Download Administration of Parenteral Medications

C H A P T E R
Administration
of Parenteral
Medications
Chapter Outline
Administration of Parenteral
Medications
Parenteral Equipment and Supplies
Preparing Medications
General Guidelines for Parenteral
Medications
Routes of Administration
Intradermal Injections
Subcutaneous Injections
Intramuscular Injections
Parenteral Complications
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Immunizations
Contraindications and Precautions
in Vaccine Administrations
Basics of Intravenous Therapy
Equipment and Supplies Employed
in Intravenous Therapy
Documentation of IV Therapy
Risks, Complications, and Adverse
Reactions of IV Therapy
Discontinuation of Intravenous
Infusion Therapy
Intra-articular Injections
34
Essential Terms
ampule
aqueous
aspirate
bolus
cannula
cartridge unit
cubic centimeter (cc)
diluent
extravasation
gauge
hypodermic
infiltration
intra-articular
intradermal
intramuscular (IM)
Luer-Lok
occlusion
parenteral
patency
phlebitis
precipitate
primary drug
secondary drug
continues
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CHAPTER 34
KEY COMPETENCIES
CAAHEP
ABHES
Withdraw Medication from a Vial
III.C.3.b.4.g
VI.A.1.a.4.m
Withdraw Medication from an Ampule
III.C.3.b.4.g
VI.A.1.a.4.m
Reconstitute a Powdered Base Medication with a Diluent
III.C.3.b.4.g
VI.A.1.a.4.m
Mix Two Medications into One Syringe
III.C.3.b.4.g
VI.A.1.a.4.m
Load a Cartridge or Injector Device
III.C.3.b.4.g
VI.A.1.a.4.m
Administer an Intradermal Injection
III.C.3.b.4.g
VI.A.1.a.4.m
Administer a Subcutaneous Injection
III.C.3.b.4.g
VI.A.1.a.4.m
Administer an Intramuscular Injection
III.C.3.b.4.g
VI.A.1.a.4.m
Administer a Z-Track Medication
III.C.3.b.4.g
VI.A.1.a.4.m
subcutaneous
taut
thrombosis
trocar
vial
viscosity
wheal
Developmental Objectives
After completing this chapter, you should be able to:
1. Correctly spell and define the essential terms.
2. List six separate routes used for delivering parenteral medications.
3. List four common parenteral routes by injection and list which ones are
routinely performed by the medical assistant.
4. Name and describe the components of a hypodermic needle and syringe.
5. Describe various designs of needle safety devices, and discuss the importance of using these devices.
6. Describe the importance of needle safety when administering injections.
7. Describe factors that help determine the size of the syringe, the length of
needle, and the gauge of needle to be used.
8. List complications that may occur when incorrect equipment is used or
the medication is administered using the wrong route.
9. Describe the role of the medical assistant in the administration of intravenous medications.
10. List several complications that may occur when administering IV
medications.
11. List instances in which IV therapy should be discontinued.
Introduction
Medical assistants are often responsible for the administration of parenteral medications. The most common form of parenteral medication is injectables. In order
to successfully perform this task, the medical assistant must be able to select the
appropriate equipment, properly prepare the medication, select a suitable site,
and administer the medication using the correct technique. Both providers and
patients want to know that they can depend on the medical assistant to institute
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safety checks along the way to ensure that the entire
procedure is performed with absolute accuracy.
Failure to institute safety measures can result in serious consequences for the patient and possible litigation
for the office. This chapter will address the many duties
associated with parenteral drug administration and
provide useful tips that will aid in decreasing patient
discomfort and anxiety.
ADMINISTRATION OF
PARENTERAL MEDICATIONS
The term parenteral means pertaining to outside
the intestines. When referring to parenteral medication, it means to deliver medication via a route other
than through the digestive tract. The most common route used to deliver parenteral medications is
through injection; however, other parenteral routes
include intravenous (within the vein), transdermal
(through the skin), transmucosal (through the mucus
membrane), topical (on the skin), and inhalation
(through the respiratory tract). This chapter addresses
parenteral medications delivered through the injection and intravenous routes; refer to Chapter 32
for all enteral and parenteral routes.
Common parenteral routes by injection include
intradermal, subcutaneous, intramuscular, and intra-
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articular. Of those routes, only three are routinely used
by the medical assistant: intradermal, subcutaneous,
and intramuscular. Some medical assistants are also
responsible for administering intravenous medications;
however, this will vary according to the state’s medical
practice act and office policy.
Parenteral medications are delivered into the blood
stream much more rapidly than oral medications, usually within minutes. The following list provides information regarding the amount of time it takes for a
medication to enter the bloodstream through selected
parenteral routes:
❖ Intravenous: Instantly to seconds
❖ Intramuscular: 5 to 15 minutes, depending
on the drug
❖ Subcutaneous: Several minutes
Table 34-1 lists both the advantages and disadvantages of parenteral administration.
Parenteral Equipment and Supplies
There is a multitude of equipment and supplies available
for the delivery of parenteral medications. Syringes and
needles come in many sizes and are selected according
to the route the medication is to be given, the patient’s
body size, the viscosity (or thickness) of the medication, and the amount of medication to be given.
TABLE 34-1 Advantages and Disadvantages of the Parenteral Route of Administration
ADVANTAGES
DISADVANTAGES
Effective route when other routes would be difficult to
use. For example, if the patient is unconscious or
unresponsive.
Unsanitary equipment or mishandling of the equipment could cause microorganisms to be introduced
into the patient.
Medications administered by injection do not cause
irritation to the patient’s digestive system, nor are
they altered by gastric acids.
An allergic reaction to a parenteral drug may occur
more rapidly and may be more severe than an allergic
reaction to an oral medication because of how
quickly it is absorbed into the bloodstream and the
amount that is given in one dose.
An exact dose can be administered to a direct site
by injection.
Improper injection procedures could cause damage to
the patient’s nerves, tissue, veins, and other vessels.
Effects of the medication take place much more
rapidly than the oral route, so a patient that is in
excessive pain would receive faster relief from a
parenteral pain reliever than an oral pain reliever.
Veins could be traumatized by an intravenous
injection.
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CHAPTER 34
Syringes
Syringes (Figure 34-1) used today are primarily made of
plastic and are completely disposable. Typical syringe
sizes range from 1 mL to 5 mL. Larger syringes (10 to
60 mL) are used for irrigating wounds or body cavities, drawing large amounts of blood, and for aspirating fluid from a patient’s joint or body cavity. Syringe
selection is primarily based on the amount of medication to be administered.
Syringes are packaged in hard plastic containers or
peel-apart packages and are sealed to ensure sterility. If a syringe package appears to have already been
opened, the syringe should not be used and should be
disposed of properly.
The components of a syringe include the calibrated
barrel, plunger, flange, and tip (Figure 34-2). Table 34-2
explains each component of a syringe.
TOOL BOX
FI E L D S M A RTS
In order to prevent the medication from becoming
contaminated, you must never touch the inside of
the barrel of the syringe, the rubber stopper on
the plunger, or the tip of the syringe that connects to the needle.
FIGURE 34-2 The parts of a syringe
Luer-Lok tip
Needles
Needles are available in various sizes and lengths and
come in disposable and nondisposable forms. Needle
selection is determined by the type of medication to be
administered, the route of administration, and the size
of the patient. Disposable needles are more commonly
used and are prepackaged in sterile plastic or paper
wrappers.
A needle’s gauge (G) refers to the diameter of the
needle. Gauge selection is determined by the viscosity
or thickness of the medication. Gauge sizes that are typically used in ambulatory care range from 20 to 27 G.
The larger the gauge, the smaller the diameter of the
needle (for example, a 22-G needle would be smaller in
diameter than a 20-G needle). Figure 34-3 shows the
different needle gauges and lengths available.
FIGURE 34-1 Syringes can range from 1 mL to 60 mL.
Barrel
Tip
Rubber
stopper
Rubber
stopper
Plunger
Plunger
Flange
Flange
3 mL syringe
separated
5 mL syringe separated
and together
FIGURE 34-3 Examples of different needle gauges and lengths
60 mL syringe
30 mL syringe
10 mL syringe
5 mL syringe
3 mL syringe
Tuberculin
Insulin syringe with needle
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TABLE 34-2 Description of the Components of a Syringe
Barrel
The cylinder that holds the medication and contains calibrations for precise measuring. The barrel
is typically calibrated in milliliters (mL) or cubic centimeters (cc) but may be also be calibrated in
minims (M). Some specialty syringes contain other calibrations such as
the insulin syringe, which is calibrated in Units.
Plunger
A plastic rod with a rubber stopper on one end that seals the medication
within the syringe and flared edges on the other end for maneuvering
the plunger. This apparatus either draws medication in or pushes medication out of the barrel.
Flange
The flared plastic rim on the syringe used for guiding the plunger.
Tip
The part of the syringe in which the needle is attached. Different types
of syringe tips include: the Slip-tip (Figure 34-4), a smooth tip in which
the needle is attached just by slipping it onto the syringe; and the
Luer-Lok tip (Figure 34-5), which has a threaded end in which the
needle can be locked by twisting. The tip of the syringe must remain
sterile throughout the entire procedure.
Table 34-3 provides specific details for selecting the
appropriate gauge based on the route and the viscosity of the medication. Note: General guidelines for needle
gauges are provided later in the chapter under Routes of
Administration and should be used as guidelines for certification and registration testing.
The length of the needle is determined by the route
of administration, the site of the injection, and the
amount of adipose tissue over the injection site. Intramuscular (IM) injections will require a longer needle
FIGURE 34-4 Slip-tip
FIGURE 34-5 Luer-Lok tip
than a subcutaneous or intradermal injection because
muscles are deeper than the other two types of tissue. The location of the injection also plays a role in
the selection of needle length. The deltoid and gluteal
muscles are two common muscles that are used for
intramuscular injections, but each muscle is a different
size and at a different depth. The deltoid is smaller and
more superficial than the gluteal muscle and, therefore,
would take a shorter needle. Finally, the amount of
adipose tissue that the patient has in the area in which
TABLE 34-3 Common Gauge Sizes Based upon the Route of Administration and Viscosity of the Medication
GAUGE OF
NEEDLE
VISCOSITY OF
MEDICATION
ROUTE
EXAMPLES
19–20
Thicker or oil-based medications
IM
Hormones, steroids, penicillin, and certain
vitamin preparations
21–23
Aqueous- or water-based medications
IM
Immunizations and other water-based
medications
23–25
Aqueous-based medications
Sub-Q
Immunizations, allergy medications, etc.
26–27
Aqueous-based medications
ID
Allergy testing extracts and PPD extract
30
(usually
ultra-fine
point)
Aqueous-based medications
Sub-Q
Used when repeated injections are given,
such as insulin
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CHAPTER 34
the injection is being administered will also play a role
in the length of the needle that is used. Patients with
larger amounts of adipose tissue will require a longer needle to penetrate through the extra layers than
patients with little adipose tissue.
Table 34-4 provides common needle lengths based
upon the route of administration, the location of the
injection, and the size of the patient. Note: General
guidelines for needle lengths are provided later in the chapter under Routes of Administration and should be used as
guidelines for certification and registration testing.
Parts of the Needle Even though needles come in
disposable and nondisposable forms, they all have
similar components. Figure 34-6 shows different needles that are used for various routes and Figure 34-7
shows the different parts of a needle.
