Injection

Question 1

What is an injection ? What are the different type ?

Answer 1

It is the administration of a fluid in a tissue or blood vessel using a syringe and needle.
Injections : intradermal, subcutaneous, intramuscular, intravenous.

Question 2

What is the purpose of intradermal injections where are they done ?

Answer 2

Used for diagnosis, only a minimal amount of fluid is injection. Inner side of the arm and in the back.

Question 3

What is the purpose of subcutaneous injection and where are they done ?

Answer 3

Administered in the abdomen, lateral upper arm, front and lateral side of the thigh.
Small amount of fluids slowly absorbed by the surrounding tissues.

Question 4

What is important about intramuscular injections, where are they done ?

Answer 4

Administration of large amount of fluid 5mL quickly absorbed. It is important to avoid hitting blood vessels.
Administered in the buttock (upper outer quadrant), thigh (middle lateral side), upper arm (lateral side).

Question 5

What is intravenous injection where is it done ?

Answer 5

Fluid administered into the blood stream, direct result.
Generally below the elbow in the inside.

Question 6

What should you check before the injection ?

Answer 6

Verify the medication and its dosage.
Verify all expiration date
Verify the identity of the patient
How is the medication given
Document properly
The contra-indication possible : coagulation disorder, allergies, inflammation, haematoma, scar tissue

Question 7

How do you prepare the injection ?

Answer 7

Hand hygiene and non sterile glove. Clean work surface, check package. Open package put leave seringue in it. Open the package of the drawing up needle. Connect syringe and drawing up needle. Check expiration date.

Take the good amount of the liquid using an ampoule or a vial.

Question 8

Preparing injection with an ampoule ?

Answer 8

Put 3 gauzes around the ampoule and break the head.
Insert needle inside ampoule.
Hold the ampoule inside down and draw the correct amount of liquid.
Dispose of the empty ampoule in the glass container.

Question 9

Preparation of injection with a vial ?

Answer 9

Disinfect the rubber stopper of the vial with alcohol.
Draw up air in the seringue (10% more than the amount needed.
Insert the needle with 90° degrés angle through the vial.
Inject the air in the vial - tip of needle above fluid level.
Turn vial upside down and draw correct amount of fluid -tip of needle under fluid level.
Withdraw the needle.

Question 10

What are the step after getting the right liquid into the needle ?

Answer 10

Push seringue a little bit to get rid of air and get the good amount of fluid to inject.
Remove drawing up needle by rotating the seringue and dispose.
Take safety needle and attach it to the seringue by rotation.
Put final material in kidney dish.

Question 11

How do you perform an injection ? General

Answer 11

Introduce yourself, identify the patient, inform them about the procedure and check for contraindication.
Perform hand hygiene and wear non sterile glove - not mandatory except in case of wounds in your hands.
Choose skin spot and disinfect the skin.
Remove excess medication
Push safety cap backward.

Question 12

How do you perform an intramuscular injection ?

Answer 12

Pull skin tightly at the injection site.
Insert needle with 90° angle.
Draw back needle to see if there’s blood.
Inject fluid slowly
Withdraw the needle in one mouvement.
Flip safety cap on with thumb.

Question 13

How do you perform an subcutaneous injection ?

Answer 13

Pull the skin tight at injection site.
Insert needle with 30-45° angle.
Let go of fold.
Move needle side to side.
Draw back the seringue to see if there’s blood.
Inject fluids slowly.
Withdraw the needle in one mouvement.
Flip safety cap on with thumb.

Question 14

How do you perform intravenous injection ?

Answer 14

Apply tourniquet with release strap.
Find accessible vein and disinfect the spot.
Pull the skin tight in the opposite direction from the needle.
Align seringue and needle with vein.
Insert needle with 45 angle then decrease to 30° angle.
Drawback to see if there’s blood.
Release the tourniquet.
Inject fluids slowly.
Withdraw the needle in one mouvement.
Flip safety cap on with thumb.
If necessary apply bandage.

Question 15

Why are injection needle and filling needle different ?

Answer 15

Injection needle has a cap because there’s risk of transmission of disease.
Injection needle size tell for which injection to do.

Question 16

What are different contraindications for an injection ?

