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CLINICAL GUIDELINES Intramuscular and sub-cutaneous injections guideline Reference Date approved September 2012 Matron’s Forum Approving Body

CLINICAL GUIDELINES

Intramuscular and sub-cutaneous injections guideline

Reference

 

Date approved

 
 

September 2012 Matron’s Forum

Approving Body Supporting Policy/ Working in

NUH Medicines Code of Practice –

New Ways (WINW) Package

Administration of Medicines 2011

Implementation date

 
 

October 2007 Version

Supersedes Consultation undertaken

Nursing Practice Guidelines Group, Ward Sisters/Charge Nurses, Practice Development Matrons (PDMs), Clinical Leads, Matrons.

Target audience

Registered Clinical staff

Document derivation / evidence base:

 

Review Date

September 2015

Lead Executive

 
 

Director of Nursing Kate Belfield – Sister – Winifred 2

Author/Lead Manager Further Guidance/Information

 

Distribution:

Ward Sisters/Charge Nurses, PDMs, Clinical Leads, Matrons, Nursing Practice Guidelines Group (includes University of Nottingham representative), Clinical Quality, Risk and Safety Manager, Trust Intranet.

Add any extra groups/organisations to whom guideline has been circulated

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using the guidelines after the review date.

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CONTENTS Intramuscular and sub-cutaneous injections guideline INTRODUCTION 3 EQUIPMENT LIST 4 PREPARING THE INJECTION 4 SUBCUTANEOUS
 

CONTENTS Intramuscular and sub-cutaneous injections guideline

 

INTRODUCTION

3

 

EQUIPMENT LIST

4

 

PREPARING THE INJECTION

4

 

SUBCUTANEOUS INJECTIONS

7

 

INTRAMUSCULAR INJECTIONS

9

 

REFERENCES

13

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Nottingham University Hospitals NHS Trust

CLINICAL GUIDELINES

Administration of Intramuscular and Subcutaneous Injections

INTRODUCTION

The NUH Medicines Code of Practice –Administration of Medicines 2011 and the Nursing and Midwifery Council Standards For Medicines Management (NMC 2007) must be adhered to at all times.

Only medications for one individual patient should be drawn up at any one time.

Severe drug reactions can occasionally occur; the patient must be carefully observed during administration of the medicine.

Intramuscular and subcutaneous injections are frequently referred to as a “basic skill” but involve a complex series of considerations and decisions relating to:

Volume of injection Medication to be given Technique Site selection Equipment

Other considerations are patients’ age, physical build, pre-existing conditions such as bleeding disorders and the environment where the injection is given. (Plotkin et al, 2008)

For administration of insulin, please refer also to the NUH Diabetes Package – Guideline, 2011

Poor practices can create adverse risks for patients and health care workers (National Patient Safety Agency, 2007). Adverse events for patients include:

Haemorrhage in those with bleeding disorders Pain Sciatic nerve injury Injection fibrosis Infection

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Best Practice Concentrated or irritating solutions may cause sterile abscesses to form. Repeated injections in the same site can cause lipodystrophy which can be minimised by rotating injection sites. (Lippincott Williams & Wilkins, 2008)

EQUIPMENT LIST

Appropriate sized syringe and needle (see page 7) Non sterile receiver Sharps bin Non sterile gloves Gauze Prescription chart

PRINCIPLES OF CARE

See General Principles for All Procedures.

PREPARING THE INJECTION

PRINCIPLE

RATIONALE

1.

Prepare the injection in a designated clean area of the clinical area/department.

To reduce the risk of contaminating the equipment or medication used.

2.

Check the medication in accordance with the NUH Medicines Code of Practice, 2011

To reduce the risk of error in administration.

3.

Check that the packaging of all equipment is intact.

To reduce the risk of cross infection.

4.

Perform hand decontamination, then prepare the syringe and needle for use, checking that the plunger of the syringe moves freely in the syringe barrel.

To ensure equipment is working correctly.

5.

Check for any particles and discard if present.

To prevent the patient from receiving an unstable or contaminated drug.

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PRINCIPLE

RATIONALE

6.

Draw up the medication into the syringe

 
   
  • i) Ampoules

 
 

a

Tap the stem of the ampoule whilst holding the

To facilitate movement of medication in the stem to the body

 

b

ampoule vertically. If available, use an ampoule breaker to snap off the top, or use a small piece of gauze around the neck of the glass ampoule.

of the ampoule. To protect fingers when the ampoule is broken

 

c

Use a snapping motion to break off the top of the ampoule, or use an ampoule breaker if present, along the scoreline, at its neck.

 
 

d

Draw medication up into the syringe using a drawing up needle if the ampoule is made of plastic. Use a drawing up needle with a filter if the ampoule requires glass to be snapped. Expel all air bubbles.

