vial to make certain that the rubber is completely intact. Check the medication in the vial to make sure the there is no precipitate (pieces of solid material or crystals) or unusual cloudiness. If anything unusual does appear, do not use the medication and check with a supervisor to see if it should be discarded. Always check to see how the medication should be stored, both before and after opening. (a) (b) TOOL BOX FIELD SMARTS There is no need to clean the stopper on a medication vial immediately after removing the seal. The stopper is sterile at this point unless you contaminate it when removing the seal. Once the first dose of medication has been removed, the stopper is no longer considered sterile and will need to be cleansed with an alcohol wipe with each subsequent use. (c) 27187_34_c34_p indd Sec1:843 9/4/08 6:50:51 PM

10 844 CHAPTER 34 within the barrel back to the calibration line that matches the amount of medication to be removed. For example, if removing ml of medication from the vial, ml of air must be inserted into the vial before withdrawing the medication. There is an air pressure vacuum inside the vial that makes it easier to pull up the medication. The purpose of forcing air into the vial is to equalize the pressure within the vial after the medication has been removed. If the proper amount of air is not inserted within the 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 to be involuntarily forced out through the stopper and out into the syringe. Once the vial is prepared and the plunger is pulled back to the amount of medication being withdrawn, insert the needle into the vial. With the vial still in an upright position, push the plunger forward to expel the air within the syringe into the vial (Figure 34-11). Pick up the vial and invert it with the needle in it. Make certain that the needle is below the liquid line before pulling back on the plunger (Figure 34-12). TOOL BOX CRITICAL THINKING CHALLENGE When withdrawing medication from a vial, you notice that it is very difficult to pull back on the plunger. 1. What may be the cause of this problem? 2. What can you do to correct the problem? Carefully pull back on the plunger until reaching the desired amount of medication to be withdrawn. Gently pull the needle out of the vial and carefully place the cap on the needle following institutional policy. (Tiny air bubbles in the syringe may need to be removed by gently flicking the syringe prior to withdrawing the needle from the vial.) Procedure 34-1 lists the proper steps for performing this procedure. Withdrawing Medication from an Ampule An ampule is made of sterile glass and contains one single dose of medication premeasured to the exact volume or amount needed. Examples of single-dose medications contained in an ampule include heparin FIGURE Expel an amount of air into the vial that is equal to amount of medication to be withdrawn. FIGURE The needle must be below the liquid line in the vial before withdrawing the medication _34_c34_p indd Sec1:844 9/4/08 6:50:52 PM

11 ADMINISTRATION OF PARENTERAL MEDICATIONS 845 TOOL BOX FIELD SMARTS It is not against OSHA policy to recap a sterile needle. The Needle Stick Safety and Prevention Act is in reference to contaminated needles, not sterile needles. and morphine. The neck of the ampule is constricted and may cause medication to become trapped at the top of the ampule (Figure 34-13). By flicking the ampule with your wrist and hand, any trapped medication in the top will be forced down into the body of 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, meaning 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- paring the medication. The neck of the ampule should be placed in a sharps container. A special needle that contains a small filter within the lumen can be used to remove any glass particles that may have mixed with the medication when the top was snapped from the body of the ampule. A membrane filter (Figure 34-15) may also be attached 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 injecting the patient. Refer to Procedure 34-2 for the proper steps to follow when withdrawing medication from an ampule. FIGURE Cover the neck of the ampule with gauze and snap the neck off away from you. FIGURE Force medication from the neck of the ampule by a quick snap of the wrist. FIGURE Various membrane filters that can be attached to syringes of all sizes, in place of using a standard filter needle 27187_34_c34_p indd Sec1:845 9/4/08 6:50:53 PM