Answer 16

Allergies : egg => avoid influenza and yellow fever vaccine

Coagulopathy : for intramuscular injection

Pregnant patient : avoid live virus vaccine

Active infective, multiple puncture or scars at the site

Varicose veins

Axillary dissection side : more prone to infection

Dialysis shunt side

Thrombosis side

Question 17

Potential complication of an injection ?

Answer 17

Pain, burning, erythema
Infection
Lidodystrophy : in patient with multiple repeated injection s at the same site
- rotate injection site
Injury to surrounding structures
Allergic reaction
Medical error

Question 18

How to reduce injection pain ?

Answer 18

Ensure patient is relaxed : muscular contraction intensify pain
Allow antiseptic solution to dry completely and gently massage the area after.

Question 19

How do you perform an intradermal injection ?

Answer 19

Ventral forearm lying on hard surface, patient seated.
- prepare site (10cm from antecubital fossa)
- disinfect and dry
Hold forearm and stretch skin with thumb
- insert needle at 15° angle into upper skin layer
Inject slowly : can see a blob signalling proper intradermal placement
Withdrawal needle at 15° angle
- blob disappear gradually
Dispose of supplies

Question 20

What should you remember for an insulin administration ?

Answer 20

Only compatible type of insulin should be combined.
Roll gently the vial in your palm to ensure proper distribution.
Rotate site to avoid lipodystrophy

Question 21

What is the purpose of venipuncture ?

Answer 21

Draw blood from a vein, used for diagnose purpose.

Question 22

Where should you perform venipuncture ?

Answer 22

At the antecubital fossa : cephalic vein, median cubital vein, basilic vein (never on proximal side because brachial artery and nerve run here).
- inspect right/left arm using tourniquet to choose the best vein
- choose accessible vein to avoid hitting artery or nerve

Question 23

What materials are needed for a venipuncture ?

Answer 23

Sharp container and kidney dish
Tourniquet
Vacuum extraction tube
Non sterile glove
Gauze pads
Disinfectant
Chux protective underpad
Bandage

Question 24

What do you prepare before venipuncture ?

Answer 24

Wash hands and collect all materials needed on clean surfaces. Check if they are all sealed, dry with adequate date.
Check patient information.
Make patient sit/lie down with arm extended and supported.

Question 25

Venipuncture technique : finding the vein

Answer 25

Connect vacutainer needle holder and needle while leaving the protection on the needle. Apply tourniquet around upper arm (10 cm above antecubital fossa). - put the release strap on the side of non dominant hand so it can be loosened easily Once you have found suitable vein. - loosen tourniquet - disinfect skin, put non sterile gloves

Question 26

Venipuncture technique : drawing blood

Answer 26

Apply tourniquet again. Hold vacutainer needle holder between thumb and index with bevel upward. Be aligned with vein. Pull skin taunt with non dominant hand. Enter vein at 45° then reduce it to 30° - support dominant hand on arm to hold needle steady Use non dominant hand to pick up a vacuum extraction tube and slide it into the vacuum holder - middle and index finger on the vacutainer wings and thumb push tube in - avoid pushing the needle as well When vacuum tube start to fill release tourniquet - leaving it on for too long can affect laboratory result Remove filled vacuum tube - hold it between thumb and middle finger - push wings with index finger - gently mix content of tube x8 After removing the last tube, remove needle. Apply pressure using gauze. Deposit needle in sharp container and press green button to disconnect it.

Question 27

Why do we use IV cannula ?

Answer 27

Direct access to bloodstream for medication at any given moment. Can be done preventively and isn’t painful once it is placed. Medications can be administered fast in greater quantity, over longer period of time.

Question 28

What indications of IV cannula ?

Answer 28

Medical emergency : volume depletion, burns, electrolyte disturbances, heat stroke, shock, trauma Administration of antibiotics, chemotherapy, blood products, nutritional component Administration of diagnostic substances (contrast)

Question 29

What are contraindications of IV cannula ?

Answer 29

Extremities with : - Significant burns, edema, injury, infections - Dialysis shunt - Impaired circulation - Indwelling fistula - Proximal phlebitis Appropriate therapy can be given via a less invasive road.

Question 30

Why should you prefer a peripherally inserted central catheter ?

Answer 30

Too caustic or hypertonic medication. Sclerosing or vasopressor agents. Given for longer than 6 days.