TOOL BOX
FI E L D S M A RTS
Many practices stock a limited variety of needle
gauges and lengths. This can be a real problem
when the patient does not meet the parameters of
what is considered to be average. The smart medical assistant will stock a wide variety of needle
gauges and lengths to accommodate patients of
all sizes and medications of all viscosities.
The parts of a needle include the following:
❖ Point: The sharpened end of the needle, cut in a
slanted edge called the bevel
TABLE 34-4 Common Needle Lengths Based upon the Route of Administration,
Location of the Injection, and Size of the Patient (Adult Chart)
INTRADERMAL INJECTIONS
3
⁄8⬙ to 1⁄2⬙
Patients with little adipose tissue (muscular patients)
3
⁄8⬙ to 1⁄2⬙
Patients with an average to large amount of adipose tissue
1
⁄2⬙ to 5⁄8⬙
5
⁄8⬙
Patients of all sizes
SUBCUTANEOUS INJECTIONS
INTRAMUSCULAR INJECTIONS
Deltoid: Adult with an underdeveloped or atrophied deltoid muscle and very little adipose
tissue (i.e., frail adult)
Deltoid: Adult with a well-developed deltoid muscle and an average amount of adipose tissue
1⬙
Deltoid: Adult with a well-developed deltoid and a large amount of adipose tissue
11⁄4⬙
Gluteal: Adult with very little adipose tissue
11⁄4⬙ to 11⁄2⬙
Gluteal: Adult with an average amount of adipose tissue
11⁄2⬙
Gluteal: Adult with a large amount of adipose tissue
2⬙ to 3⬙
Vastus lateralis (thigh): Adult with very little adipose tissue
1⬙
Vastus lateralis (thigh): Adult with an average amount of adipose tissue
11⁄4⬙
Vastus lateralis (thigh): Adult with a large amount of adipose tissue
11⁄2⬙ to 2⬙
Little adipose tissue: Can only pull up very little adipose tissue when lightly pinching the skin in the area
in which you are administering the injection (females or males less than 130 lb).
Average amount of adipose tissue: Can pull up an average amount of adipose tissue when lightly pinching the
skin in the area in which you are administering the injection (females 130 to 200 lb or males 130 to 260 lb).
Large amount of adipose tissue: Can pull up a large amount of adipose tissue when lightly pinching the skin in
the area in which you are administering the injection (females 200+ lb or males 260+ lb).
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TOOL BOX
Intramuscular
841
Subcutaneous
C R I T I C A L TH I N K I N G
C H A LL E N G E
An elderly, frail patient comes into the practice
to obtain a flu vaccine, which is an aqueous or
water-based solution. The patient’s deltoid muscle is not very prominent and the patient has very
little fat over the deltoid. The needles available
are 23 G 5⁄8⬙, 22 G 1⬙, and 20 G 11⁄2⬙.
1. What needle would work best for this
particular medication and patient? Give
the reason for your selection.
❖
Intradermal
Intracatheters
for intravenous
use
Butterfly needle and tubing for
infusions of medications i.v.
over a period of time
FIGURE 34-6 Different needles used for various routes of
administration
TOOL BOX
Lumen
C R I T I C A L TH I N K I N G
C H A LL E N G E
Mrs. Sims in room 2 is waiting for an ACTH injection. ACTH is a very thick, oily hormone. Mrs.
Sims has a large amount of adipose tissue around
her hips and buttocks region and weighs 253
pounds. The needle sizes available include 27 G
3⁄ ⬙, 25 G 5⁄ ⬙, 22 G 1⬙, 21 G 11⁄ ⬙, and 20 G 2⬙.
8
8
2
1. Which needle would work best under
these conditions? List your reasons.
❖ Lumen: The bore of a hollow needle
❖ Bevel: The flat, slanted edge of the needle that
helps to ease the insertion of the needle into the
tissue; there are finer cuts and different lengths of
bevels, such as a fine tip bevel, which is used for
insulin syringe needles. The finer the cut of the
bevel, the less pain felt by the patient and the less
trauma to the patient’s tissue.
❖ Shaft: The hollow steel tube of the needle through
which the medication passes into the patient
❖ Hub: The component that facilitates the attachment of the needle to the syringe; the hub is
color-coded for easy recognition of the size and
must remain sterile when assembling the needle
and syringe.
❖ Safety device: A mechanism to shield the needle
after use (see Figure 34-8)
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Point
Shaft
Bevel
Plastic sheath
Point
Shaft
Lumen
Hub
Hilt
FIGURE 34-7 The parts of a needle
TOOL BOX
FI E L D S M A RTS
Even though most injection equipment looks very
similar, you should refrain from mixing one manufacturer’s equipment with another manufacturer’s equipment. There may be slight variations in
the equipment’s locking mechanisms, preventing
the needle from firmly attaching to the syringe.
This may cause leakage of medication from the
syringe and detachment of the needle during the
procedure.
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CHAPTER 34
Needle Safety when Using Parenteral Equipment
Needle safety is very important when working with
parenteral equipment. Each office should use safety
devices to help prevent accidental needlesticks from
contaminated needles. There are a variety of different
types of safety devices, including retractable needles
and plastic sheaths that slide down over the needle.
Figure 34-8 shows a couple of different types of safety
devices.
If a dirty needlestick occurs while performing an
injection, the medical assistant should wash the area
immediately with soap and water and report the incident to a supervisor. An incident report should be
completed and the employee should receive counseling regarding what lab testing should be performed
and possible treatment options. Refer to Chapter 10
for a review of needle safety guidelines and procedures
to follow in the event of a needlestick.
Preparing Medications
Medications for parenteral administration are stored in
a variety of different containers. Medications may be
stored in a(n):
❖ Ampule (Figure 34-9a): A glass container with a
stem that holds a single dose of medication
❖ Cartridge unit (Figure 34-9b): A disposable,
prefilled, single-dose cartridge of medication that
slips into a nondisposable injection device
❖ Vial (Figure 34-9c): A glass or plastic container
that may contain either a single dose or multiple
doses of medication
(a)
(b)
(c)
FIGURE 34-9 Various medication containers: (a) ampule;
(b) cartridge unit; (c) vial
Measuring Medication in a Syringe
The type of syringe used will be based on the amount
of medication to be administered and sometimes on
the type of medication (for example, insulin). Syringe
sizes 3 cc and below are normally calibrated using two
scales: minims and milliliters (mL). Larger syringes are
normally calibrated in mL only. To draw up the correct amount of medication, the medical assistant must
be able to properly read the calibrations on the outside
of the syringe. The shorter lines on a 1-cc tuberculin
FIGURE 34-8 Examples of safety needles that assist in preventing accidental needlesticks (Courtesy and © Becton,
Dickinson, and Company.)
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syringe are measured in increments of hundredths.
Each small line represents 0.01 cc, or 1⁄100 of a cubic
centimeter. The longer lines are measured in tenths—
each line represents 0.1 cc, or 1⁄10 of a cc, and range
from 0.1 to 1.0 cc. On a 3-cc syringe, the smaller calibrations are measured in tenths and represent 0.1, or
1
⁄10 of a cc. The larger lines represent increments of 1⁄2,
1, 11⁄2, 2, 21⁄2, and 3 cc. On a 5-cc syringe, the smaller
calibrations are measured on a scale of 0.2, or 2⁄10 of a
cc, with the longer calibration lines representing 1, 2,
3, 4, and 5 cc.
Some specialty syringes are measured in units. A
unit is the amount of a substance necessary to stimulate a biological effect. The biological effect that one
unit of medication has upon body tissue is decided
upon by the International Conference for the Unification of Formulas. Unit increments are commonly used
for substances such as insulin and particular vitamins
and are specific to the individual substance or medication being administered; therefore, insulin syringes
may not be interchanged with other types of syringes.
To correctly fill a syringe, the plunger should be
pulled back so that the top of the rubber stopper is
even with the calibration line on the outside of the
syringe, matching the amount of medication ordered
by the physician (Figure 34-10).
Withdrawing Medication from a Vial
When medication is stored in a vial, it may be in a singledose vial (containing an individual dose of medication)
or a multiple-dose vial (containing several doses). The
FIGURE 34-10 Examples of syringes containing specific
amounts of medication: (a) 3 mL syringe filled to 1.5 mL;
(b) standard U-100 insulin syringe filled with 70 U of U-100
insulin; (c) 1 mL syringe filled to 0.3 mL
❖
843
name and strength of the drug should be checked on
the medication label a minimum of three times and
verified with the physician’s order. Always check the
expiration date on the vial as well. This information is
usually checked:
❖ When removing the medication vial from the shelf
❖ Right before preparing the medication
❖ Right after preparing the medication
A vial is packaged with a sterile cap that protects the
rubber stopper. The sterile cap will need to be removed
in a manner that prevents the stopper from becoming
contaminated prior to removal of the medication. Care
must also be taken not to contaminate or damage the
vial when preparing the medication.
Medication in a vial must be aspirated, or pulled
into the syringe through a needle, by pulling back on
the plunger of the syringe.
To prepare the syringe for use, remove it from the
wrapper and assemble the needle. Pull the plunger
TOOL BOX
FI E L D S M A RTS
Always inspect the rubber stopper of the vial to
make certain that the rubber is completely intact.
Check the medication in the vial to make sure
the there is no precipitate (pieces of solid material or crystals) or unusual cloudiness. If anything
unusual does appear, do not use the medication
and check with a supervisor to see if it should be
discarded. Always check to see how the medication should be stored, both before and after
opening.
TOOL BOX
(a)
FI E L D S M A RTS
(b)
There is no need to clean the stopper on a medication vial immediately after removing the seal.
The stopper is sterile at this point unless you contaminate it when removing the seal. Once the first
dose of medication has been removed, the stopper is no longer considered sterile and will need
to be cleansed with an alcohol wipe with each
subsequent use.
(c)
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CHAPTER 34
within the barrel back to the calibration line that
matches the amount of medication to be removed. For
example, if removing 11⁄2 mL of medication from the
vial, 11⁄2 mL of air must be inserted into the vial before
withdrawing the medication.
There is an air pressure vacuum inside the vial that
makes it easier to pull up the medication. The purpose
of forcing air into the vial is to equalize the pressure
within the vial after the medication has been removed.
If the proper amount of air is not inserted within the
vial, the pressure within the vial will drop, making it
very difficult to pull back on the plunger when filling
subsequent syringes. On the other hand, if too much
air is inserted within the vial, the pressure within the
vial will become very powerful, causing the medication
to be involuntarily forced out through the stopper and
out into the syringe.
Once the vial is prepared and the plunger is
pulled back to the amount of medication being withdrawn, insert the needle into the vial. With the vial
still in an upright position, push the plunger forward to expel the air within the syringe into the vial
(Figure 34-11). Pick up the vial and invert it with the
needle in it. Make certain that the needle is below
the liquid line before pulling back on the plunger
(Figure 34-12).
TOOL BOX
C R I T I C A L T H I N K ING
C H A L L E N GE
When withdrawing medication from a vial, you
notice that it is very difficult to pull back on the
plunger.