12 846 CHAPTER 34 Reconstituting Medications for Injection Certain medications are packaged in powdered (dry) form and must be reconstituted with a liquid in order to be injected. Powder forms of medication have a longer shelf life than liquid forms. A diluent (liquid) is used to reconstitute the powder. Normally this solution is sterile saline (NaCl), sterile water (H 2 O), or lidocaine. The diluent may be supplied with the medication or may need to be drawn up separately. The medical assistant must always follow the manufacturer s instructions when reconstituting a medication. Once the diluent is removed from its original container, it is injected into the powdered drug vial and gently mixed by rolling the solution between both hands until the all of the powder particles are dissolved. Once the particles are completely dissolved, the medical assistant will draw up the freshly made dilution (medication) following the physician s orders. Procedure 34-3 provides detailed instructions on the steps required for reconstituting powdered drugs. Mixing Two Medications in a Single Syringe When a physician orders two medications, it is sometimes possible to combine the two drugs into one syringe, thus making it possible to give one injection instead of two separate injections. It is most important to check with the physician or pharmacist to clarify if the two medications can be combined. Some medications are not compatible and may cause problems if combined. When combining two medications, the medical assistant must determine which medication is the primary drug and which is the secondary drug. The primary drug is the first drug to be drawn up into the syringe. When administering insulin, the primary drug is the clear insulin and the secondary drug is the cloudier insulin. Always check with the physician when in doubt. Procedure 34-4 lists step-by-step instructions for mixing two medications in a single syringe. Using a Medication Cartridge or an Injector Device Some medications come in sealed, prefilled glass cartridges that hold a single dose of medication. Depo- Provera, penicillin G benzathine, Phenergan, and interferon are examples of medications that are available in cartridges. The prefilled cartridge needle units require no mixing, no special calculations, and are easily administered to the patient. The cartridge needle units are designed to fit into a cartridge unit syringe, referred to as an injector device (Figure 34-16). Injector devices, such as Tubex and Carpuject syringes, are usually nondisposable, made of nonchrome-plated brass or plastic, and are interchangeable with many brands of cartridges. Procedure 34-5 lists steps that are performed when using a cartridge injector device. General Guidelines for Parenteral Medications In most medical facilities, the medication is prepared in a different room than the examination room and transferred to the exam room prior to injecting. Below are guidelines to follow when preparing and administering all types of injections: TOOL BOX FIELD SMARTS 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 pain for the patient. In addition, irritating substances 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, promoting a painful local reaction at the site of the injection. FIGURE A cartridge needle unit and a reusable injector device Plunger rod Rubber collar Plunger Disposable sterile cartridge-needle unit 27187_34_c34_p indd Sec1:846 9/4/08 6:50:55 PM

13 ADMINISTRATION OF PARENTERAL MEDICATIONS 847 Prepare only one order of medication at a time and for one patient at a time. If the patient is to be given multiple injections, prepare each one separately and label syringes or syringe wrappers with a marking pen so that you can identify which syringe holds what medication. Follow standard safety precautions when dealing with needles and syringes. Ensure that contamination does not occur to the equipment during preparation or transport. Never allow another health care worker to prepare a medication that you will administer, nor should you prepare a medication for someone else. The responsibility for a medication error falls on the person who administers the medication. Follow the seven rights (from Chapter 32) when administering all medications. Use two patient identifiers before administering any medications (part of the Patient Safety Act). Check the patient s drug allergy status, latex allergy status, and adhesive allergy status prior to administering any medication. Wash your hands and wear gloves just prior to administering any parenteral medications. The gloves are to protect you against possible bleeding from the site. Never allow a patient to stand while receiving an injection. The patient s blood pressure may drop and the patient may faint. Sites should be free of scar tissue, wounds, lesions, rashes, moles, or any other disturbance in tissue growth. Cleanse all sites with an approved skin antiseptic using a circular motion prior to the injection. Stabilize your hand when holding the needle and syringe. Hand movement may cause the needle to move, nicking a blood vessel or nearby nerve. Follow the same track coming out of a site that you use going in. This will decrease injury to the surrounding tissue. Engage the needle sheath or safety device on the syringe immediately following the injection and dispose of the unit in the sharps container. Patients should wait a minimum of 20 to 30 minutes following the injection to monitor for anaphylaxis. Guidelines for Aspiration When administering intramuscular and subcutaneous injections, the medical assistant should aspirate to make certain that the needle is not in a blood vessel. Depositing drugs directly into the bloodstream that are meant for slower absorption may result in serious complications to the patient. To aspirate, pull back slightly on the plunger and look for blood in the tip of the syringe. If this occurs, the needle syringe unit must be removed and disposed of according to OSHA guidelines. Some drug manufacturers discourage aspiration when administering certain types of medications. Medical assistants should check the drug package insert when in doubt. Table 34-5 lists general guidelines for aspiration. Guidelines for Massaging the Site Following the Injection At the conclusion of subcutaneous and intramuscular injections, gently massage the site with a cotton ball or gauze pad to assist with the disbursement of the medication. Massaging is contraindicated with particular types of medications, especially those that may be irritating to the tissue or those that can stain the skin. Examples of medications in which massage is contraindicated include heparin, imferon, insulin, Fragmin, and Lovenox. Massaging after these injections can damage tissue at the site or cause the medication to be absorbed incorrectly. Massaging is contraindicated when performing all intradermal injections due to the disbursement of the extract into deeper tissue and when administering all Z-track injections. TABLE 34-5 General Guidelines for Aspiration Intradermal Subcutaneous Intramuscular (IM) Do not aspirate on any intradermal injections. General guidelines call for aspiration during subcutaneous injections; however, some medications given through this route discourage aspiration, including Heparin, Lovonox, and insulin. Always check the manufacturer s insert for clarification. General guidelines call for aspiration for IM injections; however, always check the drug package insert for clarification _34_c34_p indd Sec1:847 9/4/08 6:50:58 PM

