The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [566]
5 Remove appropriate garments to expose the injection site. To gain access for injection. E.
6 Assess the injection site for signs of inflammation, oedema, infection and skin lesions. To promote effectiveness of administration (Perry 2007, E).
To reduce the risk of infection (Fraise and Bradley 2009, E; Workman 1999, E).
To avoid skin lesions and possible trauma to the patient (Perry 2007, E).
7 Pinch the skin of the area and select the correct needle size. To minimize the risk of missing the subcutaneous tissue and any ensuing pain (Perry 2007, E).
8 Clean the injection site with a swab saturated with isopropyl alcohol 70% and apply gloves. To reduce the number of pathogens introduced into the skin by the needle at the time of insertion. E (For further information on this action see Skin preparation.)
9 Gently pinch the skin up into a fold. To elevate the subcutaneous tissue, and lift the adipose tissue away from the underlying muscle (Perry 2007, E).
10 Remove the needle sheath and hold syringe between thumb and forefinger of dominant hand as if grasping a dart. To enable a quick smooth injection (Perry 2007, E).
11 Insert the needle into the skin at an angle of 45° and release the grasped skin (unless administering insulin when an angle of 90° should be used). Inject the drug slowly. Injecting medication into compressed tissue irritates nerve fibres and causes the patient discomfort (Perry 2007, E).
The introduction of shorter insulin needles makes 90° the more appropriate angle (Trounce and Gould 2000, E).
12 Withdraw the needle rapidly. Apply gentle pressure. Do not massage area. To aid absorption. Massage can injure underlying tissue (Perry 2007, E).
Postprocedure
13 Ensure that all sharps and non-sharp waste are disposed of safely and in accordance with locally approved procedures. To ensure safe disposal and to avoid laceration or other injury to staff (MHRA, 2004, C; DH, 2005b, C).
14 Record the administration on appropriate sheets. To maintain accurate records, provide a point of reference in the event of any queries and prevent any duplication of treatment (NMC 2008a, C; NMC 2009, C; NPSA 2007d, C).
Postprocedural considerations
Education of patient and relevant others
Patients often have to administer their own subcutaneous injections, for example insulin for diabetics. The nurse must teach the patient how to prepare and administer self-injection, including aspects such as equipment, storage, handwashing, injection technique and safe disposal of equipment and sharps (Perry 2007).
Complications
Medications collecting within the tissues can cause sterile abscesses, which appear as hardened, painful lumps (Perry 2007). The nurse must monitor and report these.
Intramuscular injections
Definition
An intramuscular injection deposits medication into deep muscle tissue under the subcutaneous tissue (Chernecky et al. 2002). The vascularity of muscle aids the rapid absorption of medication (Perry 2007).
Evidence-based approaches
Site and volume of injection
Selecting the site requires correct identification of the muscle groups by landmarking correct anatomical features (Hunter 2008). Choice will be influenced by the patient’s physical condition and age. Intramuscular injections should be given into the densest part of the muscle (Pope 2002). An active patient will probably have a greater muscle mass than older or emaciated patients (Hunter 2008).
The injectable volume will depend on the muscle bed. In children, injectable volumes should be halved because muscle mass is less (Workman 1999). However, it appears that it is the medicine rather than just the volume that affects how a patient tolerates the injection. Malkin (2008) uses Botox injections as an example where a volume of 1–3 mL can be injected into facial muscle groups, supporting the view that tolerance of the drug is more important than the volume.
Current research evidence suggests that there are five sites that can be utilized for the administration of intramuscular