Administer Intra-muscular, Subcutaneous and Intra-dermal Injections
TERMINAL LEARNING OBJECTIVE
Give the necessary medical equipment in a holding or ward setting. You are providing casualty care as part of an integrated team in a Minimal Care Ward. Performed basic nursing care for casualty without causing further injury or illness.
INTRODUCTION
As a soldier medic, you will be required to administer injections. Thorough knowledge of this skill is necessary for administering various medications and immunizations as well as sensitivity tests. The information you will receive today, together with the practical exercise will prepare you for this task.
Purpose
(1) Utilized when rapid absorption/rate of onset (10-20 minutes) and long duration (hours to weeks) are desired
(2) Used when administering viscous or irritating medications
(3) Used when a large volume of medication is needed for a stronger effect
WARNING: Absorption of medications administered by the intramuscular route relies on adequate blood flow to the muscles, IM injections should not be used in individuals with poor circulation or symptoms of shock.
Needle characteristics
(1) Not less than one inch for an adult. You may use a smaller size if the patient is thin
(2) May need up to a 2 inch needle for obese patients
CAUTION: Selection of a needle long enough to reach the muscle is essential. Using a needle, which is too short, will cause the medication to be injected into subcutaneous tissue, potentially reducing absorption and effectiveness.
(3) Gauge (diameter) range, 20-22
Primary IM injection sites
(1) Deltoid muscle
(a) Used for medication volumes up to 2 ml. in an adult
(b) Faster absorption than other IM sites
(c) Muscle is located in the outer one-third of arm between the shoulder bone (acromion process) and axilla
(d) Injection site is approximately three finger-widths below the shoulder bone, in the middle of the deltoid muscle mass
(2) Gluteus maximus
(a) Used for larger medication volumes, up to 5 ml.
(b) May require a long needle (two inches or longer in large adults)
(c) Located by dividing one buttock into four imaginary quadrants - injection area is in upper, outer quadrant
CAUTION: An injection given in an area outside this site could cause damage to the sciatic nerve or puncture the superior gluteal artery, causing either paralysis or severe bleeding. Use extreme care when identifying the gluteal site!
(3) Vastus lateralis
(a) One of the safest sites due to absence of major nerves and blood vessels
(b) May be more painful due to number of small nerve endings
(c) Medication volume up to 5 ml. in adults
(d) Muscle mass is on lateral thigh
(e) Injection site extends from the middle of the anterior thigh to the middle of the lateral thigh, and from one hand's width below the hip joint to one hand's width above the knee
NOTE: Length and gauge selected will vary depending on the amount of muscle mass, age, size, and condition of patient
Purpose, Needle Characteristics, and Site for Subcutaneous (SQ) Injections
(1) Utilized when absorption rate desired is slower than IM route. Absorption rate for SQ injection is 15-30 minutes. Duration is comparable to IM route - hours to weeks.
(2) Used for small amounts of watery and nonirritating medications
(1) Length ½" to 1"
(2) Gauge (diameter) range, 23 to 25
(3) Selection of needle length and gauge will vary depending on the amount of subcutaneous tissue, age, size, and condition of patient.
(1) Upper arm
(a) Rear lateral aspect
(b) Injection area is approximately one-hand width down from the shoulder and one-third of the way around laterally.
(c) Medication volume - not to exceed 0.5 ml
(2) Vastus lateralis
(a) Injection site extends from the middle of the anterior thigh to the middle of the lateral thigh, and from one hand's width below the hip joint to one hand's width above the knee.
(b) Medication volume - not to exceed 2 ml
(3) Abdomen
(a) Medications such as insulin and heparin are administered in the subcutaneous tissue of the abdomen.
(b) The amount of medication given will vary according to the needs of the patient
(c) A physician will prescribe the dosage to be given in the abdomen
(1) Identify the patient
(2) Verify the required injection(s)
(a) Check the physician's order
(b) Review the patient's medical record to identify allergies and previous reactions to medications
(c) If immunizations are to be given, carefully screen the immunization record (SF 601), located inside the medical record) and/or international shot record (PHS 731), for dates of previous immunizations/boosters.
(3) Verify compatibility of medications if multiple injections are ordered
(4) Ensure emergency equipment and personnel are available
WARNING: Have an emergency tray available for the immediate treatment of serious reactions. Include a constricting band and syringe containing a 1:1000 solution of epinephrine.
(5) Wash hands
(6) Identify route of delivery and select the injection site
(a) Route of delivery for medication will be indicated in the order and/or the medication container
(b) Be sure to select the appropriate site for the medication ordered to assure rate of onset and duration are as intended by the provider
(7) Gather equipment (appropriate size needle, syringe, and type of medication) and prepare medication
(8) Don gloves
(9) Position patient with selected injection site exposed
CAUTION: All injection sites must be completely exposed prior to injection. Clothing which prevents access to injection site for visualization, cleaning, and administration of injection will be removed, and patient privacy assured by using a sheet, towel, or pad to cover exposed areas/or using privacy screens.
(a) Upper arm - standing or sitting with arm at side, muscles relaxed and area completely exposed
(b) Gluteus maximus - lying face down or leaning forward and supported by a stable object with the weight shifted to the leg that will not be injected. The area is completely exposed
(c) Vastus lateralis - lying supine or seated. Injection area completely exposed
CAUTION: It is permissible to use a standing position for injections. However, some patients even young, healthy soldiers may experience a vasovagal response to an injection and become dizzy or lose consciousness. The seated or lying positions are therefore preferable.
