Put on gloves.
To apply externally, use gloves or a gauze pad to spread medication over the anal area.
To apply internally, attach the applicator to the tube of ointment and coat the applicator with water-soluble lubricant.
Expect to use about 1″ (2.5 cm) of ointment. To gauge how much pressure to use during application, squeeze a small amount from the tube before you attach the applicator.
Lift the patient's upper buttock with your nondominant hand to expose the anus.
Instruct the patient to take several deep breaths through his mouth to relax the anal sphincters and reduce anxiety or discomfort during insertion.
Gently insert the applicator, directing it toward the umbilicus.
Slowly squeeze the tube to eject the medication.
Remove the applicator and place a folded 4″ × 4″ gauze pad between the patient's buttocks to absorb excess ointment.
Detach the applicator from the tube and recap the tube. Then clean the applicator thoroughly with soap and warm water.
HOW TO ADMINISTER A RECTAL SUPPOSITORY OR OINTMENT
When inserting a suppository, direct its tapered end toward the side of the rectum so that it contacts the membranes to encourage absorption of the medication.
When applying a rectal ointment internally, be sure to lubricate the applicator to minimize pain on insertion. Then direct the applicator tip toward the patient's umbilicus
Special considerations
Because the intake of food and fluid stimulates peristalsis, a suppository for relieving constipation should be inserted about 30 minutes before mealtime to help soften the feces in the rectum and facilitate defecation. A medicated retention suppository should be inserted between meals.
Instruct the patient to avoid expelling the suppository. If he has difficulty retaining it, place him on a bedpan.
Make sure the patient's call button is handy, and watch for his signal because he may be unable to suppress the urge to defecate. For example, a patient with proctitis has a highly sensitive rectum and may not be able to retain a suppository for long.
Be sure to inform the patient that the suppository may discolor his next bowel movement. Anusol suppositories, for example, can give feces a silver-gray pasty appearance.
Documentation
Record the administration time, dose, and patient's response.
PARENTERAL ADMINISTRATION
Part of "5 - Drug Administration"
ADMIXTURE OF DRUGS IN A SYRINGE
Combining two drugs in one syringe avoids the discomfort of two injections. Usually, drugs can be mixed in a syringe in one of four ways. They may be combined from two multidose vials (for example, regular and long-acting insulin), from one multidose vial and one ampule, from two ampules, or from a cartridge-injection system combined with either a multidose vial or an ampule.
Such combinations are contraindicated when the drugs aren't compatible and when the combined doses exceed the amount of solution that can be absorbed from a single injection site.
Equipment
Prescribed medications • patient's medication record and chart • alcohol pads • syringe and needle • optional: cartridge-injection system and filter needle.
The type and size of the syringe and needle depend on the prescribed medications, patient's body build, and route of administration. Medications that come in prefilled cartridges require a cartridge-injection system. (See Cartridge-injection system.)
Implementation
Verify that the drugs to be administered agree with the patient's medication record and the physician's orders.
Calculate the dose to be given.
Wash your hands.
Mixing drugs from two multidose vials
Using an alcohol pad, wipe the rubber stopper on the first vial. This decreases the risk of contaminating the medication as you insert the needle into the vial.
Pull back the syringe plunger until the volume of air drawn into the syringe equals the volume to be withdrawn from the drug vial.
Without inverting the vial, insert the needle into the top of the vial, making sure that the needle's bevel tip doesn't touch the solution. Inject the air into the vial and withdraw the needle. This replaces air in the vial, thus preventing creation of a partial vacuum on withdrawal of the drug.
Repeat the steps above for the second vial. Then, after injecting the air into the second vial, invert the vial, withdraw the prescribed dose, and then withdraw the needle.
Wipe the rubber stopper of the first vial again and insert the needle, taking care not to depress the plunger. Invert the vial, withdraw the prescribed dose, and then withdraw the needle.