1. What may be the cause of this problem?
2. What can you do to correct the problem?
Carefully pull back on the plunger until reaching the
desired amount of medication to be withdrawn. Gently
pull the needle out of the vial and carefully place the
cap on the needle following institutional policy. (Tiny
air bubbles in the syringe may need to be removed by
gently flicking the syringe prior to withdrawing the
needle from the vial.) Procedure 34-1 lists the proper
steps for performing this procedure.
Withdrawing Medication from an Ampule
An ampule is made of sterile glass and contains one
single dose of medication premeasured to the exact
volume or amount needed. Examples of single-dose
medications contained in an ampule include heparin
FIGURE 34-11 Expel an amount of air into the vial that is equal
to amount of medication to be withdrawn.
FIGURE 34-12 The needle must be below the liquid line in
the vial before withdrawing the medication.
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TOOL BOX
F IEL D S M A R T S
It is not against OSHA policy to recap a sterile
needle. The Needle Stick Safety and Prevention
Act is in reference to contaminated needles, not
sterile needles.
and morphine. The neck of the ampule is constricted
and may cause medication to become trapped at the
top of the ampule (Figure 34-13). By flicking the
ampule with your wrist and hand, any trapped medication in the top will be forced down into the body of
the ampule. The outer surface of the ampule should be
cleaned with an alcohol pad or other antiseptic prior
to opening.
The glass ampule is hermetically sealed, meaning the dose is completely enclosed in glass, and the
neck is scored (indented), so it will break easily when
opened. The medical assistant should practice safety
procedures when separating the neck of the ampule
from the body of the ampule by covering the neck with
a gauze square and breaking it away from the body
(Figure 34-14). This will help prevent tiny particles of
glass from flying into the face or eyes of the person pre-
❖
845
paring the medication. The neck of the ampule should
be placed in a sharps container.
A special needle that contains a small filter
within the lumen can be used to remove any glass particles that may have mixed with the medication when
the top was snapped from the body of the ampule. A
membrane filter (Figure 34-15) may also be attached
to the syringe before attaching the needle to keep glass
out of the syringe. The filter needle is then removed
and replaced with a hypodermic needle before injecting the patient. Refer to Procedure 34-2 for the proper
steps to follow when withdrawing medication from an
ampule.
FIGURE 34-14 Cover the neck of the ampule with gauze and
snap the neck off away from you.
FIGURE 34-13 Force medication from the neck of the ampule
by a quick snap of the wrist.
FIGURE 34-15 Various membrane filters that can be attached to
syringes of all sizes, in place of using a standard filter needle
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❖
CHAPTER 34
Reconstituting Medications for Injection
Certain medications are packaged in powdered (dry)
form and must be reconstituted with a liquid in order
to be injected. Powder forms of medication have a longer shelf life than liquid forms. A diluent (liquid) is
used to reconstitute the powder. Normally this solution is sterile saline (NaCl), sterile water (H2O), or
lidocaine. The diluent may be supplied with the medication or may need to be drawn up separately. The
medical assistant must always follow the manufacturer’s instructions when reconstituting a medication.
Once the diluent is removed from its original container, it is injected into the powdered drug vial and
gently mixed by rolling the solution between both hands
until the all of the powder particles are dissolved.
Once the particles are completely dissolved, the
medical assistant will draw up the freshly made dilution (medication) following the physician’s orders.
Procedure 34-3 provides detailed instructions on the
steps required for reconstituting powdered drugs.
Mixing Two Medications in a Single Syringe
When a physician orders two medications, it is sometimes possible to combine the two drugs into one
syringe, thus making it possible to give one injection
instead of two separate injections. It is most important
to check with the physician or pharmacist to clarify if
the two medications can be combined. Some medications are not compatible and may cause problems if
combined.
When combining two medications, the medical
assistant must determine which medication is the
TOOL BOX
primary drug and which is the secondary drug. The
primary drug is the first drug to be drawn up into the
syringe. When administering insulin, the primary drug
is the clear insulin and the secondary drug is the cloudier insulin. Always check with the physician when in
doubt. Procedure 34-4 lists step-by-step instructions
for mixing two medications in a single syringe.
Using a Medication Cartridge or an Injector Device
Some medications come in sealed, prefilled glass cartridges that hold a single dose of medication. DepoProvera, penicillin G benzathine, Phenergan, and
interferon are examples of medications that are available in cartridges. The prefilled cartridge–needle units
require no mixing, no special calculations, and are easily administered to the patient.
The cartridge–needle units are designed to fit into a
cartridge unit syringe, referred to as an injector device
(Figure 34-16). Injector devices, such as Tubex® and
Carpuject® syringes, are usually nondisposable, made of
nonchrome-plated brass or plastic, and are interchangeable with many brands of cartridges. Procedure 34-5
lists steps that are performed when using a cartridge
injector device.
General Guidelines for Parenteral
Medications
In most medical facilities, the medication is prepared
in a different room than the examination room and
transferred to the exam room prior to injecting. Below
are guidelines to follow when preparing and administering all types of injections:
FIGURE 34-16 A cartridge–needle unit and a reusable injector device
F IEL D S M A R T S
Changing the needle between the vial and patient
reduces complications during and following the
injection. Each time the needle is pushed through
the stopper of a vial, it becomes dulled, making it
difficult to puncture the skin and creating more
pain for the patient. In addition, irritating substances such as allergy extracts may adhere to
the needle upon aspiration from the vial. As the
needle penetrates the skin, a small amount of the
medication may adhere to the outside of the skin,
promoting a painful local reaction at the site of
the injection.
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Plunger rod
Plunger
Rubber collar
Disposable sterile
cartridge-needle
unit
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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
❖ Prepare only one order of medication at a time
and for one patient at a time. If the patient is to
be given multiple injections, prepare each one
separately and label syringes or syringe wrappers
with a marking pen so that you can identify which
syringe holds what medication.
❖ Follow standard safety precautions when dealing
with needles and syringes.
❖ Ensure that contamination does not occur to the
equipment during preparation or transport.
❖ Never allow another health care worker to
prepare a medication that you will administer,
nor should you prepare a medication for someone
else. The responsibility for a medication error
falls on the person who administers the
medication.
❖ Follow the seven rights (from Chapter 32) when
administering all medications.
❖ Use two patient identifiers before administering
any medications (part of the Patient Safety Act).
❖ Check the patient’s drug allergy status, latex
allergy status, and adhesive allergy status prior to
administering any medication.
❖ Wash your hands and wear gloves just prior to
administering any parenteral medications. The
gloves are to protect you against possible bleeding
from the site.
❖ Never allow a patient to stand while receiving an
injection. The patient’s blood pressure may drop
and the patient may faint.
❖ Sites should be free of scar tissue, wounds, lesions,
rashes, moles, or any other disturbance in tissue
growth.
❖ Cleanse all sites with an approved skin antiseptic
using a circular motion prior to the injection.
❖ Stabilize your hand when holding the needle and
syringe. Hand movement may cause the needle to
move, nicking a blood vessel or nearby nerve.
❖ Follow the same track coming out of a site that
you use going in. This will decrease injury to the
surrounding tissue.
❖
847
❖ Engage the needle sheath or safety device on the
syringe immediately following the injection and
dispose of the unit in the sharps container.
❖ Patients should wait a minimum of 20 to
30 minutes following the injection to monitor
for anaphylaxis.
Guidelines for Aspiration
When administering intramuscular and subcutaneous injections, the medical assistant should aspirate
to make certain that the needle is not in a blood vessel. Depositing drugs directly into the bloodstream that
are meant for slower absorption may result in serious
complications to the patient. To aspirate, pull back
slightly on the plunger and look for blood in the tip
of the syringe. If this occurs, the needle–syringe unit
must be removed and disposed of according to OSHA
guidelines.
Some drug manufacturers discourage aspiration
when administering certain types of medications. Medical assistants should check the drug package insert
when in doubt. Table 34-5 lists general guidelines for
aspiration.
Guidelines for Massaging the
Site Following the Injection
At the conclusion of subcutaneous and intramuscular
injections, gently massage the site with a cotton ball
or gauze pad to assist with the disbursement of the
medication. Massaging is contraindicated with particular types of medications, especially those that may be
irritating to the tissue or those that can stain the skin.
Examples of medications in which massage is contraindicated include heparin, imferon, insulin, Fragmin,
and Lovenox. Massaging after these injections can
damage tissue at the site or cause the medication to be
absorbed incorrectly.
Massaging is contraindicated when performing all
intradermal injections due to the disbursement of the
extract into deeper tissue and when administering all
Z-track injections.
TABLE 34-5 General Guidelines for Aspiration
Intradermal
Do not aspirate on any intradermal injections.
Subcutaneous
General guidelines call for aspiration during subcutaneous injections; however, some
medications given through this route discourage aspiration, including Heparin, Lovonox, and insulin. Always check the manufacturer’s insert for clarification.
Intramuscular (IM)
General guidelines call for aspiration for IM injections; however, always check the drug
package insert for clarification.
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CHAPTER 34
Following the Procedure
Patients should be monitored for anaphylaxis (lifethreatening allergic reaction) for 20 to 30 minutes following the injection. Most anaphylactic reactions will
occur during this time period. Check the patient at the
end of the monitoring period to make certain there are
no concerns. Observe the site where the injection was
administered and look for any local reactions including
redness, wheals, or swelling. Ask if the patient is experiencing any breathing difficulties or any other unusual
symptoms. If the patient experiences anything out of
the ordinary, check with the provider before dismissing the patient. Provide the patient with education on
how to manage the injection site and what to expect
over the next few days. Document the procedure and
the follow-up observations in the patient’s chart. Refer
to Chapter 4 for a complete procedure on documenting medications. Medications such as immunizations
and narcotics should also be documented in designated
log. Figure 34-17 shows a hospital medication log.
ROUTES OF ADMINISTRATION
The route that is selected for parenteral delivery will be
primarily based on the manufacturer’s recommendation and the intended use of the drug. Routes selected
by the manufacturer are based on absorption properties
of the drug and possible irritants or dyes in the drug
FIGURE 34-17 An example of
a hospital medication log used to
document all medications for a
specific patient
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849
TOOL BOX
F IEL D S M A R T S
Patients will often tell you that they do not have
to wait following an injection because they are
not allergic to the medication. Remind patients
that they can develop an allergy at any time and
that office protocol requires the patient to wait.
Patients refusing to wait should sign a refusal
form that states the possible consequences of not
waiting. Place the refusal form in the patient’s
chart and document the refusal on the progress
note. Know your office’s protocol in the event a
patient does have a reaction. EpiPens or epinephrine should be stocked in any room where injections are administered.
that may make it harmful to surrounding tissue. Altering any drug routes could cause harmful side effects for
the patient, such as tissue abscess and degeneration,
tissue staining, and shock.
Intradermal Injections
The term intradermal means pertaining to within the
skin. The epidermis (outer layer of the skin) is the layer
of skin that is used for intradermal injections. In order
for the needle to stay within this layer, the needle should
be positioned at a 10° to 15° angle (Figure 34-18).
FIGURE 34-18 The needle is inserted at a 10° to 15° angle for
an intradermal injection.
When the medication is slowly injected at this angle, a
bubble of fluid called a wheal (Figure 34-19) should
appear on the outer surface of the skin.
The standard sites used for intradermal injections
are the inner lower forearm and the middle of the back
(Figure 34-20). These sites are used due to the lack of
hair found in these areas and the thinness of the skin.