To prevent glass particles from being drawn up

 

e

Detach the used needle (forceps may be used) and dispose into a sharps bin. Attach the new hypodermic needle.

To avoid re-sheathing any needle.

 
  • i) Vials

   
 

a

If large volumes are withdrawn from the vial the air should be introduced in stages as the fluid is withdrawn i.e. introduce a small volume of air, withdraw equal volume of fluid, and

To avoid aerosol formation of the medication and reduce the risk of inhalation.

 

b

repeat until complete. Dispose of the used needle into a sharps bin and attach the new hypodermic needle.

To avoid re-sheathing and maintain comfort for the patient.

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PRINCIPLE

RATIONALE

7.

Place the syringe and needle on the tray and take the injection, prescription chart, sharp disposal and gauze to the patient.

To ensure that all equipment is ready at the point of administration including the final checks to be made and that sharps may be disposed of effectively and safely thus avoiding needlestick injuries.

8.

Check the identity of the patient with the prescription chart as

To ensure that you have identified the correct patient

specified in the NUH Positive Identification of Patients Procedure (2012)

To reduce the risk of errors in administration.

9.

Ensuring privacy, position the patient comfortably and expose the site to be injected.

To allow ease of access to the injection site.

10.

If the skin is socially clean, insert the needle into the skin (refer to advice on page 8 for the correct angle of needle insertion) and administer the injection. If not socially clean, use soap and water, rinse and dry.

 

11.

Withdraw the needle quickly, and, either place the used syringe and needle into the sharps container intact, or use the integral needle separator device on the container to dispose of the needle only. DO NOT RE-SHEATH the needle.

Either method is thought to reduce the risk of needlestick injury.

12.

Check the site for any bleeding.

 

13.

Ensure the patient is comfortable, sign the prescription card and record in the appropriate documentation.

Good record keeping is an integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care. (NMC 2010)

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INTRAMUSCULAR INJECTIONS

Intramuscular injections deliver medication through the skin and subcutaneous tissues into certain muscles. Muscles have larger and a greater number of blood vessels than subcutaneous tissue, allowing faster onset of action than with subcutaneous injections. (Lynn, 2011) This route is suitable for a wide range of drugs, provided they are soluble and non-irritant to soft tissues.

INTRODUCTION: Sites of Administration

  • a) Mid-Deltoid Upper outer aspect of the arm. Used for injections of less than 2ml volume and for rapid onset injections (see diagram 1).

  • b) Rectus Femoris and Vastus Lateralis Outer/middle aspect of the thigh. Used for deep intramuscular injections and self-administered injections (see diagram 2).

  • c) Gluteal Muscles Upper outer quadrant of the buttock. Used for deep intramuscular injections. Care is required to avoid damaging the sciatic nerve and the superior gluteal arteries (see diagram 3).

INTRAMUSCULAR INJECTIONS Intramuscular injections deliver medi cation through the skin and subcutaneous tissues into certain muscles.

Diagram 1

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INTRAMUSCULAR INJECTIONS Intramuscular injections deliver medi cation through the skin and subcutaneous tissues into certain muscles.

Diagram 2

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Adapted from Taylor & Lillis, 1997

Adapted from Taylor & Lillis, 1997 Diagram 3 The dotted line represents the upper outer quadrant

Diagram 3

The dotted line represents the upper outer quadrant

CONTRAINDICATIONS

The intramuscular route may be contra-indicated for patients with clotting disorders and thrombocytopaenia.

Best practice - Needle size Needle length must be sufficient to penetrate the subcutaneous fat layer using at least 25mm (23 gauge) blue needles or 38mm (21 gauge) green needles for adults. For children, 16mm is recommended, although decisions depend on other factors such as age and subcutaneous fat. (Department of Health,

2006)

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ADMINISTERING AN INTRAMUSCULAR INJECTION

PRINCIPLE

RATIONALE

 
  • 1. Explain procedure to patient and obtain verbal consent.

To obtain consent and reduce

  • 2. Stretch the skin to one side around the injection side.

potential anxiety. When the retracted skin is released the tissue closes over the deposit of medication and prevents it leaking from the site (Workman, 2000)

  • 3. Hold the syringe with the needle at an angle of 90º. Quickly plunge into the skin, leaving a third of the needle exposed (see diagram 4).

This angle facilitates entry into muscle tissue. Speed reduces discomfort. Leaving part of the needle exposed will aid location and removal if the stem should break.

  • 4. With the needle in position pull

If blood is present, the needle

back on the plunger of the syringe to check for the presence of blood.

may be situated in vessel.

a blood

If blood is present, withdraw the

If

the

needle

is

in

a

blood

syringe and needle and dispose

vessel

and

the medication is

of intact, apply pressure to the

given,

the

injection

will

be

an

site. The whole procedure will then have to be repeated.

intravenous one.