Mixing drugs from a multidose vial and an ampule
Using an alcohol pad, clean the vial's rubber stopper.
Pull back on the syringe plunger until the volume of air drawn into the syringe equals the volume to be withdrawn from the drug vial.
Insert the needle into the top of the vial and inject the air. Then invert the vial and keep the needle's bevel tip below the level of the solution as you withdraw the prescribed dose. Put the sterile needle cover over the needle.
Wrap a sterile gauze pad or an alcohol pad around the ampule's neck to protect yourself from injury in case the glass splinters. Break open the ampule, directing the force away from you.
If desired, switch to the filter needle at this point to filter out any glass splinters.
Insert the needle into the ampule. Be careful not to touch the outside of the ampule with the needle. Draw the correct dose into the syringe.
If you switched to the filter needle, change back to a regular needle to administer the injection.
Mixing drugs from two ampules
An opened ampule doesn't contain a vacuum. To mix drugs from two ampules in a syringe, calculate the prescribed doses and open both ampules, using sterile technique. If desired, use a filter needle to draw up the drugs. Then change to a regular needle to administer them.
Special considerations
Insert a needle through the vial's rubber stopper at a slight angle, bevel up, and exert slight lateral pressure. This way you won't cut a piece of rubber out of the stopper, which can then be pushed into the vial.
When mixing drugs from multidose vials, be careful not to contaminate one drug with the other. Ideally, the needle should be changed after drawing the first medication into the syringe. This isn't always possible because many disposable syringes don't have removable needles.
NURSING ALERT Never combine drugs if you're unsure of their compatibility, and never combine more than two drugs. Although drug incompatibility usually causes a visible reaction, such as clouding, bubbling, or precipitation, some incompatible combinations produce no visible reaction even though they alter the chemical nature and action of the drugs. Check appropriate references and consult a pharmacist when you're unsure about specific compatibility. When in doubt, administer two separate injections.
Some medications are compatible for only a brief time after being combined and should be administered within 10 minutes after mixing. After this time, environmental factors, such as temperature, exposure to light, and humidity, may alter compatibility.
To reduce the risk of contamination, most facilities dispense parenteral medications in single-dose vials. Insulin is one of the few drugs still packaged in multidose vials. Be careful when mixing regular and long-acting insulin. Draw up the regular insulin first to avoid contamination by the long-acting suspension. (If a minute amount of the regular insulin is accidentally mixed with the long-acting insulin, it won't appreciably change the effect of the long-acting insulin.) Check your facility's policy before mixing insulins.
When you combine a cartridge-injection system and a multidose vial, use a separate needle and syringe to inject air into the multidose vial. This prevents contamination of the multidose vial by the cartridge-injection system.
Documentation
Record the drugs administered, injection site, and time of administration. Document adverse drug effects or other pertinent information.
SUBCUTANEOUS INJECTION
When injected into the adipose (fatty) tissues beneath the skin, a drug moves into the bloodstream more rapidly than if given by mouth. Subcutaneous (S.C.) injection allows slower, more sustained drug administration than I.M. injection; it also causes minimal tissue trauma and carries little risk of striking large blood vessels and nerves.
Absorbed mainly through the capillaries, drugs recommended for S.C. injection include nonirritating aqueous solutions and suspensions contained in 0.5 to 2 ml of fluid. Heparin and insulin, for example, are usually administered S.C. (Some diabetic patients, however, may benefit from an insulin infusion pump.)
Drugs and solutions for S.C. injection are injected through a relatively short needle, using meticulous sterile technique. The most common S.C. injection sites are the outer aspect of the upper arm, anterior thigh, loose tissue of the lower abdomen, upper hips, buttocks, and upper back. (See Locating subcutaneous injection sites, page 238.) Injection is contraindicated in sites that are inflamed, edematous, scarred, or covered by a mole, birthmark, or other lesion. It may also be contraindicated in patients with impaired coagulation mechanisms.