Question 31

What are ‘complications’ due to IV cannula technique ?

Answer 31

No flash of blood => not in vein and shouldn’t be advanced Flash of blood but cannot be advanced => vessel valve Threaded catheter but fluid doesn’t move freely => clotted catheter.

Question 32

What are local complications of an IV cannula ?

Answer 32

Failure to cannulate Minor bleeding. Thrombophlebitis : trauma to the vein when a foreign body is already present. Local infection / cellulitis Allergic reaction

Question 33

What makes the risk of local infection / cellulitis more likely ?

Answer 33

Catheter left in place for more than 72-96 hours. Inadequate aseptic technique

Question 34

How do you reduce the risk of thrombophlebitis due to IV cannula ?

Answer 34

Avoid trauma. Securely tape the cannula in place. Avoid placing cannula near joint line due to frequent movement.

Question 35

What are the possible systemic complications of an IV cannula ?

Answer 35

Septicaemia / bacteraemia : non adequate aseptic technique. Catheter embolisation Pulmonary embolism : CVC peripherally placed. During placement it may dislodge an already present clot. Air embolism : lines aren’t properly flushed.

Question 36

What is important to consider when choosing a site for IV ?

Answer 36

Avoid valve and bifurcation (easier to do in lower arm). Determine the longest section of obstruction free vein. Commonly used : metacarpal, basilic, cephalic vein

Question 37

What site can you use for IV cannula in children ?

Answer 37

They generally have good feet and ankles circulation => equally acceptable site. - Less visible => decrease anxiety Greater / lesser saphenous veins and medial marginal veins are used.

Question 38

IV technique : patient preparation

Answer 38

Identify patient Verbal consent if possible Identify allergies Offer injections for anaesthesia

Question 39

IV technique : materials

Answer 39

Appropriate gauge IV catheter Glove IV fluid + administration set (IV pole + infusion set) Disinfectant Tourniquet + scissors Biohazards waste + needle container + kidney dish

Question 40

IV technique : preparation

Answer 40

Hand hygiene. Collect all materials on clean surface. Check package (sealed, dry, expiration date) Hook IV bag to pole and remove protecting covering. Open IV set. Close roller clamp. Insert spike of infusion set in the IV fluid bag. Squeeze drip chamber until the marker line. Flush to avoid air. Set correct flow with roller clamp. Clamp the end of the tube and hang on IV stand.

Question 41

IV technique : procedure

Answer 41

Apply tourniquet Find suitable vein. Palpate them for stability : compressible, stable, valve free Release tourniquet, verify materials are secured. Open IV catheter package, hold needle in dominant hand. Support patient arm. Apply tourniquet Clean site with aseptic and allow site to dry. Hold arm / hand with non dominant hand and retract the skin distally. Insert needle at 30°angle. Then reduce this. Blood flash in the chamber. You can then advance the catheter into the vein a bit so the cannula is in. Hold needle securely and advance cannula. Place sterile gauze pad between skin and cannula hub. Remove needle and dispose of it.

Question 42

IV technique : what do you do if the IV line isn’t started immediately ?

Answer 42

Flush cannula with 5 mL of saline to prevent clot then recapped it with plug.

Question 43

IV technique : Follow up care

Answer 43

Clean and dry the skin with sterile gauze. Secure catheter with non occlusive dressing. Tape tubing arm. Minimize tape-skin contact. Check how the patient is doing. IV site should be changed every 96 hours.

Question 44

What are things to consider for pediatric and geriatric population ?

Answer 44

Smaller, more fragile veins. In children it is essential to secure the line so they don’t remove it. Large vessels may be sclerotic in elderly. And their lower extremities should be avoided due to the chance of vascular insufficiency.

Question 45

IV technique : how to connect the infusion set ?

Answer 45

Remove the forceps from the tube and open the roller clamp. Twist dripping tube onto connecting part of the cannula. Secure tubing. Verify that fluid isn’t running into subcutaneous tissues (would lead to swelling). Set flow rate with the flow regulator.

Question 46

IV technique : removal

Answer 46

Put on gloves. Clamp the IV tube. Remove adhesive securing the cannula hub to the skin. Pull the cannula out. Apply pressure with sterile gauze and secure it.