(10) Cleanse the injection site with an alcohol prep pad, beginning in the center of the site and with a circular motion, clean outward approximately 3 inches
(11) Place alcohol prep pad between ring and little finger of non-dominant hand for use after the injection
(1) Pull needle cover/cap straight off and dispose of it in a waste receptacle
(2) Isolate the injection site
(a) IM Injections - grasp the muscle mass with thumb and fingers of the non-dominant hand and hold it firmly in place.
(b) SQ injections - gently pinch the skin with the thumb and fingers of the non-dominant hand and hold it firmly in place.
(3) Hold syringe in the dominant hand between the thumb and index finger, and position the needle bevel up and about ½ inch from the skin surface
(4) Inject medication
(a) IM injections - hold syringe at a 90-degree angle to the site and plunge the needle straight into the muscle to the depth of the needle. Hand position will be similar to holding a dart
(b) SQ injections - hold syringe at a 45-degree angle. Hand position will be similar to holding a pool cue
(5) Release hold on the skin with the non-dominant hand
WARNING: Failure to aspirate may cause the medication to be injected directly into the bloodstream.
(6) Aspirate by pulling back slightly on the plunger of the syringe
(a) If blood appears, stop the procedure. Dispose of the needle and syringe in a sharps container, prepare a new set, select a different injection site, and begin again
(b) If no blood appears, continue the procedure
(7) Using a slow, continuous movement, completely depress the plunger, injecting the medication
(8) Place either an alcohol pad or sterile gauze pad lightly over the injection site and withdraw the needle at the same angle in which it was inserted
(9) Gently massage the site, unless this is contraindicated for the type of medication that has been injected. Place an adhesive bandage over the injection site
(10) DO NOT RECAP THE NEEDLE; drop the used needle and syringe into the sharps container
(11) Record the administration of the injection on the appropriate documents
(12) Either have the patient wait for at least 20 minutes or IAW local SOP and monitor for adverse reactions
Intra-dermal (ID) Injections
(1) Testing sensitivity (allergy testing) to environmental allergens, medications
(2) Testing for exposure to diseases (e.g., tuberculosis, mumps)
(3) Evaluation of the immune system (e.g., AIDS and cancer patients)
(1) Needle
(a) Needle length - ¼" to ½"
(b) Gauge diameter range - 25 to 27
(2) Tuberculin or other 1.0 ml syringe
(1) Free of hair, tattoos and scars
(2) NOT over a vein or bony area
(3) Inner forearm - inner, flat portion (Primary injection site for ID)
NOTE: This is the preferred site for tuberculin testing and most other ID injections routinely given by the soldier medic.
(4) Back of upper arm
(5) On the back below the shoulder blades
(1) Preparation
(a) Identify patient
(b) Verify injection
(c) Verify compatibility of medications if multiple injections are ordered
(d) Assure availability of emergency equipment and personnel
(e) Wash hands
(f) Select injection site
(g) Gather equipment and prepare medication
(h) Don gloves
(i) Clean the area with an alcohol prep pad or acetone in a spiral motion, clean outward 3 inches
(j) Position patient with injection site exposed
(i) Inner forearm - standing, sitting, or supine. Palm up with the arm relaxed and supported
(ii) Back of upper arm - standing or sitting
(iii) On the back - prone or seated and leaning forward with body supported by a stable object
(k) Pull needle cover/cap straight off and dispose of it in a waste receptacle
(l) Using the thumb of the non-dominant hand, pull the skin below the injection site downward and hold it taut
(2) Administration
(a) Position the syringe with the needle bevel up, at a 15-20 degree angle to the skin surface
(b) Insert the needle just until the bevel is under the skin surface
(c) Gently release the skin tension held by the non-dominant hand
(d) Do not aspirate. Push the plunger slowly forward until all medication has been injected and a wheal (a round or elongated elevation of the skin caused by the injection of fluid under the dermis) appears at the site of the injection.
(e) The appearance of a wheal indicates that the medication has entered the area between the intra-dermal tissues.
(i) If a wheal does not appear, withdraw the needle completely from the arm at the angle of insertion, dispose of the needle and syringe in a sharps container, prepare a new set, and repeat the procedure in another site.
(ii) If a wheal does appear, continue the procedure
(f) Quickly withdraw the needle at the same angle that it was inserted
(g) Without applying pressure to the skin surface, cover the injection site with dry sterile gauze
(h) Instruct the patient not to scratch, rub, or wash the injection site
(i) If appropriate, instruct the patient when and where to have the test read IAW local SOP
(j) Discard the needle and syringe into the sharps container without recapping needle
(k) Check the site for bleeding and observe the patient for allergic reactions
(l) Record the procedure on the appropriate form
CAUTION: If this injection was given to determine sensitivity (PPD), follow local SOP for patient care and instructions for reading of the results in 48-72 hours.
SUMMARY
Although the process for administering injections is simple, you must follow the correct procedural steps. Failure to follow the steps may result in the compromising of aseptic technique, improper administration of the medication/immunization, and injury to the patient.