14 848 CHAPTER 34 Following the Procedure Patients should be monitored for anaphylaxis (lifethreatening allergic reaction) for 20 to 30 minutes following the injection. Most anaphylactic reactions will occur during this time period. Check the patient at the end of the monitoring period to make certain there are 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 experiencing any breathing difficulties or any other unusual symptoms. If the patient experiences anything out of the ordinary, check with the provider before dismissing the patient. Provide the patient with education on how to manage the injection site and what to expect over the next few days. Document the procedure and the follow-up observations in the patient s chart. Refer to Chapter 4 for a complete procedure on documenting medications. Medications such as immunizations and narcotics should also be documented in designated log. Figure shows a hospital medication log. ROUTES OF ADMINISTRATION The route that is selected for parenteral delivery will be primarily based on the manufacturer s recommendation and the intended use of the drug. Routes selected by the manufacturer are based on absorption properties of the drug and possible irritants or dyes in the drug FIGURE An example of a hospital medication log used to document all medications for a specific patient 27187_34_c34_p indd Sec1:848 9/4/08 6:50:59 PM

15 ADMINISTRATION OF PARENTERAL MEDICATIONS 849 TOOL BOX FIELD SMARTS 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 epinephrine should be stocked in any room where injections are administered. FIGURE The needle is inserted at a 10 to 15 angle for an intradermal injection. that may make it harmful to surrounding tissue. Altering any drug routes could cause harmful side effects for the patient, such as tissue abscess and degeneration, tissue staining, and shock. Intradermal Injections The term intradermal means pertaining to within the skin. The epidermis (outer layer of the skin) is the layer of skin that is used for intradermal injections. In order for the needle to stay within this layer, the needle should be positioned at a 10 to 15 angle (Figure 34-18). When the medication is slowly injected at this angle, a bubble of fluid called a wheal (Figure 34-19) should appear on the outer surface of the skin. 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 hair found in these areas and the thinness of the skin. Because of the location of the injection, aspiration is not necessary when performing intradermal injections. Common types of injections administered through this route include allergy extract for testing purposes and the PPD or tuberculin skin test. Intradermal injec- TOOL BOX EMR APPLICATION Many EMR software applications have a Logs section integrated within the software. Medication 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. FIGURE A wheal should appear on the surface of the arm following an intradermal injection _34_c34_p indd Sec1:849 9/4/08 6:51:00 PM