Because of the location of the injection, aspiration is not
necessary when performing intradermal injections.
Common types of injections administered through
this route include allergy extract for testing purposes
and the PPD or tuberculin skin test. Intradermal injec-
FIGURE 34-19 A wheal should appear on the surface of the arm
following an intradermal injection.
TOOL BOX
E M R A P P L I C AT I O N
Many EMR software applications have a “Logs”
section integrated within the software. Medication logs can be easily accessed by clicking on
the “Logs” icon or equivalent name and clicking
on the appropriate medication log. Often, the
manufacturer’s name, lot number, and expiration
date will automatically appear from the previous
entry. Make certain that these items match the
current medication label. If they do not, change
these items to match the current label.
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CHAPTER 34
FIGURE 34-20 Sites for
an intradermal injection
include the inner forearm
and the upper portion of
the back.
tions should never be massaged because it will force
the liquid to be dispersed in deeper tissues, causing the
wheal to disappear.
Patients receiving intradermal injections will need
to have the site evaluated within a prescribed time
frame. The provider will measure the site where the
wheal was induced. If the wheal extends over a specific
parameter, it means that the test is positive. Table 34-6
is a summary chart for key information regarding
intradermal injections. Refer to Procedure 34-6 for
a complete procedure on administering intradermal
injections. Chapter 16 provides additional information
on TB skin testing.
Subcutaneous Injections
The term subcutaneous is a medical term that means
pertaining to under the dermis (or true layer of the
skin). Subcutaneous tissue is made up of fatty and connective tissue. When administering a subcutaneous
injection, the adipose tissue should be slightly pinched
between the finger and thumb to help differentiate the
adipose tissue from the muscle. The injection is placed
in the fatty tissue of the body, not the muscle. In order
to reach this tissue, the medical assistant should position the needle at a 45° angle (Figure 34-21); however,
a 90° angle may be appropriate for patients with lots of
adipose tissue or when using a shorter needle.
TABLE 34-6 Intradermal Injection Summary Chart
NEEDLE SIZE
26–27 G, 3⁄8⬙–5⁄8⬙
SYRINGE SIZE
1 mL
ANGLE OF INSERTION
10°–15°
ASPIRATE
No
COMMON MEDICATIONS OR
EXTRACTS GIVEN THIS ROUTE
Allergy extract, TB extract
MAXIMUM AMOUNT OF ML
PER LOCATION
0.1 mL
MASSAGE
No
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Intramuscular
90-degree
angle
Subcutaneous
45-degree
angle
❖
851
Intradermal
Intravenous
25-degree
angle
10- to 15degree angle
Epidermis
Dermis
Subcutaneous
tissue
Muscle
Intramuscular
(IM)
Subcutaneous
(SC)
Intravenous
(IV)
Aspiration is recommended for many medications
given subcutaneously, but is contraindicated in a select
few. Sites commonly used for this route include the
fatty outer portion of the upper arms, the lower abdomen, the middle and lower back, and the thigh region
(Figure 34-22). Table 34-7 lists important facts about
subcutaneous injections. Refer to Procedure 34-7
for instructions on how to administer subcutaneous
injections.
FIGURE 34-21 Angles
for injection into the
correct layer of skin or
muscle
Intradermal
(ID)
Intramuscular Injections
The term intramuscular (IM) means within the muscle. Intramuscular injections are given with a longer
needle and at a steeper angle of 90°. The needle must
be long enough to penetrate through the skin and subcutaneous tissues and deep into the muscular tissue;
otherwise, the medication will seep into the subcutaneous tissue and may cause a sterile abscess or malabsorption of the medication.
FIGURE 34-22 Common sites for
a subcutaneous injection
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CHAPTER 34
TABLE 34-7 Subcutaneous Injection Summary Chart
NEEDLE SIZE
23–25 G, 1⁄2⬙–5⁄8⬙
SYRINGE SIZE
1–3 mL (use an insulin syringe when giving insulin)
ANGLE OF INSERTION
45°–90°
ASPIRATE
The majority of drugs given through this route should be aspirated, but
aspiration is contraindicated in a select few drugs (refer to Table 34-5).
COMMON MEDICATIONS OR
EXTRACTS GIVEN THIS ROUTE
Allergy injections, insulin injections, heparin, Lovonox, MMR vaccine,
small pox vaccine, IPV vaccine, VAR vaccine
MAXIMUM AMOUNT OF ML
PER LOCATION
1 mL
MASSAGE
Yes, except in a select few medications (read manufacturer’s instructions)
Body areas normally used for intramuscular injection sites are the musculature of the dorsogluteal and
ventrogluteal regions, vastus lateralis, and the deltoid.
When administering an intramuscular injection, the
tissue overlying the muscle should be held taut (a term
that means to pull or draw tight) to ascertain that the
medicine is deposited into the muscle and not the subcutaneous tissue. Table 34-8 provides facts regarding
IM injections. Procedure 34-8 lists specific steps for
administering IM injections.
Dorsogluteal
The dorsogluteal site is used to administer injections
in adults and older children. Viscid or thicker medications or medications greater than 1 mL are usually
injected into this muscle. Extreme caution is to be used
TOOL BOX
FI E L D S M A RTS
Ask the patient to relax the muscle when giving
an IM injection. The relaxed muscle will help
with absorption of the medication and cause less
pain for the patient.
when administering injections in this area to ensure
that damage does not occur to underlying structures,
bones, vessels, or nerves.
When locating the correct site for this injection,
first locate the greater trochanter of the femur. Next,
TABLE 34-8 Intramuscular Injection Summary Chart
NEEDLE SIZE
20–23 G, 1⬙–3⬙
SYRINGE SIZE
3–6 mL
ANGLE OF INSERTION
90°
ASPIRATE
Yes
COMMON MEDICATIONS OR
EXTRACTS GIVEN THIS ROUTE
Most vaccines, analgesics, antibiotics, steroids, hormones
MAXIMUM AMOUNT OF ML
PER LOCATION
Deltoid: l mL; large muscles such as the dorsogluteal and vastus lateralis:
3 mL
MASSAGE
Generally: yes; Z-Track: no
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TOOL BOX
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853
TOOL BOX
F IEL D S M A R T S
FI E L D S M A RTS
When a physician orders a medication that
exceeds the maximum number of mL that the site
can hold, inquire about dividing the dose into
two even doses and giving it in two different locations. Always check with physician for approval
prior to dividing.
To assist with relaxation of the dorsogluteal muscle, place the patient in a prone position with the
toes turned inward.
emaciated, thin, or elderly patients due to a lack of sufficient muscle tissue.
locate the posterior iliac spine. Draw an imaginary line
between these two landmarks. Any place above and
outside of the imaginary line (Figure 34-23) is considered acceptable for this site.
The danger involved with using this site is the accidental penetration of or damage to the sciatic nerve,
the superior gluteal artery or vein, or the iliac crest
of the hip. Do not use the dorsogluteal site on infants
and use careful consideration with small children and
FIGURE 34-23a The dorsogluteal site
Iliac crest
Gluteus medius
muscle
Posterior superior
iliac spine
Gluteus minimus
muscle
Greater trochanter
of femur
Sciatic nerve
Gluteus maximus
muscle
Iliotibial tract
FIGURE 34-23b The landmark for dorsogluteal injections
Ventrogluteal
The ventrogluteal muscle can accommodate many of
the same medications injected into the dorsogluteal
muscle and may be used for patients of all ages. The
ventrogluteal area is free of major nerves and vessels so
it is considered safer than the dorsogluteal site.
To locate the ventrogluteal site, the medical assistant should be positioned to face the lateral side of the
patient’s hip. Center the top of the hand or fingers over
the patient’s gluteal medial muscle, just below the iliac
crest. If facing the patient’s right side, place the left
palm over the greater trochanter of the femur, place the
index finger of the left hand on the anterior superior
iliac spine, and spread the middle finger posteriorly
as far as it will reach along the iliac crest. This should
create a “V.” Within the “V” is where the injection will
be administered (Figure 34-24).
Vastus Lateralis
The vastus lateralis is part of the quadriceps group
of the thigh and is the preferred site for administering injections on infants and young children. This is
because it is larger and more developed than any of the
other large muscle groups at birth. The vastus lateralis
can also be used to administer IM injections to adults
and is relatively free of large vessels and major nerves.
Some adults may find it more painful to use this site
than the dorsogluteal or ventrogluteal sites. To find
the correct location of the vastus lateralis in adults, the
TOOL BOX
FI E L D S M A RTS
To assist with relaxing the vastus lateralis, have
the patient sit at the edge of the table with legs
dangling over the edge of the table.
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CHAPTER 34
Tubercle of
iliac crest
Femoral
nerve
Gluteus medius
muscle
Anterior superior
iliac spine
Gluteus minimus
muscle
Anterior
superior
iliac spine
Tensor
fasciae
latae muscle
Tensor fasciae latae
muscle
Gluteus
maximus
muscle
Femoral
artery and
vein
Greater trochanter
of femur
Sartorius
muscle
Vastus
lateralis
muscle
FIGURE 34-24a The ventrogluteal site
Patella
FIGURE 34-25a The adult vastus lateralis site
FIGURE 34-24b The landmark for ventrogluteal injections
medical assistant should position the hand so that it is
at least one hand’s width below the proximal end of the
greater trochanter of the femur. Place the other hand so
that it is at least one hand’s width above the kneecap.
The injection may be placed anywhere between those
two landmarks along the lateral or outer portion of
the thigh (Figure 34-25). Sites for infant and pediatric
injections are found in Chapter 19.
Deltoid
The deltoid is a smaller muscle than the other intramuscular sites, but can be used for thinner, less viscid
medications with a limited volume, such as immunizations. No more than 1 mL of medication should be
given in this location. The deltoid is not recommended
for infants and small children because the muscle is not
yet fully developed. The deltoid can be located by placing two fingers on the acromion process and measuring 1 to 2 inches below it (Figure 34-26). The injection
should be administered in the most prominent portion
of the muscle.
27187_34_c34_p835-882.indd Sec1:854
FIGURE 34-25b The landmark for vastus lateralis injections
TOOL BOX
FI E L D S M A RTS
To assist with relaxation of the deltoid muscle,
have the patient drop the arm against the side of
the body.
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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
Acromion
Clavicle
Deltoid muscle
Brachial artery
and vein
Cephalic vein
Humerus
FIGURE 34-26a The deltoid site
❖
855
cutaneous tissue over the dorsogluteal tissue are displaced or pulled laterally before the needle is inserted
by placing the palm of the nondominant hand on the
surface of skin, and pulling it several inches to the
side. This hand should not move until the end of the
procedure. The needle is inserted and the syringe is
aspirated (one-handed technique) to make certain that
the needle is not in a blood vessel. Following aspiration, medication is slowly injected into the tissue. Wait
10 seconds before removing the needle to give the
medication time to be absorbed. Immediately remove
the hand, holding the tissue to help create a seal
(Figure 34-27). The displaced tissue will return to its
original shape or location and stop the medication from
leaking out into the subcutaneous tissue. The pathway
of the needle is interrupted when using this technique
and is quite effective in preventing the loss of medication or discoloration of the skin from occurring. Do not
massage Z-track injections. Procedure 34-9 provides further details on how to perform this procedure. Common medications given by the Z-track method include
iron preparations and medications that are irritating to
superficial tissue, such as Vistaril®.
