Giving injections

 

Attention

  • To prevent needle stick injuries, always carry injections in plastic tray or kidney dish and have sharps container close by

Before giving injection

  • Always check file notes, ask person about allergies or adverse reactions
  • Remember the RIGHTS before giving any medicine
  • Always check manufacturer's instructions
  • If injection site dirty or bloody — wash with soap and water

Preparing injection

  • Draw up solution, put drawing up needle in sharps container
  • Put on fresh, sterile needle to give injection except insulin syringes — needles can't be removed

To stop injection stinging

  • Before giving — clean site with Chlorhexedine 2% in isopropyl alcohol 70% wipes, let dry completely
  • After giving — use gauze or cotton wool to press down firmly on site

Angle and depth of injections — Figure 6.7

Figure 6.7  

Injection sites

Subcutaneous (subcut) or intramuscular (IM) injection sites

  • Anterolateral (outside) thigh (vastus lateralis), baby or toddler — Figure 6.8
  • Anterolateral (outside) thigh (vastus lateralis), child or adult — Figure 6.9
  • Deltoid (upper arm) — Figure 6.10
    • Do not use for children under 12 months
    • Best site for small injections in adults

Figure 6.8  Outside thigh — baby or toddler

Figure 6.9  Outside thigh — child or adult

Figure 6.10  Upper arm

IM injection sites

  • Ventrogluteal 
    • Better than gluteal (buttock) as less risk of damage to nerves or blood vessels
    • Best site for large injections in adults
    • Child — lie over carer’s knee, upper leg flexed — Figure 6.11
    • Adult — Figure 6.12 OR lie on side, upper leg flexed and forward
  • Gluteal (buttock) — Figure 6.13
    • Do not use for babies, toddlers, small preschool children

Figure 6.11  Ventroguteal — child

Figure 6.12 Ventroguteal — adult 

Figure 6.13  Gluteal

Intradermal injections

Attention

  • Used for Mantoux test or Mycobacterium bovis (Bacillus Calmette and Guerin [BCG] strain) vaccine
  • First check person’s Mantoux status
  • Only give Mantoux test or BCG immunisation if authorised to do so
  • Mantoux test — usually given in inner forearm — Figure 6.14
  • BCG immunisation
    • Give in deltoid area (upper arm)
    • ​Check regional guidelines to see if right or left arm used
  • Do not cover Mantoux test or BCG immunisation injection site with dressing

Figure 6.14  

What you need

  • Injection tray
  • Insulin syringe
  • Gauze swab
  • Injection solution

What you do

  • Choose injection site, clean if needed, let dry completely
  • Draw up solution
  • Hold syringe with needle lying flat to skin and bevel edge facing up
  • Slide needle under skin until it disappears, then a little further so it goes into intradermal tissue. Keep level with skin — Figure 6.14
  • Slowly inject solution until you see wheal (raised area)
  • If wheal is not appearing — do not repeat dose —  adjust needle position and continue injection
  • Do not put pressure on site after taking out needle. Ask person to blow on area until it dries
  • Do not rub site or put on sticking plaster. Leave open to air

Subcutaneous injections

Attention

  • If person has daily injections (eg insulin for diabetes) — change injection site often

What you do

  • For angle and depth of injection — Figure 6.7
  • For injection sites — see Figure 6.8, Figure 6.9
    • Fatty pad below umbilicus can also be used in diabetes

Subcutaneous cannula

Attention

  • Used for people in palliative care or who can't swallow medicines
    • More comfortable than repeated IM or IV injections
    • Less likely to become infected
  • Do not use metal butterfly needles. Less comfortable and site needs to be changed more often
  • Subcut catheter system (eg Intima)— Figure 6.15 allows regular administration of medicine by
    • Injecting into side portal
    • OR Continuous infusion through syringe driver
  • If catheter system not available use 22–24G cannula
  • Rotate sites. Make a plan using sites that allow person the most movement

Figure 6.15  

What you do

Choose site

  • Do not use
    • Breast tissue or skin folds
    • Portacath or CVC sites
    • Stoma sites
    • Tumour masses, tumour nodules, oedematous areas
    • Scar tissue, mastectomy sites
    • Bony areas
  • Consider these sites
    • Intercostal spaces on anterior chest wall
    • Above pectoralis muscle
    • Anterior abdominal wall — do not use if ascites, abdominal disease, oedema
    • Upper arm — do not use if bed-bound and needs frequent turning
    • Outer thigh
    • Above shoulder blades — good if person restless or disorientated

Put in subcut catheter system or cannula

  • Trim hairs if needed
  • Clean site with Chlorhexedine 2% in isopropyl alcohol 70% wipes, allow to dry
  • Prime line with sterile water or normal saline
  • Lift fold of skin between forefinger and thumb, put in full length of cannula at 30° angle
  • Tape down butterfly flaps with transparent film dressing
  • Remove metal insert, put in sharps container
  • Attach injectable bungs to outlets (if not already there)

Follow-up

  • Label site with date of insertion, record site in file notes
  • Check site regularly and before giving medicine for swelling, redness, leakage
    • If present — change site straight away
    • If not present — change site in 7–10 days

Intramuscular injections

Attention

  • Using small bore needle causes more pain, as more pressure needed
  • Usually use 25mm long needle, may need larger if obese. Use 16mm for small babies

What you do

  • Choose site — Figure 6.8 — Figure 6.12
    • If repeat injection — use different site to last time
  • Position limb so muscle being injected into is relaxed
  • Ventrogluteal
    • Child — lie over carer’s knee, upper leg flexed
    • Adult — lie on side, upper leg flexed and forward
  • Gluteal (buttock) — stand bent forward with hands on bed OR lie on stomach (prone) with foot on same side turned inward
    • If person large or tall — suggest lying down, won't hurt themself or you if they faint
  • Outside thigh — lie on back (supine) with toes pointing straight up
  • Upper arm — sit with elbow bent and forearm supported
  • Clean site if needed, let air dry
  • Pull skin tight, or use Z-track method — put in needle quickly at 90° to skin
  • If giving in gluteal (buttock) — pull back plunger a little to make sure you are not in blood vessel. If blood seen — change site
  • Slow steady injection
  • Remove needle quickly, apply pressure to injection site

To lessen pain of thick injections — (eg Bicillin L-A) (benzathine benzypenicillin, penicillin G), procaine benzylpenicillin (procaine penicillin)

  • These injections are very painful. Best to have helper, person may try to grab syringe
  • Consider individualised strategies for managing pain, fear and distress
  • Mix well by shaking
    • OR Warm and mix by rolling syringe in your hands for 1 minute
  • Use needle provided with pre-loaded syringe
    • Do not change to smaller bore needle, more likely to get blocked
    • Do not pre-load needle — leave hollow part of needle empty
  • Before injecting
    • Put ice pack on site
    • Press hard on site with thumb and count to thirty (30–60 seconds)

Z-track injections

Attention

  • Use for
    • Thick injection fluids (eg Bicillin L-A) — can leak out through large bore needle track
    • Iron injections — can permanently stain skin if solution leaks out

What you do

  • Choose site
  • Larger/older children and adults — IM into
  • Small children — IM into
  • Pull skin down from chosen site, hold in this spot — Figure 6.16
  • Put needle into muscle and give injection slowly
  • When finished, leave needle in place for about 10 seconds. This stops medicine solution leaking out onto skin surface
  • Take needle out, let go of skin — this will make Z-track — Figure 6.17

Figure 6.16  

Figure 6.17