1. Subcutaneous Injections NURS128 Instructor: Marilyn Gilbert Winter: 2006 Thank you to Sherrie Bade and Susan Ross and Laura Ford

2. Routes of Medication Administration • Parenteral medication: administration of a medication by injection into body tissues • Subcutaneous (SC) – into tissue below dermis of skin • Intramuscular (IM) – into the body muscle • Intravenous (IV) – into a vein • Intradermal (ID)– into the dermis just under the epidermis • Can you give examples of above?

4. Syringes • Three main parts: • Barrel – chamber that holds the medication • Plunger – part within the barrel that moves back and forth to withdraw and instill medication • Tip – part that the needle is attached to • Calibration: • Syringe sizes from 1 ml to 50 ml • Measure to a 1/10th or 1/100th depending on calibration

6. Needles • Shaft of the needle • Length 3/8th of an inch – 1 ½ inches • Length chosen depends on the depth to which medication will be instilled • Tip of shaft is beveled or slanted to pierce the skin more easily • Gauge: width of the needle (18 – 27 gauge) – a smaller number indicates a larger diameter and larger lumen inside the needle

7. Considerations when choosing a syringe and needle • Type of medication • Depth of tissue penetration required • Volume of medication • Viscosity of medication • Size of the client

9. Asepsis: Sterile technique • Sterile technique: method of creating and maintaining an area free of all pathogens (microorganisms; spores) • Used for all parenteral injections including subcutaneous injections • The primary purpose of asepsis for injections is to prevent infection

10. Asepsis related to the syringe and needle • Follow principles to keep needle and syringe parts sterile: • Shaft of the needle • Inside the hub of the needle • Tip of the syringe • Inside the barrel of the syringe • The part of the plunger entering the barrel of the syringe

11. Asepsis of Medication Containers • Vials: have a rubber stopper are glass or plastic - single and multidose • Must be cleansed with alcohol prior to inserting needle through it • Self sealing when needle withdrawn • Date outside of container when first used • Ampoules: glass and plastic – narrow neck that is broken – single dose • Neck cleansed with alcohol and broken away from you • Needle inserted only into opening into ampoule

14. Assessments prior to administration of subcutaneous injection • Use Clinical Decision Making (CDM) process: • Assessment – collect data (follow with analysis & synthesis of data). • Planning – what actions to take? • Implementation – carry out actions/ interventions. • Evaluation – did the interventions work?

15. Pharmacokinetics • The study of how drugs: • Enter the body- absorption • Reach their site of action-distribution • Are metabolized-metabolism • Exit the body-excretion • Pharmacokinetics necessary influences: • Choice of medications for a specific client • Timing of drug administration • Selection of route for administration

16. Dosage Calculations • Dose Ordered X Unit/Volume = Amount • Dose Available (ml, tab, cap) to give • D/A X unit= dose to give

18. The 7 Rights of Drug Administration • Right client • Right medication • Right dose • Right route • Right time • Right reason • Right documentation

19. Administration of Medication • Wash hands • Compare MAR with order or note RN initials present indicating order checked • Three checks of client name, allergies, date and time and medication • Calculate correct dose • PREPARE MEDICATION • Confirm right client by checking name band, asking to state name or alternatives depending on agency • Document on MAR [document on chart if needed]

20. Preparing Medication: Withdrawing from an Ampoule • Tap top of ampoule to move liquid down • Place alcohol pad around neck of ampoule • Snap neck of ampoule away from you • Insert needle into opening – may hold upside down or on a flat service but keep needle tip under liquid • Remove needle – tap syringe remove air bubbles – establish dosage – may have to discard some med in sink • Put cap back on needle ( only cap a needle that has not been used) NEVER RECAP A USED NEEDLE

21. Preparing Medication: Withdrawing from a Vial • Select appropriate syringe and needle • Remove cover from rubber stopper • Clean a pre-opened vial by swabbing it firmly with an alcohol swab - circular motion from inside to outside • Fill syringe with volume of air equal to volume to be withdrawn from vial • Insert needle – invert vial and hold/brace it while pulling on end of plunger • Tap barrel to remove air • Push on plunger to move medication to tip of needle • Replace cap

22. Insulin • A hormone – regulates glucose metabolism - only given parenterally (SC, IV) • Prescribed in units – insulin syringe calibrated in units (100 u/ml) 100 units = 1ml or 100units=1cc • Two sizes of syringes • 0.5 ml = 50 units • 1.0 ml = 100 units • Clients generally require one or more injections daily • Blood glucose monitoring (BGM) – A ‘normal’ range is 4 - 7

23. Insulins: • Rapid-acting: • Humalog: Onset – 5 minutes, Peak – 1 hour, Duration – 2-4 hours • Regular (Humulin R – clear): Onset – 1 hour, Peak – 2-4 hours, Duration – 5-7 hours - Regular insulin is CLEAR • Intermediate-acting: • NPH (Humulin N – cloudy): Onset – 1 – 2.5 hours, Peak – 6-12 hours, Duration – 18-24 hours

24. Insulins: • Long-acting Insulin (cloudy): • Ultralente: Onset – 4-8 hours, Peak – 12-20 hours, Duration – 24-48 hours • Mixed Insulins: • 30/70 most usual one • 20/80 • 50/50 Onset – 30-60 minutes then 1-2 hours, Peak – 2-4 hours then 6-12 hours, Duration – 6-8 hours then 18-24 hours

25. Mixing Insulins • Roll cloudy vial to mix • Cleanse rubber stoppers of both vials of insulin • Instill an amount of air equal to the volume that will be withdrawn from the cloudy vial • Repeat with clear insulin and withdraw required amount • Pierce cloudy vial – withdraw required units • Always CLEAR before CLOUDY

26. To Ensure Safe Drug Administration • Focus: Don’t carry on a conversation • Always Check physician orders for insulin in patient`s chart • If uncertain ALWAYS check PRIOR to administration of a drug • Check for client allergies • Keep medications within your sight at all times • Withhold a medication if client demonstrating an undesirable reaction – Report and Record this • Record drug administration as soon as possible after medication administration • If an error is made, record it IMMEDIATELY so measures may be taken to minimize effects of the error – an agency incident report and TRU incident report filled out

27. Injection technique for SC • Locate site for injection • Cleanse with an alcohol swab cleaning from center outward in a circular motion – 5 cm (2 in) circle • Clean gloves • Pinch up skin or spread taut depending on site and size of client • Dart needle quickly and firmly into tissue at either a 45° or 90° angle – stabilize by resting hand doing injection on skin surface • Inject medication • Withdraw needle quickly and immediately into sharps container – DO NOT RECAP

29. Administration of controlled substances i.e. narcotics • All narcotics in locked cabinet – RN carries keys • When narcotic taken from cabinet documentation on ledger of: • Client’s name and Dr.’s name • Time taken from cabinet • The count of drug remaining • Signature of nurse administering – cosign for wastage • At change of shift oncoming and nurse completing shift do a count of all controlled substances in locked cabinet • Any drug discrepancies are reported immediately

30. Common Medication Errors • Errors in mathematical calculation of doses – check decimal point • Incorrect reading of labels on medications • Lack of knowledge about med administered • Failure to properly identify client before administering med or failure to listen to client – double check when a client raises questions about a medication • Administration of medications without critically thinking ( CT)