FIGURE 34-27 Remove the hand holding the Z-track immediately after withdrawing the needle.
FIGURE 34-26b The landmark for deltoid injections
TOOL BOX
F IEL D S M A R T S
When administering an immunization in the
deltoid muscle, use the patient’s dominant arm.
Increased muscle use will promote better circulation and will help to work out the soreness from
the injection much faster.
Skin pulled taut
Skin released
Z-Track Method of Injection
The Z-track method is used when the medication may
cause irritation to the skin or cause discoloration of
the tissues. This method seals the medication deeply
within the muscle and allows no exit path back into
the subcutaneous tissue and skin. The skin and sub-
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CHAPTER 34
PARENTERAL COMPLICATIONS
To reduce the risks of parenteral complications, follow
the guidelines listed throughout the chapter. Table 34-9
lists potential ramifications of performing injections
using incorrect techniques.
IMMUNIZATIONS
When most people think about immunizations, often
they just think about children (refer to Chapter 19 for
information about immunizations in children), but
adults receive their fair share of immunizations as well.
Immunizations such as the hepatitis B series, DT immunizations, and flu and pneumonia vaccinations are just
a few of the common immunizations that are listed on
the adult immunization schedule. There have been a
few new immunizations introduced in recent years,
including the shingles vaccine and the HPV vaccine.
It is important to help patients stay up to date with
immunizations and provide patients with education
about the newest immunizations available and their
benefits. Figure 34-28 lists the standard immunizations for adults.
TABLE 34-9 Possible Parenteral Complications
INCORRECT TECHNIQUE
CONSEQUENCES
EFFECTS
Failure to change the needle
between the vial and patient
Tissue irritation or discoloration
Excess pain to the patient
Local reaction to the skin or muscle
Discoloration of the skin
Increased amount of pain because of the
needle’s dullness
Using a needle that is too
short
Medication will be deposited
into incorrect tissue
Medication will not be absorbed the
way the manufacturer intended it to be
absorbed, thus changing the desired
effects of the medication
Abscess
Tissue degeneration
Using a needle that is too
long
Medication will be deposited
into incorrect tissue
Medication will not be absorbed the
way the manufacturer intended it to be
absorbed, thus changing the desired
effects of the medication
Could cause damage to the periosteum
resulting in infection and bone retardation
Needle could break off into the bone
Failing to aspirate on
medications that should
be aspirated
Deposition of medication
directly into a vein or artery
Shock: Medication was not intended
to go directly into the bloodstream.
May cause patient’s heart to beat faster,
respiration rate to increase, blood pressure to drop. Patient may become
unconscious.
Break in sterile technique
The introduction of microorganisms into the muscle,
subcutaneous tissue, or blood
stream
Blood infection
An abscess in the subcutaneous tissue,
muscle tissue, or surrounding tissue
Tissue degeneration
Choosing a muscle that is
underdeveloped
May cause injury to the nearby
nerves
Tingling
Excruciating pain
Paralysis
Injecting a patient with a
small-gauge needle when
administering a viscid
solution
May cause injury to the
surrounding tissue
Burning
Tissue degeneration
Increased pain to the patient
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857
Recommended Adult Immunization Schedule
Note: Thes ons must be read with the footnotes that follow.
Figure 1. Recommended adult immunization schedule, by vaccine and age group
United States, October 2007 – September 2008
AGE GROUP
VACCINE
19–49 years
Measles, mumps, rubella (MMR) 3,*
> 65 years
1 dose Td booster every 10 yrs
Tetanus, diphtheria,
pertussis (Td/Tdap)1,*
Human papillomavirus (HPV)2,*
50–64 years
Substitute
doseofofTdap
Tdapforfor
Substitute 11dose
TdTd
3 doses
females
(0, 2, 6 mos)
1 or 2 doses
1 dose
Varicella 4,*
2 doses (0,
In uenza 5,*
4– 8 wks)
1 dose annually
Pneumococcal (polysaccharide) 6,7
1–2 doses
Hepatitis A 8,*
1 dose
2 doses (0,
Hepatitis B 9,*
6–12 mos or 0,
3 doses (0, 1–2,
Meningococcal 10,*
6–18 mos)
4– 6 mos)
1 or more doses
Zoster 11
1 dose
*Covered by the Vaccine Injury Compensation Program.
For all persons in this category who meet the age
requirements and who lack evidence of immunity
(e.g., lack documentation of vaccination or have
no evidence of prior infection)
Recommended if some other risk factor is
present (e.g., on the basis of medical,
occupational, lifestyle, or other indications)
Report all clinically signi cant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on ling a VAERS report are available
www.vaers.hhs.gov
at
or by
telephone, 800-822-7967.
CS115143
Information on how to le a Vaccine Injury Compensation Program claim is availablewww.hrsa.gov/vaccinecompensation
at
or by telephone, 800-338-2382. To le a claim for vaccine injury, contact the U.S. Court of
Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400.
Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available
at
www.cdc.gov/vaccines
or from the CDC-INFO Contact Center at
800-CDC-INFO (800-232-4636) in English and Spanish, 24 hours a day, 7 days a week.
Use of trade names and commercial sources is for identi cation only and does not imply endorsement by the U.S. Department of Health and Human Services.
FIGURE 34-28 Recommended adult immunization schedule by vaccine and age group, updated annually and posted on the CDC’s Web
site, http://www.cdc.gov.
TOOL BOX
C R I T I C A L TH I N K I N G
C H A LL E N G E
You are performing a flu vaccine on a very frail
senior adult. Upon insertion of the needle, the
needle suddenly comes to a stop and you feel like
you hit a brick wall.
1. What probably just occurred?
2. How can you correct this?
3. Should you tell the patient what just
happened? How about the provider?
4. How could this have been prevented?
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Contraindications and Precautions
in Vaccine Administrations
There are many misconceptions regarding immunizations among the general population. It is important for
medical offices to stock brochures that will assist in
answering these questions and in helping to calm the
fears of patients and parents of pediatric patients about
risks involved with immunizing.
Some of the more common misconceptions are that
immunizations should not be given to women who
are pregnant or breastfeeding. The only two vaccines
known to actually cause harm to a developing fetus are
the MMR and Varicella due to the fact that they are live
vaccines. Some of the newer vaccines, such as the HPV
vaccine, are still being experimented with to determine
if there are risks to the developing fetus.
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Immune-compromised patients should explore the
benefits and risks of immunizing and make an informed
decision on what is best for their particular situation.
Some contraindications to vaccines include the
addition of preservatives or stabilizers that may be
the cause of allergy sensitivity such as gelatin, eggs,
or other types of plant derivatives used in processing
the vaccines. Read the package inserts very carefully
and screen the patient before administering the immunizing agents to verify prior history of sensitivity or
allergic reaction. The CDC has a great deal more information regarding immunization contraindications on
their Web site at http://www.cdc.gov.
BASICS OF INTRAVENOUS
THERAPY
Intravenous (IV) therapy is the administration of fluids or medications directly into a vein. The purpose of
administering fluids intravenously may be to replace
lost fluids or to introduce medication, solutions, or
nutrients to a patient. IV injections are usually administered directly into the vein (bolus) or injected into
an access port on the IV line. Intravenous therapy is
preferred when the patient requires fast absorption and
can bring quick results because fluids enter the bloodstream immediately. IV therapy is drug specific, meaning only certain drugs are administered by this route.
It is important to understand the difference between
intravenous injections and intravenous infusion. IV
injections consist of a relatively small amount of fluid
being introduced into the veins, while IV infusion is the
process of infusing fluid volumes of 50 mL to 500 mL
or more into the body.
Laws vary from state to state as to whether medical assistants can perform procedures directly related
to intravenous therapy. Health care facilities such as
ambulatory care clinics and urgent care centers have
started to delegate specific job duties to the medical
assistant including gathering the supplies, starting the
IV, monitoring the patient for adverse reactions, and
discontinuing the IV. A licensed physician is the one
who prescribes IV therapy. Whether or not the medical
assistant will be able to start IVs will be determined by
state law and office policy. The medical assistant must
be aware of the laws in the state in which she practices
so that the medical assitant does not go beyond the
scope of duty.
ply with federal and state laws regarding safe work
practices and for patient comfort. Containers for
IV fluids have changed from glass containers to pliable plastic bags (Figure 34-29) that are lightweight
and not at risk of becoming broken or damaged.
IV fluid bags range in size from 50 to 2000 mL,
with the smaller bags often referred to as “piggyback”
bags. When prescribed, the pharmacy will open the bag
to add additional medications to the fluids and label
the bag with the specific prescription the physician has
ordered. If a bag is found with the opaque outer bag
removed, do not use the solution because sterility and
viability of the product may be compromised.
The tamper-proof additive caps are removed when
additive drugs are mixed within the IV bag. Piggyback
containers are used for reduced volume of fluid infusion and are filled with ready-to-use medications at the
time of manufacturing. The pharmacy will add additional medications if prescribed, such as antibiotics.
Commonly used fluids contained within an IV bag
for infusion are normal saline (NaCl) or dextrose in
water. Infusions are given to replace lost body fluids,
restore fluid balance of cellular tonicity, or to provide
medications or nutrients to the body. Homeostasis of
FIGURE 34-29 Flexible IV solution containers (Courtesy of
Baxter Healthcare Corp.)
Equipment and Supplies Employed
in Intravenous Therapy
Equipment and supplies available for use in IV
therapy are continually being updated to com-
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TABLE 34-10 Common Fluids Used for IV Therapy
INFUSION
INDICATIONS
5% Dextrose in water (D5W)
Fluid replacement for rehydration
Normal saline (0.9% NaCl)
Used to replace sodium losses
Dextrose in saline solutions
Fluid replacement for burns, rehydration, maintenance infusion, circulatory
insufficiency, and in cases of shock
Ringer’s Solution
Na 147 mEq/L, K 4 mEq/L,
Cl 155 mEq/L
Restores fluid and electrolyte balance, used when patients have lactose
intolerance, may be used as a blood replacement for a short time
the body and its functions is the primary reason for
infusion of fluids. The fluid choice is based on the
electrolyte balance and the patient’s needs at the time.
While there are numerous types of fluids used during IV administration, some common products are
included in Table 34-10.
Infused fluids are introduced to the body through
administration sets, which is tubing that connects the
IV bags to the IV cannula in the patient. Administration sets come in a variety of styles, from the very basic
solution set to multiple administration tubing. All
IV tubing sets have common components including
clamps, a piercing pin, a drip chamber, and a cannula
adapter.
Basic IV Administration Sets
FIGURE 34-30 An IV administration tubing set
FIGURE 34-31 Tubing clamps
Each IV administration set has similar components,
including:
❖ Piercing pin (Figure 34-30): A hollow spike that is
inserted into the administration port of the IV bag.
It is important this remains sterile when inserted.
❖ Drip chamber (Figure 34-30): This is where the
solution flows prior to its entry into the tubing; it
acts as a pressurizing chamber for non-vented bags.
❖ Roller clamp (Figure 34-31): This is used to regulate the flow of fluids through the IV tubing.