LOCATING SUBCUTANEOUS INJECTION SITES
Subcutaneous (S.C.) injection sites (as indicated by the dotted areas in the illustration below) include the fat pads on the abdomen, upper hips, upper back, and lateral upper arms and thighs. For S.C. injections administered repeatedly, such as insulin, rotate sites. Choose one injection site in one area, move to a corresponding injection site in the next area, and so on.
When returning to an area, choose a new site in that area. Preferred injection sites for insulin are the arms, abdomen, thighs, and buttocks. The preferred injection site for heparin is the lower abdominal fat pad, just below the umbilicus.
Equipment
Prescribed medication • patient's medication record and chart • 25G to 27G 5/8″ or ½″ needle • gloves • 1- or 3-ml syringe • alcohol pads • 2″ × 2″ gauze pad • optional: antiseptic cleaning agent, filter needle, insulin syringe, insulin pump. (See Types of insulin infusion pumps.)
Preparation of equipment
Verify the order on the patient's medication record by checking it against the physician's order. Also note whether the patient has any allergies, especially before the first dose.
Inspect the medication to make sure it isn't abnormally discolored or cloudy and doesn't contain precipitates (unless the manufacturer's instructions allow it).
Wash your hands. Choose equipment appropriate to the prescribed medication and injection site, and make sure it works properly.
Check the medication label against the patient's medication record. Read the label again as you draw up the medication for injection.
For single-dose ampules
Wrap an alcohol pad around the ampule's neck and snap off the top, directing the force away from your body. Attach a filter needle to the needle and withdraw the medication, keeping the needle's bevel tip below the level of the solution. Tap the syringe to clear air from it. Cover the needle with the needle sheath.
Before discarding the ampule, check the medication label against the patient's medication record. Discard the filter needle and the ampule. Attach the appropriate needle to the syringe.
For single-dose or multidose vials
Reconstitute powdered drugs according to instructions. Make sure all crystals have dissolved in the solution. Warm the vial by rolling it between your palms to help the drug dissolve faster.
Clean the vial's rubber stopper with an alcohol pad. Pull the syringe plunger back until the volume of air in the syringe equals the volume of drug to be withdrawn from the vial.
Without inverting the vial, insert the needle into the vial. Inject the air, invert the vial, and keep the needle's bevel tip below the level of the solution as you withdraw the prescribed amount of medication. Cover the needle with the needle sheath. Tap the syringe to clear any air from it.
Check the medication label against the patient's medication record before discarding the single-dose vial or returning the multidose vial to the shelf.
Implementation
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Explain the procedure to the patient and provide privacy.
Select an appropriate injection site. Rotate sites according to a schedule for repeated injections, using different areas of the body unless contraindicated. (Heparin, for example, should be injected only in the abdomen if possible.)
Put on gloves.
Position and drape the patient if necessary.
Clean the injection site with an alcohol pad, beginning at the center of the site and moving outward in a circular motion. Allow the skin to dry before injecting the drug to avoid a stinging sensation from introducing alcohol into subcutaneous tissues.
Loosen the protective needle sheath.
With your nondominant hand, grasp the skin around the injection site firmly to elevate the subcutaneous tissue, forming a 1″ (2.5-cm) fat fold.
Holding the syringe in your dominant hand, insert the loosened needle sheath between the fourth and fifth fingers of your other hand while still pinching the skin around the injection site. Pull back the syringe with your dominant hand to uncover the needle by grasping the syringe like a pencil. Don't touch the needle.
Position the needle with its bevel up.
Tell the patient he'll feel a needle prick.
Insert the needle quickly in one motion at a 45- or 90-degree angle. (See Technique for subcutaneous injection.) Release the patient's skin to avoid injecting the drug into compressed tissue and irritating nerve fibers.
Pull back the plunger slightly to check for blood return. If none appears, begin injecting the drug slowly. If blood appears on aspiration, withdraw the needle, prepare another syringe, and repeat the procedure.
