Medication Administration
Mastering the art of injection and intravenous medication administration is crucial for delivering precise and patient-centered care. This section focuses on key practices, including subcutaneous and intramuscular injections, and the appropriate choice of needles and methods. You’ll gain insights into administering low molecular weight heparin (LMWH) and insulin, using needleless devices, and performing intravenous bolus and volume-controlled infusions.
By the end of this section, you should know about:
- Subcutaneous injection
- Choice of injection and needle method
- Special considerations for low molecular weight heparin (LMWH) and insulin
- Intramuscular Injections
- Needleless Devices
- Intravenous Administration
- Intravenous Bolus
- Volume-Controlled Infusions
- Intermittent Venous Access
- Administration of Intravenous Therapy in the Home
- Safety Guidelines for Nursing Skills
Let’s take a look at them.
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Subcutaneous injection in Medication Administration
Subcutaneous injections involve the delivery of the drug into the weakened connective tissues beneath the skin. The absorption rate of this route of administration is slower compared to intramuscular (IM) injection. And that is because the subcutaneous tissue is less vascular. However, the patient’s circulatory system is usually normal as long as the drug is fully absorbed. Patients experience minimal discomfort with injections due to pain nerves in the skin.
The most recommended areas for subcutaneous injections are the back of the upper arm. The abdomen (from the cervix down to the front of the pelvis). And the anterior region of the thigh The abdomen is particularly susceptible to heparinization. Other sites for subcutaneous injection are the upper back areas of the buttocks. The upper abdominal or posterior gluteal areas. The chosen implant site should be free of skin lesions, bone exposure. And underlying large veins or large vessels to avoid complications.
Choice of injection and needle method
For subcutaneous drug delivery, the size and injection site should be selected based on the anatomy of the patient. A 5/8-inch (16 mm) needle inserted at 45 degrees, or a 3/8-inch (12 mm) needle inserted at 90 degrees, for an adult size the most common and. For obese patients, it may be necessary to stretch the vein and use a long needle to ensure it reaches the subcutaneous layer of the skin. On the other hand, in lean patients, the upper abdomen is often the best site for injection. As adequate skin tissue may be lacking elsewhere
Rotate injection sites within the same anatomic region to ensure consistent absorption during insulin administration. For example, if the patient receives an insulin injection in the right arm, the next injection should be placed at a different site on the same arm, at least 1 inch away from the previous injection site. Avoid using the same site for at least a month to minimize irritation. In addition, it is important to limit the doses administered to the skin, typically 0.5 to 1.5 mL for adults and 0.5 mL for children.
Special considerations for low molecular weight heparin (LMWH) and insulin
For drugs like enoxaparin and low-molecular-weight heparin (LMWH), administer the drug into the abdominal cavity. Ensuring the injection site is at least 2 inches away from the umbilicus. Pinch the skin at the insertion site during administration to create a fold, ensuring proper diffusion of the drug into the subcutaneous tissue. Administer LMWH without removing the air bubble from the prefilled syringe, as doing so may affect the dose. Research has shown a slow injection rate (over 30 seconds). may reduce bruising and pain. Similarly, for insulin injections, shorter needles (4 to 5 mm) are recommended, as they minimize discomfort and improve blood sugar control, especially for patients with a body mass index (BMI) under 25.
Intramuscular Injections in Medication Administration
Due to the high vascularity of intramuscular (IM) sites, IM injections carry a higher risk of complications compared to percutaneous injections. Administer IM therapy with caution, ensuring the site and dosage are appropriate. Larger, deeper muscles, such as the gluteus medius, are often preferred for administering larger doses.The IM needle is usually longer and thicker to reach deeper tissue, and the insertion angle is 90 degrees.
IM injections are commonly used for vaccinations, such as hepatitis B and tetanus, diphtheria, and pertussis (Tdap) vaccines, as well as for other active or irritating vaccines. The volume of vaccine administered should generally not exceed 2 to 5 mL in adults. For children, elderly individuals, and thin patients, use smaller doses to prevent tissue rigidity. Carefully palpate the tissue to avoid injecting into swollen areas, and ensure proper positioning of the patient to minimize discomfort during the injection.