❖ IV cannula or catheter (Figure 34-32): A flexible tube that is used to insert medication within
Piercing pin
Open
Flange
Drip chamber
Open
Close
Drop orifice
Close
Luer
slip
Close
Open
Close
Open
Slide clamp
FIGURE 34-32 A catheter and needle
Flow control
clamp
Injection port
Protective
cap
Catheter
hub
Catheter
Flashback
area
Needle
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a body cavity or blood vessel. It has a trocar (a
sharp-pointed needle) attached to it that punctures the skin to get the catheter within the vein.
❖ Slide clamp: This is used to restrict fluid flow and
act as a quick on/off control of the IV tubing. The
tubing ends in a sterile-capped adapter, which is
attached to the cannula.
Because of the legal issues involved with IV administration, the medical assistant’s responsibilities for
IV therapy are usually to collect the equipment and
supplies and to assist with taping the IV in place (Figure 34-33). The provider or nurse will usually be
responsible for starting the IV.
The infusion of fluids can be achieved by either an
infusion pump (Figure 34-34) or by gravity flow. The
gravity method is controlled by the roller clamps on
the IV tubing. The tighter the clamp, the less fluid that
flows through the tube. The drip chamber is used in
calculating the drops per minute that flow into the IV
tubing.
The IV pumps are more concise in delivery and more
practical and safe for the patient. Constant monitoring
of the IV set for occlusions is not necessary with the IV
pumps. The pump will sound an alarm if an occlusion
(blockage or closure) is detected or if the timing of the
flow rate indicates the bag is almost empty. With the
pump, the fluid is forced with light pressure into the
veins and lessens reflux, which is the backing up of
fluids into the veins and tissues. The pump can be set
for different lengths of time and rates of infusion. Some
pumps can run multiple IV lines on the same patient.
Documentation of IV Therapy
The health care professional that inserts and starts the
IV will be responsible for documenting the procedure.
Documentation in the patient’s chart should include
the IV site location, number of attempts of insertion,
any complications of the procedure, the date and time
of insertions, the needle gauge and length, and the
person’s initials that inserted the catheter. Any adverse
reactions to the procedure such as redness, pain, swelling, bruising, and other essential findings that are not
problematic at this point but could lead to complications
at a later date and time should also be documented.
FIGURE 34-33 Proper taping of an IV site: (a) Place a foam pad under the cannula; (b) apply the dressing; (c) pinch to secure the dressing to tubing; (d) secure with tape; (e) when removing, use alcohol to loosen tape. (Courtesy of ConMed Corp.)
(a)
(d)
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(b)
(c)
(e)
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Pressure History
Graphically displays
pressure trend for
last two hours.
Large Backlit Center
Display
(Scratch Pad)
Facilitates programming.
Dual-Channel
Delivery
Permits simultaneous
delivery of two separate
infusions at independent
rates.
Rapid Rate, On-Line
Titration
Facilitates rapid rate
adjustments without
interrupting flow.
861
RS-232 Data Port
Enables communication
with a variety of
information and
remote monitoring
systems.
Micro/Macro Infusion
Capability
Delivers precise infusions
at rates from 0.1 to
99.9 mL/hr in 0.1 mL/hr
increments and from 1 to
999 mL/hr in 1 mL/hr
increments.
Pump/Controller
Modes
Eliminates timeconsuming instrument
exchanges (based on
hospital infusion
protocols). Can switch
between pump and
controller modes with
the press of a single
key.
Programmable
Start Time
Can automatically start
multiple infusions at
specified times.
All Fluids Air-In-Line
Detector
Significantly reduces
the chance of
accidental administration
of air.
Multi-Dosing
Enables the automatic
delivery of a series of
infusions, from the
same IV container, at
specified times.
❖
Flo-Stop® Device
Provides disposablebased protection
against accidental IV
free-flow.
Dual-Rate
Piggybacking
Automatically switches
to primary parameters
upon completion of
secondary (piggyback)
infusion.
Volume/Time
Dosing
Automatic calculation
of rate by programming
volume and time.
Automatic Drug
Calculation
Calculates drug dose or
rate automatically for all
standard units of measure.
FIGURE 34-34 An IV infusion pump (Courtesy of Alaris Medical Systems.)
Risks, Complications, and Adverse
Reactions of IV Therapy
Intravenous therapy can have numerous inherent risks
and complications associated with this type of medication administration procedure. The medical assistant
must be knowledgeable in recognizing the complications, signs, and symptoms that may arise from the IV
infusion. The different complications can be classified
as local, systemic, or be a combination of the two.
Local complications may consist of pain and irritation at the insertion site, cannula dislodgement, catheter or needle occlusion, and phlebitis (inflammation of
the vein). Other complications may involve hematoma
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formation, venous spasm, vessel collapse, thrombosis
(blood clot), and nerve, tendon, or ligament damage.
It is essential to communicate with the patient to
assess complications of IV therapy or patient intolerance of the IV catheter. The medical assistant may be
the health care professional that monitors the patient
for complications and should know when the provider
or nurse should be alerted. Table 34-11 explains some
questions to ask a patient to clearly define the effectiveness of the therapy and patient tolerance.
Once the medical assistant has assessed the patient’s
pain, it is important to relay this information to the
provider so a determination can be made for the most
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TABLE 34-11 Guideline Questions for Patient
Pain Assessment
1. Tell me about the pain you are having.
2. Where does it hurt?
3. When did it start?
4. Is the pain in one spot, or does it radiate to
other places?
5. What kind of pain is it? Aching? Gnawing?
Burning? Stabbing or piercing? Dull?
Throbbing?
6. Are there any other symptoms of discomfort?
7. Rate the pain on a scale of 1 to 10, with 10
being the worst pain.
appropriate intervention. Depending on the findings,
the actions may include discontinuation of the therapy,
changing position of the extremity, adjusting the flow
rate of infusion, re-taping the site, or applying a warm
or cool compress. Table 34-12 explains in further detail
more of the complications and risks of IV therapy.
Systemic complications are much more dangerous and can be life threatening. The medical assistant
should become familiar with symptoms that may indicate a systemic reaction. Table 34-13 provides details
of systemic complications that may occur during IV
infusion therapy. If the medical assistant notices any of
the signs below, immediately alert the provider.
Discontinuation of Intravenous
Infusion Therapy
When the physician determines the patient no longer needs IV infusion, the IV must be discontinued.
The first step in discontinuing IV infusion is proper
aseptic technique and the application of gloves. Then
the IV tubing is clamped off and removed from the
adapter or extension set. Take care to not remove the
TABLE 34-12 Complications and Risks of Intravenous Therapy
COMPLICATIONS
AND RISKS
Infiltration or
extravasation
DESCRIPTION
SYMPTOMS
Medication fluid leaks from the
cannula or from the vein into the
tissues surrounding the site.
Redness, severe swelling, hardness at the
site, pain, and edema
Catheter and needle
displacement
Redness
Occlusion
The cannula becomes blocked and
allows blood to back up into the
IV tubing.
Blood in IV tubing
Loss of patency
(the openness of
the vein)
Occurs when the vein wall has
been damaged
Blood in IV tubing
Phlebitis
(inflammation of
the vein wall)
Bacteria can form as a normal
immune response due to the death
of leukocytes and other tissue cells.
Vein may be hard, red streak along vein,
inflammation, and swelling
Thrombosis
Blood clots form, causing slow or
stopped infusion.
Slow or stopped infusion
Fever and malaise may be present.
Hematoma
Blood infiltrates into the tissues.
Discoloration of the skin, discomfort, and
swelling
Cellulitis
A bacterial infection that can spread
to surrounding tissues
Redness, red streak at the site of the needle
or nearby
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TABLE 34-13 Signs and Symptoms of Systemic Complications
SYSTEMS AFFECTED BY
SYSTEMIC COMPLICATIONS
SIGNS AND SYMPTOMS
Cardiovascular system
Facial edema, generalized edema, erythema along veins, palpitations,
hypotension, cardiac arrest
Gastrointestinal system
Dysphagia, gastric cramping, intestinal cramping, nausea, vomiting
Integumentary system
Flushing, red flare, rash, IV site edema, pruritus (itching), urticaria (hives)
Nervous system
Agitation, anxiety, confusion, disorientation, headache, loss of sensation or
numbness, vertigo
Respiratory system
Nasal congestion, runny nose, cough, sensation of tightness in throat,
mucous membrane edema, bronchospasm, respiratory arrest
Special senses
Pruritus, watery eyes, scratchy throat, tinnitus (ringing in ears), buzzing
sound in ears, tingling or numbness in fingers or toes, vertigo
adapter—this will cause blood to leak profusely out of
the cannula hub. Remove the transparent dressing by
rubbing the patient’s skin with an alcohol pad, which
will loosen the adhesive in the dressing. This helps
patients who have a lot of hair on their arm or in cases
in which the adhesive dressing has adhered to skin and
is difficult to remove.
Once the transparent dressing is removed, the tape
securing the cannula hub should be removed. Take
care not to accidentally dislodge the hub from the
site during this process. When the tape is completely
removed, prepare a gauze pad and place above the
cannula site. Inform the patient to take a deep breath
and when the patient breathes in, remove the cannula
in one smooth continuous movement without pressing down on the cannula. Place the gauze over the site
and apply pressure for five minutes. Be sure to inspect
the cannula (Figure 34-35) to make sure it is in one
piece and has not broken off within the vein. Document in the patient’s chart the state of the cannula for
its “intact” form (for example, “Cannula removed from
right anterior forearm. Cannula intact. Patient tolerated procedure well. No swelling, no bruising, or other
complications noted.”).
Intravenous therapy is a concise procedure and
should be performed only by specially trained individuals. If medical assistants are asked to perform duties that
exceed their training, life-threatening incidences may
occur to the patient. If unsure of what exactly is detailed
in the procedure, verify with the ordering physician to
ensure complete understanding of the expectations of
performance and completion of the administration of
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FIGURE 34-35 Inspect the cannula following withdrawal from
the patient’s vein.
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intravenous therapy. If medical assistants are allowed
to perform IVs in their state but feel uncomfortable
performing the procedure, they should get assistance
from their superior or the provider.
INTRA-ARTICULAR
INJECTIONS
The term intra-articular means within a joint. Some
injections are given within a joint to help reduce inflammation and pain. Patients that suffer with osteoarthritis
are usually good candidates for these types of injections.
The knee is the most common joint in which these
injections are given but other joints can be injected as
well. Steroids to reduce inflammation are the common
drug category used to treat osteoarthritis.
The medical assistant’s duty for these injections
would be to prepare the patient for the injection and
to have all of the equipment ready for the physician.
The medical assistant may need to help hold the joint
still during the injection procedure.
TOOL BOX
C R I T I C A L T H I N K ING
C H A L L E N GE
You work in an urgent care center and the physician instructs you to start an IV on a specified
patient. You know that the Medical Practice Act
in the state in which you work requires a licensed
health care provider or registered nurse to perform this procedure. All of the rest of the medical assistants in the facility start IVs. One of the
medical assistants tells you that she will assist you
with your first IV.
1. How will you respond to the physician?
PROCEDURE 34-1 Withdraw Medication from a Vial
Objective:
To prepare medication from a vial for administration.
Equipment/Supplies:
❖ Vial of medication
❖ Antiseptic wipe
❖ Needle and syringe appropriate for
procedure
❖ Gauze 2x2 sponges
❖ Sharps container
❖ Medication tray
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and apply gloves.