 
  • 5. Administer the medication.

 

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Diagram 4 Intramuscular Injection Diagram 5 Adapted from Taylor & Lillis, 1997 Subcut Injections Final Draft

Diagram 4 Intramuscular

Injection

Diagram 5 Adapted from Taylor & Lillis, 1997

Diagram 4 Intramuscular Injection Diagram 5 Adapted from Taylor & Lillis, 1997 Subcut Injections Final Draft

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SUBCUTANEOUS INJECTIONS

This is an injection into the highly vascular layer beneath the epidermis where drugs can be absorbed steadily (at a slower rate than intramuscular route).

If frequent subcutaneous injections are necessary, consideration should be given to the use of a winged infusion device as indicated in the NUH guideline for Siting of a Subcutaneous Infusion Device (2012)

INTRODUCTION: Sites of Administration

The lateral aspect of the upper arm, thigh or the abdomen (see diagram 5) are most commonly used.

ADMINISTERING A SUBCUTANEOUS INJECTION

Best Practice

Refer to the NUH Guideline Subcutaneous Administration of Low Molecular Weight Heparin (Enoxaparin) 2011 for low molecular weight heparin.

PRINCIPLE

RATIONALE

1

Explain procedure to patient and obtain verbal consent.

To obtain consent and reduce potential anxiety.

2.

Raise a skinfold at the chosen site firmly between the finger and thumb of the non dominant hand.

This will elevate the subcutaneous tissues and reduce the chance of an inadvertent intramuscular injection being given

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  • 3. Insert the needle at an angle of 45º or 90º depending on the length of the needle and/or depth of subcutaneous layer.

To position the needle into the subcutaneous layer (see diagram 6).

  • 4. Give the medication and then release the skin fold.

 
 Brown needle 26G for 90°  Orange needle 25G for 45° Diagram 6 Subcutaneous
 Brown needle 26G for 90°
 Orange needle 25G for 45°
Diagram 6
Subcutaneous

Best Practice It is not necessary to draw back on the plunger to ensure that the needle is not in the vein as it is unlikely that a blood vessel will be pierced. (McAskill and Goodhand 2007)

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REFERENCES

Department of Health (2006) Immunisation against infectious disease – “The Green Book. DH: London

Lippincott Williams & Wilkins (2008) Nursing Procedures 5 th Edition. Wolters Kluwer Health.

Lynn. P (2011) Taylor’s Handbook of Clinical Nursing skills. Wolters Kluwer Health / Lippincott, Williams and Wilkins.

McAskill H, Goodhand K, (2007) Administration of medicines in Jamieson EM, Whyte LA, McCall JM, Clinical Nursing Practices 5 th Edition, Churchill Livingstone Elsevier, Edinburgh

Nottingham University Hospitals NHS Trust (2010) Clinical Guidelines Policy. NUH, Nottingham

Nottingham University Hospitals NHS Trust (2011) Diabetes Package – Guideline, Nottingham NUH

Nottingham University Hospitals NHS Trust (2011) Medicines Code of Practice –Administration of Medicines 2011, Nottingham NUH

Nottingham University Hospitals NHS Trust (2012) Positive Identification of Patients Procedure Nottingham NUH

Nottingham University Hospitals NHS Trust (2009). Safe Handling, Disposal and Reporting of Sharps and Blood Borne Viruses Exposure Injuries Policy, Nottingham NUH,

Nottingham University Hospitals NHS Trust (2011) Nursing Practice Guidelines for the Subcutaneous Administration of Low Molecular Weight Heparin (Enoxaparin). Nottingham, NUH

National Patient safety Agency National reporting and Learning service (2007) Safety in Doses: Improving the use of medicines in the NHS, London, NPSA

Nursing and Midwifery Council (2010) Record Keeping – Guidance for Nurses and Midwives London, NMC

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Nursing and Midwifery Council (2007) Standards for Medicine Management London, NMC

Plotkin, S. et al (2008) Vaccines (5 th ed) Saunders Elsevier.

Taylor, C and Lillis, C. (1997) Fundamentals of Nursing Stanley Thornes Limited, Lippincott, Philadelphia

Workman, B (2000) Safe injection techniques. Primary Healthcare 10 (6)

pp43-49

SUGGESTED AUDIT POINTS

  • 1. Has the injection been prepared in a designated clear clinical area?

  • 2. Has the medication been checked according to the local Medicines Code of Practice?

  • 3. Did the nurse clean their hands prior to preparing the equipment?

  • 4. Was the identity of patient checked with the prescription chart?

  • 5. Was the procedure for giving the injection discussed with the patient?

  • 6. Was the local Sharps policy adhered to regarding disposal of equipment?

  • 7. Was the drug signed for?

Authors: Kate Belfield

NPGG Link: Kirsty Jackson

For Review: September 2015

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