Choosing the Injection Site
When choosing an IM injection site, consider factors such as drug dosage, the presence of underlying veins or arteries, and patient anatomy. The ventrogluteal site is considered safe and preferred for all ages, especially for large or active drugs, due to its deep location and distance from major muscles and blood vessels. To locate the ventrogluteal area, place your hand on the greater trochanter of the hip and use your index and middle fingers to form a V shape, indicating the injection site. This site is recommended for volumes greater than 2 mL.
The vastus lateralis on the anterolateral aspect of the thigh is another IM injection site, commonly used for infants, toddlers, and children due to its well-developed structure and easy accessibility. The deltoid muscle in the upper arm is another commonly used site for vaccines; however, it should only be used for small medication volumes (up to 2 mL). Careful technique is essential to avoid injuring nearby nerves and blood vessels in the area.
Z-Track Method for IM Injections
Use the Z-track method for IM injections to prevent medication irritation and leakage into the subcutaneous tissue. To perform this technique, pull the skin and subcutaneous tissue laterally before inserting the needle into the muscle. The needle remains in place for a few seconds after injection to allow the medication to disperse evenly. This technique effectively seals the medication in the muscle tissue and reduces the likelihood of leakage, improving patient comfort and minimizing local skin irritation.
Medication Administration: Intradermal Injections
Subcutaneous injections are commonly used for skin tests, such as those for tuberculosis (TB) and syphilis. These injections are given into the skin layer with less blood flow, which allows for the slow absorption of the drug. Administering the injection slowly is crucial because the chemicals used in these tests are potent and may cause adverse effects, such as severe anaphylactic reactions, if they enter the bloodstream too quickly. Select sites for intradermal (ID) injections that are light in color, scarless, and free of hair to maintain visibility of skin color and tissue integrity. Assess the area for any noticeable changes. The upper inner and outer arms are often ideal sites for skin testing and examination.
A small hypodermic or degenerative syringe is used to administer ID injections. Insert the needle at a free angle of 5 to 15 degrees, with the bevel vertical. During the injection, a small raised area (bleb) appears that looks like a mosquito bite. If no bleb forms or if there is bleeding at the site after the needle is removed, it indicates that the drug has penetrated beyond the skin rather than remaining within the skin, which could lead to inaccurate test results.
Adverse effects: Undesired or harmful side effects that occur in response to a medication, which may range from mild to severe.
Z-track method: A technique used for administering intramuscular injections to minimize irritation by displacing the skin and tissue before injecting the medication, reducing the risk of leakage.
Anaphylactic reactions: Severe, life-threatening allergic reactions that cause symptoms like difficulty breathing, swelling, and shock, requiring immediate medical intervention.
Needleless Devices in Medication Administration
Approximately 5.6 million healthcare workers in the U.S. are at risk of contracting bloodborne infections. Such as HIV and hepatitis B, due to workplace exposures. Many injuries result from unsafe practices, such as recapping needles or mishandling catheters. To minimize the risk of needlestick injuries, the Needlestick Safety and Prevention Act mandates the use of safety devices in healthcare facilities. These include needle-free systems, safety syringes with protective caps. And proper handling protocols. Such as immediately covering needles with safety caps after use and disposing of them in designated sharps containers.
The safe disposal of knives and other sharp objects is also important. Sharp objects should never be thrown into a regular trash can. Instead, they should be stored in tear-proof and waterproof containers. It is important to avoid recapping needles and to properly plan for safe needle removal. Health care providers should always attend blood-borne infection prevention training. Follow infection prevention recommendations, and ensure that Sharps devices are equipped with safety features.