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area.
Distractions and poor lighting may lead to medication
errors.
4. Select the correct medication from the storage
area and check the drug label (Medication
Check #1).
This assists in making certain you have the correct
medication.
5. Check the expiration date.
Using a medication beyond the expiration date may
decrease the effectiveness of the drug.
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PROCEDURAL STEPS
865
RATIONALE
6. Compare the medication with the physician’s
order (Medication Check #2).
This alleviates the possibility of
mistakes and wasting of valuable medication.
7. Calculate the correct dose to be given, if needed.
Verify the correct calculations with the physician
if necessary.
Giving the correct dose helps to
obtain the desired effects and
avoid complications.
8. Open the syringe and attach the needle to the
syringe.
9. Open the antiseptic wipe and clean the vial
stopper (Figure 34-36).
❖
FIGURE 34-36
This prevents contamination of
the vial and the needle when
preparing the injection.
10. Holding the syringe at eye level, pull back on the
plunger of syringe to draw an amount of air into
the syringe equal to the amount of medication to
be withdrawn from the vial.
This keeps the pressure in the
vial at atmospheric pressure.
11. Check to make sure the needle is firmly attached
to the syringe and remove the cap from the needle.
If the needle is not firmly
attached to the syringe, it may
become disconnected and cause
an injury to the person preparing the medication or to the
patient during the procedure.
Cleanse the stopper
of the vial.
FIGURE 34-37
Insert the needle
through the rubber
stopper.
12. Insert the needle through the rubber stopper
(Figure 34-37) until it reaches the empty space
between the stopper and the fluid level.
13. Push forward on the plunger to inject air into the
vial. Keep the needle above the fluid level.
Forcing air into the medication
can cause the fluid to break
down or bubble, thus creating
more bubbles in the medication
vial.
14. Invert the vial while holding onto the syringe and
plunger. Hold the vial and syringe without contaminating the needle or hub of the syringe. These
parts of the syringe must remain sterile.
This helps prevent microorganisms from entering the vial and
the patient from obtaining an
infection.
15. Hold the syringe at eye level and withdraw the
proper amount of medication (Figure 34-38).
This ensures that you are
reading the calibration lines
correctly.
16. Keep the tip of needle below the fluid level.
This prevents air microorganisms from entering the vial
and from being drawn into the
syringe.
17. Remove any air bubbles in the syringe by tapping or flicking the side of the syringe where the
bubbles are located (Figure 34-39).
If there are air bubbles in the
syringe, you may not have the
correct amount of medication.
Air bubbles can take up extra
space. Air bubbles may also
cause pain to the patient.
FIGURE 34-38
Hold the vial at
eye level during
withdrawal of the
medication.
FIGURE 34-39
Flick the syringe
to remove any air
bubbles.
continues
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CHAPTER 34
continued
RATIONALE
PROCEDURAL STEPS
Removing air bubbles and expelling any air could
change the volume of medication in the syringe.
18. Remove any air remaining in the tip of the syringe.
Check to make certain that you still have the correct amount of medication. If you do not, make
the appropriate adjustments to ascertain you have
the correct amount before removing the needle
from the vial.
19. Remove the needle from the rubber stopper of
the vial.
Replacing the needle unit reduces the
risk of a local reaction if the needle
used to withdraw
the medication is
changed between
the vial and patient.
Pushing the needle
through the rubber stopper dulls
the needle; a new
needle pierces the
skin much easier.
20. Replace the needle cap on the syringe
(Figure 34-40) or replace with a new needle
and cap setup.
FIGURE 34-40 Replace the
needle cap.
Three checks help to ensure you have the correct medication and prevents errors from occurring.
21. Read the medication label and replace the
medication vial in the correct storage cabinet
(Medication Check #3).
22. Place the syringe onto a clean tray with other items
necessary for the injection, including an alcohol
wipe, a cotton ball, and an adhesive bandage.
PROCEDURE 34-2 Withdraw Medication from an Ampule
Objective:
To prepare medication from an ampule for administration.
Equipment/Supplies:
❖ Ampule of medication
❖ Antiseptic wipes (2)
❖ Needle and syringe appropriate for
procedure
❖ Filter needle
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❖ Gauze 2x2 sponges
❖ Sharps container
❖ Medication tray
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PROCEDURAL STEPS
1. Wash your hands and apply gloves.
❖
867
RATIONALE
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area.
Distractions and poor lighting may lead to medication
errors.
4. Select the correct medication from the storage
area and check the drug label (Medication
Check #1).
This helps to ascertain you have the correct medication
and prevents error from occurring.
5. Check the expiration date.
No medication should be given if the drug has reached
the expiration date, as it may not be effective.
6. Compare the medication with the physician’s order
(Medication Check #2).
This alleviates the possibility of mistakes and wasting
of valuable medication.
7. Calculate the correct dose to be given, if needed.
An incorrect dose could cause great harm to the
patient.
8. Open the syringe and filter needle and assemble,
if necessary.
A filter needle filters out possible glass fragments that
may be present from snapping the stem from the body
of the ampule.
9. Tap the stem of the ampule lightly, or snap the
wrist of the arm holding the ampule, to remove
any medication in the neck of the ampule.
This forces the medication into the base of the ampule
container.
10. Open the antiseptic wipe and clean the ampule
container. Allow the ampule to dry completely.
This prevents contamination of the needle when preparing the injection.
11. Place a piece of gauze around the neck of the
ampule. Hold the ampule firmly between the
fingers and the thumbs of both hands.
This protects the fingers when breaking open the neck
of the vial.
12. Break off the stem by snapping it quickly and
firmly away from the body. Discard the top in
a sharps container and carefully set the ampule
down on a flat, firm surface.
This keeps glass fragments from flying into the medical
assistant’s eyes or face.
13. Check to make sure the filter needle is firmly
attached to the syringe and remove the cap from
the needle.
If the needle is not firmly attached it may cause injury
to the person preparing the medication.
14. Insert the needle into the ampule below the fluid
level. Hold the ampule at a slight angle while
advancing the needle within the glass body. Completely draw up all the medication into the syringe
(Figure 34-41).
Tilting the ampule facilitates
emptying the entire ampule.
15. Remove the needle from the ampule without
allowing the needle to touch the edges of the
ampule.
This prevents contamination of
the needle.
16. Dispose of the ampule into the sharps container.
Check the medication label before discarding the
ampule (Medication Check #3).
Immediately disposing of the
ampule prevents injury to the
person preparing the medication for injection.
FIGURE 34-41
Hold the ampule
at a slight angle
when withdrawing
medication.
continues
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CHAPTER 34
continued
PROCEDURAL STEPS
RATIONALE
17. Remove any bubbles in the syringe.
This helps to prevent little air bubbles from entering the
patient.
18. Pull back slightly on the plunger to draw the medication from the needle into the syringe, engage
the safety device, and remove the filter needle.
This removes any medication that remains within the
filter needle. Medication cannot be administered to the
patient with the filter needle.
19. Open a new needle for administering medication
to the patient and attach it correctly to the syringe.
The filter needle may have glass fragments inside, so it
is not used.
20. Remove the cap from the needle and push slightly
forward on the plunger to remove air that is within
the tip of the syringe and shaft of the needle.
This expels any air that is within the syringe tip and
shaft of the new needle to ensure that air is not being
injected into the patient’s tissues.
21. Replace the needle cap on the syringe following
institutional policy.
22. Prepare the medication tray. Place a bandage, a
gauze pad or cotton ball, an antiseptic wipe, and
the syringe on a medication tray for transporting
to the exam room to administer the injection to
the patient.
PROCEDURE 34-3 Reconstitute a Powdered-Base Medication
with a Diluent
Objective:
To reconstitute a powdered-base medication for preparation of administering
an injection to a patient.
Equipment/Supplies:
❖
❖
❖
❖
Vial of powdered medication
Vial of diluent
Antiseptic wipe
Two needles and a syringe appropriate
for procedure
PROCEDURAL STEPS
1. Wash your hands and apply gloves.
❖ Gauze 2x2 sponges
❖ Sharps container
❖ Medication tray
RATIONALE
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area.
Distractions and poor lighting may lead to medication
errors.
4. Select the correct medication and diluent from
the storage area, and check both drug labels
(Medication Check #1).
Having the wrong medication or diluent could cause
harm to the patient.
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PROCEDURAL STEPS
❖
869
RATIONALE
5. Check the expiration date on both labels.
Medication should not be given if the drug has reached
the expiration date, because it may not be effective.
6. Compare the medication with the physician’s order
(Medication Check #2).
This alleviates the possibility of mistakes and wasting
of valuable medication.
7. Calculate the correct dose to be given, if needed.
Verify the correct calculations with the provider if
necessary.
Giving the wrong dose could cause great harm to the
patient.
8. Open the syringe and needle and assemble, if
necessary.
9. Clean both the powder vial and the reconstituting
fluid vial stopper with alcohol before use
(Figure 34-42).
This prevents possible contamination to the medication vials
or the patient.
10. Pull back on the plunger to fill the syringe with
the amount of air equal to the amount of diluting
liquid required for reconstitution from the vial
containing the diluent.
This equalizes the pressure
within the vial.
11. Check to make sure the needle is firmly attached
to the syringe and remove the needle cap.
If the needle is not firmly
attached to the syringe, it may
become disconnected and cause
an injury to the person preparing the medication.
FIGURE 34-42
Cleanse the rubber
stopper of both vials.
12. Insert the needle into the diluent vial.
13. Push in the plunger, forcing the air from the
syringe into the vial of diluent (Figure 34-43).
This equalizes the amount of air
in the vial.
14. Invert the vial in the dominant hand, holding it
between the thumb and index finger.
15. Keep the needle immersed in the solution while
drawing the solution into the barrel of the syringe.
If the needle tip is not inserted
in the fluid, air will be drawn
into the syringe.
FIGURE 34-43
Inject air into the
diluent vial.
16. Check for air bubbles and determine that the exact
amount of diluent is withdrawn from the vial
before removing the needle from the vial.
17. Carefully remove the needle from the vial.
18. Insert the needle into the vial containing the
powdered medication (Figure 34-44).
19. Add the appropriate amount of reconstituting
liquid to the powdered drug, slowly rotating vial
while injecting fluid into it.
20. Replace the needle cap on the syringe following
institutional policy.
This allows the powder to be
flushed with the fluids and
helps to minimize the formation of clumps within the
powder.
FIGURE 34-44
Inject the diluent into
powdered medication
vial.
continues
27187_34_c34_p835-882.indd Sec1:869
9/4/08 6:51:26 PM
870
❖
CHAPTER 34
continued
PROCEDURAL STEPS
RATIONALE
21. Roll the vial between the hands to thoroughly mix
the medication (Figure 34-45).
This allows all of the
particles to be suspended appropriately.
22. Record the new date of expiration on the label of
the medication vial.
Once the medication
has been prepared, it is
only good for a certain
amount of time.
23. Recheck the medication label before returning
the vial to the proper storage area (Medication
Check #3).
A third check helps in
ascertaining you have
the correct medication.
24. Prepare to administer the medication to the
patient. Place a bandage, a gauze pad or cotton
ball, an antiseptic wipe, and the syringe on a
medication tray for transporting to the exam room
to administer the injection to the patient.