Don't aspirate for blood return when giving insulin or heparin. It isn't necessary with insulin and may cause a hematoma with heparin.
After injection, remove the needle gently but quickly at the same angle used for insertion.
Cover the site with an alcohol pad or a 2″ × 2″ gauze pad and massage the site gently (unless contraindicated, as with heparin and insulin) to distribute the drug and facilitate absorption.
Remove the alcohol pad, and check the injection site for bleeding and bruising.
Dispose of injection equipment according to your facility's policy. To avoid needle-stick injuries, don't resheath the needle.
TECHNIQUE FOR SUBCUTANEOUS INJECTION
Before giving the injection, elevate the subcutaneous tissue at the site by grasping it firmly.
Insert the needle at a 45- or 90-degree angle to the skin surface, depending on needle length and the amount of subcutaneous tissue at the site. Some medications, such as heparin, should always be injected at a 90-degree angle.
Special considerations
When using prefilled syringes, adjust the angle and depth of insertion according to needle length.
For insulin injections
To establish more consistent blood insulin levels, rotate insulin injection sites within anatomic regions. Preferred insulin injection sites are the arms, abdomen, thighs, and buttocks.
Make sure the type of insulin, unit dosage, and syringe are correct.
When combining insulins in a syringe, make sure they're compatible. Regular insulin can be mixed with all other types. Prompt insulin zinc suspension (Semilente insulin) can't be mixed with NPH insulin. Follow your facility's policy regarding which insulin to draw up first.
Before drawing up insulin suspension, gently roll and invert the bottle. Don't shake the bottle because this can cause foam or bubbles to develop in the syringe.
For heparin injections
The preferred site for a heparin injection is the lower abdominal fat pad, 2″ (5 cm) beneath the umbilicus, between the right and left iliac crests. Injecting heparin into this area, which isn't involved in muscle activity, reduces the risk of local capillary bleeding. Always rotate the sites from one side to the other.
Inject the drug slowly into the fat pad. Leave the needle in place for 10 seconds after injection; then withdraw it.
Don't administer an injection within 2″ of a scar, a bruise, or the umbilicus.
Don't aspirate to check for blood return because this can cause bleeding into the tissues at the site.
Don't rub or massage the site after the injection. Rubbing can cause localized minute hemorrhages or bruises.
If the patient bruises easily, apply ice to the site for the first 5 minutes after the injection to minimize local hemorrhage and then apply pressure.
Complications
Concentrated or irritating solutions may cause sterile abscesses to form. Repeated injections in the same site can cause lipodystrophy. A natural immune response, lipodystrophy can be minimized by rotating injection sites.
Documentation
Record the time and date of the injection, medication and dose administered, injection site and route, and patient's reaction.
INTRADERMAL INJECTION
Because little systemic absorption of intradermally injected agents takes place, this type of injection is used primarily to produce a local effect, as in allergy or tuberculin testing. Intradermal injections are administered in small volumes (usually 0.5 ml or less) into the outer layers of the skin.
The ventral forearm is the most commonly used site for intradermal injection because of its easy accessibility and lack of hair. In extensive allergy testing, the outer aspect of the upper arms may be used as well as the area of the back located between the scapulae. (See Intradermal injection sites.)
Equipment
Patient's medication record and chart • tuberculin syringe with a 26G or 27G ½″ to 3/8″ needle • prescribed medication • gloves • alcohol pads.
Preparation of equipment
Verify the order on the patient's medication record by checking it against the physician's orders. Inspect the medication to make sure it isn't abnormally discolored or cloudy and doesn't contain precipitates. Wash your hands.
Choose equipment appropriate to the prescribed medication and injection site, and make sure it works properly. Check the medication label against the patient's medication record. Read the label again as you draw up the medication for injection.
INTRADERMAL INJECTION SITES
The most common intradermal injection site is the ventral forearm. Other sites (indicated by dotted areas) include the upper chest, upper arm, and shoulder blades. Skin in these areas is usually lightly pigmented, thinly keratinized, and relatively hairless, facilitating detection of adverse reactions.