Intravenous Administration in Medication Administration
Nurses may administer intravenous (IV) medications in several ways: as mixtures in large volumes of IV fluids, as a bolus (small volume of medication). Or as a “piggyback” infusion, which involves the delivery of a medication through an existing IV line. The method of administration depends on the medication, patient needs, and available resources.
For IV administration, it is critical to monitor the patient closely for adverse reactions. As IV medications act quickly in the bloodstream. And once they are administered, their effects cannot be reversed. Nurses should always follow the six rights of medication administration and check medication doses carefully. Especially when potent medications are involved. It is also important to verify the correct rate of infusion and to have antidotes available in case of severe reactions.
Large-volume infusions are the safest method of IV medication administration, as the medication is diluted in a large amount of fluid. Reducing the risk of overdose or severe reactions. Healthcare providers typically mix medications in volumes of 500 to 1000 mL of fluids, such as normal saline or lactated Ringer’s solution. The nurse must carefully monitor the infusion rate to ensure the IV is not administered too quickly. As this could result in medication overdose or fluid overload..
Nurses must never mix medications into IV fluids routinely, except in emergency situations. Current safety practices involve using pre-prepared and standardized IV medications, reducing the risk of errors during medication preparation. Always consult with a pharmacist when mixing medications for IV administration and verify calculations with another nurse.
Infusions: The slow administration of fluids or medications directly into a vein over a period of time, often through an intravenous (IV) line.
Intravenous Bolus
An intravenous bolus involves delivering a concentrated dose of medication directly into the bloodstream. This method is fast and efficient but carries significant risks, such as adverse reactions from administering the medication too quickly. Before administering an IV bolus, confirm placing the IV line is properly. Administering medication through a compromised IV site can result in severe tissue damage. Dilute medications that may cause irritation or adverse effects if given too quickly. And administer them at a slower rate, often using a piggyback infusion for safer delivery.
To calculate the rate of bolus administration, divide the total medication volume by the amount of time prescribed. For example, if you need to administer a 4 mL bolus over 2 minutes, give 2 mL per minute. Nurses should always double-check bolus administration rates and follow recommended guidelines for safe drug delivery.
Volume-Controlled Infusions
Volume-controlled infusions are another method for administering IV medications, using smaller amounts (50-100 mL) of fluid. The benefit of this method is that it reduces the risk of rapid infusion by diluting the medication and administering it over a longer period, typically 30 to 60 minutes. This method is useful for administering medications that are unstable in solution for prolonged periods, such as antibiotics. Volume-control administration also allows the nurse to monitor and control fluid intake more carefully.
Common systems for volume-controlled infusions include volume-control administration sets, piggyback systems, and syringe pumps. In the piggyback setup, you hang a smaller IV bag higher than the primary infusion. Which allows the piggyback medication to infuse first. Once administrating piggyback medication is fully, the primary IV flow resumes.
Intermittent Venous Access
Intermittent venous access (or saline locks) involves an IV catheter capped off at the end. Which allows the patient to receive medication or fluids intermittently without the need for a continuous infusion. This system is particularly beneficial for patients who do not require ongoing fluid therapy. As it saves costs and allows more mobility and comfort for the patient. Nurses must flush the saline lock with normal saline after each use to maintain patency. And some agencies may require the use of heparin for this purpose.
Administration of Intravenous Therapy in the Home
In some cases, patients may need IV therapy at home, such as for antibiotics, chemotherapy, or blood transfusions. Nurses who provide home IV therapy must assess both the patient’s and the family’s ability to manage the treatment and provide education on IV care. This includes teaching how to recognize complications, maintain the catheter, and use infusion pumps. Take necessary safety precautions to prevent complications such as infections. The nurse should provide the patient with clear instructions on recognizing potential issues. And knowing when to contact a healthcare provider if problems arise.
Safety Guidelines for Nursing Skills
Nurses must not delegate medication administration to non-licensed personnel, unless law or policy in specific states or settings explicitly permits it. Nurses must not delegate medication administration to non-licensed personnel. Unless law or policy in specific states or settings explicitly permits it.