16 850 CHAPTER 34 FIGURE 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 the liquid to be dispersed in deeper tissues, causing the wheal to disappear. Patients receiving intradermal injections will need to have the site evaluated within a prescribed time frame. The provider will measure the site where the wheal was induced. If the wheal extends over a specific parameter, it means that the test is positive. Table 34-6 is a summary chart for key information regarding intradermal injections. Refer to Procedure 34-6 for a complete procedure on administering intradermal injections. Chapter 16 provides additional information on TB skin testing. Subcutaneous Injections The term subcutaneous is a medical term that means pertaining to under the dermis (or true layer of the skin). Subcutaneous tissue is made up of fatty and connective tissue. When administering a subcutaneous injection, the adipose tissue should be slightly pinched between the finger and thumb to help differentiate the adipose tissue from the muscle. The injection is placed in the fatty tissue of the body, not the muscle. In order to reach this tissue, the medical assistant should position the needle at a 45 angle (Figure 34-21); however, a 90 angle may be appropriate for patients with lots of adipose tissue or when using a shorter needle. TABLE 34-6 Intradermal Injection Summary Chart NEEDLE SIZE G, SYRINGE SIZE 1 ml ANGLE OF INSERTION ASPIRATE No COMMON MEDICATIONS OR Allergy extract, TB extract EXTRACTS GIVEN THIS ROUTE MAXIMUM AMOUNT OF ML 0.1 ml PER LOCATION MASSAGE No 27187_34_c34_p indd Sec1:850 9/4/08 6:51:03 PM

17 ADMINISTRATION OF PARENTERAL MEDICATIONS 851 Intramuscular Subcutaneous Intravenous Intradermal 90-degree angle 45-degree angle 25-degree angle 10- to 15- degree angle Epidermis Dermis Subcutaneous tissue Muscle Intramuscular (IM) Subcutaneous (SC) Intravenous (IV) Intradermal (ID) FIGURE Angles for injection into the correct layer of skin or muscle Aspiration is recommended for many medications given subcutaneously, but is contraindicated in a select few. Sites commonly used for this route include the fatty outer portion of the upper arms, the lower abdomen, the middle and lower back, and the thigh region (Figure 34-22). Table 34-7 lists important facts about subcutaneous injections. Refer to Procedure 34-7 for instructions on how to administer subcutaneous injections. Intramuscular Injections The term intramuscular (IM) means within the muscle. Intramuscular injections are given with a longer needle and at a steeper angle of 90. The needle must be long enough to penetrate through the skin and subcutaneous tissues and deep into the muscular tissue; otherwise, the medication will seep into the subcutaneous tissue and may cause a sterile abscess or malabsorption of the medication. FIGURE Common sites for a subcutaneous injection 27187_34_c34_p indd Sec1:851 9/4/08 6:51:04 PM

18 852 CHAPTER 34 TABLE 34-7 Subcutaneous Injection Summary Chart NEEDLE SIZE G, SYRINGE SIZE ANGLE OF INSERTION ASPIRATE COMMON MEDICATIONS OR EXTRACTS GIVEN THIS ROUTE MAXIMUM AMOUNT OF ML PER LOCATION MASSAGE 1 3 ml (use an insulin syringe when giving insulin) 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). Allergy injections, insulin injections, heparin, Lovonox, MMR vaccine, small pox vaccine, IPV vaccine, VAR vaccine 1 ml Yes, except in a select few medications (read manufacturer s instructions) Body areas normally used for intramuscular injection sites are the musculature of the dorsogluteal and ventrogluteal regions, vastus lateralis, and the deltoid. When administering an intramuscular injection, the tissue overlying the muscle should be held taut (a term that means to pull or draw tight) to ascertain that the medicine is deposited into the muscle and not the subcutaneous tissue. Table 34-8 provides facts regarding IM injections. Procedure 34-8 lists specific steps for administering IM injections. Dorsogluteal The dorsogluteal site is used to administer injections in adults and older children. Viscid or thicker medications or medications greater than 1 ml are usually injected into this muscle. Extreme caution is to be used TOOL BOX FIELD SMARTS Ask the patient to relax the muscle when giving an IM injection. The relaxed muscle will help with absorption of the medication and cause less pain for the patient. when administering injections in this area to ensure that damage does not occur to underlying structures, bones, vessels, or nerves. When locating the correct site for this injection, first locate the greater trochanter of the femur. Next, TABLE 34-8 Intramuscular Injection Summary Chart NEEDLE SIZE 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 27187_34_c34_p indd Sec1:852 9/4/08 6:51:04 PM