Implementation
Verify the patient's identity by asking his name and checking the name, room number, and bed number on his wristband against his medical record.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Tell him where you'll be giving the injection.
Instruct the patient to sit up and to extend his arm and support it on a flat surface, with the ventral forearm exposed.
Put on gloves.
With an alcohol pad, clean the surface of the ventral forearm about two or three fingerbreadths distal to the antecubital space. Make sure the test site you have chosen is free from hair or blemishes. Allow the skin to dry completely before administering the injection.
While holding the patient's forearm in your hand, stretch the skin taut with your thumb.
With your free hand, hold the needle at a 10- to 15-degree angle to the patient's arm, with its bevel up.
Insert the needle about 1/8″ (0.3 cm) below the epidermis at sites 2″ (5 cm) apart. Stop when the needle's bevel tip is under the skin, and inject the antigen slowly. You should feel some resistance as you do this, and a wheal should form as you inject the antigen. (See Giving an intradermal injection.) If no wheal forms, you have injected the antigen too deeply; withdraw the needle, and administer another test dose at least 2″ from the first site.
Withdraw the needle at the same angle at which it was inserted. Don't rub the site. This could irritate the underlying tissue, which may affect test results.
Circle each test site with a marking pen, and label each site according to the recall antigen given. Instruct the patient to refrain from washing off the circles until the test is completed.
Dispose of needles and syringes according to your facility's policy.
Remove and discard your gloves.
Assess the patient's response to the skin testing in 24 to 48 hours.
GIVING AN INTRADERMAL INJECTION
Secure the patient's forearm. Insert the needle at a 10- to 15-degree angle so that it just punctures the skin's surface. The antigen should raise a small wheal as it's injected.
Special considerations
In patients who are hypersensitive to the test antigens, a severe anaphylactic response can result. This requires immediate epinephrine injection and other emergency resuscitation procedures. Be especially alert after giving a test dose of penicillin or tetanus antitoxin.
Documentation
On the patient's medication record, document the type and amount of medication given, the time it was given, and the injection site. Note skin reactions and other adverse reactions.
I.M. INJECTION
I.M. injections deposit medication deep into muscle tissue. This route of administration provides rapid systemic action and absorption of relatively large doses (up to 5 ml in appropriate sites). I.M. injections are recommended for patients who are uncooperative or can't take medication orally and for drugs that are altered by digestive juices. Because muscle tissue has few sensory nerves, I.M. injection allows less painful administration of irritating drugs.
The site for an I.M. injection must be chosen carefully, taking into account the patient's general physical status and the purpose of the injection. I.M. injections shouldn't be administered at inflamed, edematous, or irritated sites or at sites that contain moles, birthmarks, scar tissue, or other lesions. I.M. injections may also be contraindicated in patients with impaired coagulation mechanisms, occlusive peripheral vascular disease, edema, and shock; after thrombolytic therapy; and during an acute myocardial infarction because these conditions impair peripheral absorption. I.M. injections require sterile technique to maintain the integrity of muscle tissue.
Oral or I.V. routes are preferred for administration of drugs that are poorly absorbed by muscle tissue, such as phenytoin, digoxin, chlordiazepoxide, and diazepam.
Equipment
Patient's medication record and chart • prescribed medication • diluent or filter needle, if needed • 3- or 5-ml syringe • 20G to 25G 1″ to 3″ needle • gloves • alcohol pads • 2″ × 2″ gauze pad.
The prescribed medication must be sterile. The needle may be packaged separately or already attached to the syringe. Needles used for I.M. injections are longer than subcutaneous needles because they must reach deep into the muscle. Needle length also depends on the injection site, patient's size, and amount of subcutaneous fat covering the muscle. The needle gauge for I.M. injections should be larger to accommodate viscous solutions and suspensions.
Preparation of equipment