19 ADMINISTRATION OF PARENTERAL MEDICATIONS 853 TOOL BOX FIELD SMARTS When a physician orders a medication that exceeds the maximum number of ml that the site can hold, inquire about dividing the dose into two even doses and giving it in two different locations. Always check with physician for approval prior to dividing. locate the posterior iliac spine. Draw an imaginary line between these two landmarks. Any place above and outside of the imaginary line (Figure 34-23) is considered acceptable for this site. The danger involved with using this site is the accidental penetration of or damage to the sciatic nerve, the superior gluteal artery or vein, or the iliac crest of the hip. Do not use the dorsogluteal site on infants and use careful consideration with small children and FIGURE 34-23a The dorsogluteal site Iliac crest Gluteus medius muscle Posterior superior iliac spine Gluteus minimus muscle Greater trochanter of femur Sciatic nerve Gluteus maximus muscle Iliotibial tract FIGURE 34-23b The landmark for dorsogluteal injections TOOL BOX FIELD SMARTS To assist with relaxation of the dorsogluteal muscle, place the patient in a prone position with the toes turned inward. emaciated, thin, or elderly patients due to a lack of sufficient muscle tissue. Ventrogluteal The ventrogluteal muscle can accommodate many of the same medications injected into the dorsogluteal muscle and may be used for patients of all ages. The ventrogluteal area is free of major nerves and vessels so it is considered safer than the dorsogluteal site. To locate the ventrogluteal site, the medical assistant should be positioned to face the lateral side of the 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 palm over the greater trochanter of the femur, place the index finger of the left hand on the anterior superior iliac spine, and spread the middle finger posteriorly as far as it will reach along the iliac crest. This should create a V. Within the V is where the injection will be administered (Figure 34-24). Vastus Lateralis The vastus lateralis is part of the quadriceps group of the thigh and is the preferred site for administering injections on infants and young children. This is because it is larger and more developed than any of the other large muscle groups at birth. The vastus lateralis 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 than the dorsogluteal or ventrogluteal sites. To find the correct location of the vastus lateralis in adults, the TOOL BOX FIELD SMARTS 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 _34_c34_p indd Sec1:853 9/4/08 6:51:07 PM

20 854 CHAPTER 34 Gluteus maximus muscle Tubercle of iliac crest Gluteus medius muscle Anterior superior iliac spine Gluteus minimus muscle Tensor fasciae latae muscle Greater trochanter of femur Femoral nerve Anterior superior iliac spine Tensor fasciae latae muscle Femoral artery and vein Sartorius muscle FIGURE 34-24a The ventrogluteal site Vastus lateralis 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 The deltoid is a smaller muscle than the other intramuscular sites, but can be used for thinner, less viscid medications with a limited volume, such as immunizations. No more than 1 ml of medication should be given in this location. The deltoid is not recommended for infants and small children because the muscle is not yet fully developed. The deltoid can be located by placing two fingers on the acromion process and measuring 1 to 2 inches below it (Figure 34-26). The injection should be administered in the most prominent portion of the muscle. FIGURE 34-25b The landmark for vastus lateralis injections TOOL BOX FIELD SMARTS To assist with relaxation of the deltoid muscle, have the patient drop the arm against the side of the body _34_c34_p indd Sec1:854 9/4/08 6:51:07 PM

21 ADMINISTRATION OF PARENTERAL MEDICATIONS 855 FIGURE 34-26a The deltoid site Acromion Clavicle Deltoid muscle Brachial artery and vein Cephalic vein Humerus 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 subcutaneous tissue over the dorsogluteal tissue are displaced 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 side. This hand should not move until the end of the procedure. The needle is inserted and the syringe is aspirated (one-handed technique) to make certain that the needle is not in a blood vessel. Following aspiration, medication is slowly injected into the tissue. Wait 10 seconds before removing the needle to give the 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 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 medication or discoloration of the skin from occurring. Do not massage Z-track injections. Procedure 34-9 provides further details on how to perform this procedure. Common medications given by the Z-track method include iron preparations and medications that are irritating to superficial tissue, such as Vistaril. FIGURE Remove the hand holding the Z-track immediately after withdrawing the needle. FIGURE 34-26b The landmark for deltoid injections TOOL BOX FIELD SMARTS When administering an immunization in the deltoid muscle, use the patient s dominant arm. Increased muscle use will promote better circulation and will help to work out the soreness from the injection much faster. Skin pulled taut Skin released 27187_34_c34_p indd Sec1:855 9/4/08 6:51:09 PM