FIGURE 34-45 Gently roll
the vial between the hands to
mix well.
PROCEDURE 34-4 Mix Two Medications into One Syringe
Objective:
To draw two medications into one single syringe for injection administration
to a patient.
Equipment/Supplies:
❖ Two vials of medication
❖ Antiseptic wipe
❖ Two needles and a syringe appropriate
for procedure
❖ Gauze 2x2 sponges
❖ Medication tray
❖ Sharps container
PROCEDURAL STEPS
RATIONALE
1. Wash your hands and apply gloves.
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area.
Distractions and poor lighting may lead to medication
errors.
4. Select the correct medications from the storage
area and check their drug labels (Medication
Check #1).
Reading the label helps to acertain you have the correct
medication.
5. Check the expiration dates on both vials.
No medication should be given if the drug has reached
the expiration date, as the medication may not be as
effective.
27187_34_c34_p835-882.indd Sec1:870
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PROCEDURAL STEPS
❖
871
RATIONALE
6. Compare the medications with the physician’s
order (Medication Check #2).
This alleviates the possibility of mistakes and wasting of
valuable medication.
7. Calculate the correct doses to be given, if needed.
Verify the correct calculations with the provider if
necessary.
Giving an incorrect dose could cause great harm to the
patient.
8. Open the syringe and needle and remove them
from their packaging. Attach the needle to the
syringe.
9. Clean the rubber stopper of both vials with an
alcohol wipe.
This removes microbes that may be on the stoppers.
10. Determine which medication is the primary medication vial. Do not do anything with the primary
medicine at this point.
The primary medication is the first medication to be
drawn up.
11. Draw up an amount of air into the syringe that is
equal to the amount of medication required from
the second vial.
Air is injected into the second vial at this point because
once the syringe is filled with medication from the first
vial, it will no longer be possible to inject air into the vial.
12. Check to make sure the needle is firmly attached
to the syringe and remove the needle cap.
If the needle is not firmly attached it may become
detached from the syringe, causing harm to the preparer.
13. Insert the needle into the second vial and push
the air from the syringe into the vial to replace
the medication that will be taken out later. Do not
allow the needle to touch the liquid.
Pushing the needle into the medication will contaminate
the needle, affecting the next vial.
14. Carefully remove the needle from the vial.
15. Draw up an amount of air into the syringe that is
equal to the amount of medication required to be
taken from the primary vial.
This equalizes the pressure due to the fluid being
removed from the vial.
16. Insert the needle into the primary vial. Push
forward on the plunger, forcing air from the
syringe into the primary vial without contacting
the medication.
Pushing air into the liquid could create bubbles in the
syringe and vial.
17. Invert the vial in the dominant hand, holding it
between the thumb and index finger.
18. Keep the needle immersed in the solution while
drawing the solution into the barrel of the syringe.
If the needle tip is not inserted in fluid, air will be drawn
into the syringe.
19. Remove any air remaining in the tip of the syringe.
If there is medication lacking in the syringe, pull
back on the plunger so that the correct amount of
medication is drawn into the syringe.
This expels any remaining air within the syringe and the
needle and ascertains you have the correct amount of
medication.
20. Remove the needle from the stopper of the first
vial, engage the safety device, and discard into a
sharps container. Replace the needle with a new
needle.
This reduces the risk of medication from the first vial
carrying over to the second vial.
continues
27187_34_c34_p835-882.indd Sec1:871
9/4/08 6:51:28 PM
872
❖
CHAPTER 34
continued
PROCEDURAL STEPS
RATIONALE
21. Smoothly insert the needle into the secondary vial.
22. Invert the vial and slowly withdraw the medication required from the vial. Do not allow any
medication from the first vial to be inadvertently
injected into the second vial. Pulling slowly to
avoid creating air bubbles, pull the plunger back
to the correct calibration mark on the syringe.
If medication from the primary vial mixes with the
secondary vial it will contaminate the contents of the
second vial.
23. Remove the needle from the second vial.
24. Check for air bubbles and remove them from the
syringe.
25. Check again that the total amount of medication
in the syringe is the correct total to be administered.
If the incorrect dosage is in the syringe, the patient may
not obtain the full effects of the medication.
26. Replace the needle cap on the syringe following
institutional policy.
Some facilities will allow recapping of clean needles,
while other facilities prefer the scoop method.
27. Recheck the medication labels of both vials before
returning the vials to the proper storage area
(Medication Check #3).
Checking the label three times helps to ascertain you
have the correct medication and prevents errors from
occurring.
28. Prepare to administer the medication to the
patient. Place a bandage, a gauze pad or cotton
ball, an antiseptic wipe, and the syringe on a
medication tray for transporting to the exam
room to administer the injection to the patient.
PROCEDURE 34-5 Load a Cartridge or Injector Device
Objective:
To prepare medication from a prefilled cartridge for administration.
Equipment/Supplies:
❖ Prefilled cartridge of medication
❖ Cartridge holder
❖ Antiseptic wipe
27187_34_c34_p835-882.indd Sec1:872
❖ Gauze 2x2 sponges
❖ Sharps container
❖ Injection tray
9/4/08 6:51:29 PM
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
PROCEDURAL STEPS
1. Wash your hands and apply gloves.
❖
873
RATIONALE
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area.
Distractions and poor lighting may lead to medication
errors.
4. Select the correct medication from the storage
area and check the drug label (Medication
Check #1).
This ascertains that you have the correct medication.
5. Check the expiration date.
No medication should be given
if the drug has reached the
expiration date, as it may not
be effective.
6. Compare the medication with the physician’s
instructions (Medication Check #2).
This alleviates the possibility of
mistakes and wasting of valuable medication.
7. Calculate the correct dose to be given, if needed.
There may be instances in
which a patient does not need
the entire dose within the
cartridge.
FIGURE 34-46
Turn the ribbed collar
to the open position.
8. Pick up the cartridge unit holder (the injector).
9. Turn the ribbed collar toward the open position
until it stops (Figure 34-46).
This allows for the insertion of
the cartridge into the holder.
10. Hold the injector with the open end up and fully
insert the sterile cartridge–needle unit.
11. Firmly tighten the ribbed collar of the unit at the
syringe base by turning the ribbed collar toward
the “close” arrow. (Hold the cartridge to prevent it
from swiveling inside the holder while tightening.)
FIGURE 34-47
12. Thread the rod of the plunger into the cartridge
unit until a slight resistance is felt (Figure 34-47).
If the cartridge is not tightened
securely onto the holder, the
needle unit may move during
the injection procedure.
13. Prepare the medication for injection into the
patient at this time. Place a bandage, a gauze pad
or cotton ball, an antiseptic wipe, and the syringe
on a medication tray for transporting to the exam
room. Check the medication label one last time
(Medication Check #3).
Checking the label three times
ascertains you have the correct
medication and prevents errors
from occurring.
Thread the plunger
onto the cartridge
unit.
14. After use, do not recap the needle.
15. Disengage the plunger rod from the cartridge
unit holder while holding the needle down and
away from the fingers or hands over a sharps unit
(Figure 34-48).
This prevents the fingers from
being in front of the needle.
FIGURE 34-48
After the injection
is given, disengage
the plunger from the
cartridge unit.
continues
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9/4/08 6:51:30 PM
874
❖
CHAPTER 34
continued
RATIONALE
PROCEDURAL STEPS
16. Unscrew the ribbed collar of the cartridge unit
holder.
17. Allow the needle cartridge unit to drop into the
sharps container (Figure 34-49).
This helps to prevent an accidental needlestick.
18. Cleanse the cartridge holder with an antiseptic
cleanser and allow to dry.
This prevents crosscontamination from occurring
to the next patient receiving
medication from a prefilled
cartridge.
FIGURE 34-49
Allow the cartridge
to drop freely into the
sharps container.
19. Cleanse the work area and remove gloves and
wash your hands.
PROCEDURE 34-6 Administer an Intradermal Injection
Objective:
To administer an intradermal injection into a patient.
Equipment/Supplies:
❖ Appropriate sized needle and syringe
unit with correct medication
❖ Antiseptic wipe
❖ Gauze 2x2 sponges
PROCEDURAL STEPS
❖ Sharps container
❖ Disposable gloves
❖ Medication tray
RATIONALE
1. Wash your hands.
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment. Institute the Seven
Rights of Drug Administration.
Instituting the seven rights helps to alleviate errors.
3. Identify the patient using two identifiers, identify
yourself, and explain the procedure
Giving the medication to the wrong patient can cause
serious problems for the patient.
4. Ask patient about drug allergies or latex allergies.
Giving the patient a drug or using products that the
patient is allergic to can cause an anaphylactic reaction.
5. Select the proper injection site (anterior forearm or
middle of back).
6. Cleanse the site with antiseptic and allow to air
dry completely. (Cleanse in a circular motion
working outward to an area of 2 to 3 inches.)
27187_34_c34_p835-882.indd Sec1:874
This prevents the possible contamination of the injection site and ensures the removal of microorganisms
from the injection site area. Wet alcohol may cause the
site to burn when you inject the medication.
9/4/08 6:51:31 PM
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
PROCEDURAL STEPS
❖
875
RATIONALE
7. Prepare the equipment and apply gloves.
Wearing gloves prevents contamination of bloodborne
pathogens during the procedure.
8. Remove the needle cap. Pull the cap straight off,
never twist.
Twisting may loosen the needle attached to the syringe.
9. Stretch the skin taut at the site of administration.
This allows the needle to be inserted easier and keeps
the tissue from moving during insertion.
10. Insert the needle at a 10° to 15° angle
with the bevel upward just under the skin
(Figure 34-50).
11. Inject the medication slowly and steadily. A wheal
should form (Figure 34-51).
This allows the tissue
to slowly displace and
provides space for the
fluid. If the needle is
too deep, a wheal will
not form and the injection will have to be
repeated.
12. Remove the needle quickly at the same angle of
insertion.
This prevents injury to
the tissue.
13. Do not press on or massage the injection site.
Do not apply a bandage to the site.
The medication will be
dispersed into deeper
tissue if pressure is
applied to the area. A
bandage will absorb
the medication.
FIGURE 34-50 Insert the
needle bevel up just below the
surface of the skin.
FIGURE 34-51 A wheal will
form if the procedure was
performed correctly.
14. Properly engage the safety device on the needle
and dispose of the needle–syringe unit in the
sharps container.
Engaging the safety
device will help to
prevent an accidental needlestick.
15. Remove gloves and wash your hands.
This prevents contamination and the spread of
infection.
16. Give proper patient education for caring for
the site and inform the patient to wait 20 to
30 minutes.
The 20 to 30 minute wait is to observe the patient for
anaphylaxis.
17. Perform post-injection observation and document
the procedure in the patient’s chart and the appropriate logs.
Documentation illustrates that the procedure was
performed.
DOCUMENTATION EXAMPLE:
05-22-XX
3:15 p.m.
27187_34_c34_p835-882.indd Sec1:875
Tubersol, 0.1 mL, ID , right lower forearm, per Dr. Jones. Manf – Kline Beecham, Lot number—K449, exp.
date – 12/XX. Pt. tolerated well, instructions given to return to clinic 48–72 hours for PPD reading.
– complications during post-injection observation. Sherri Jones, CMA (AAMA)
9/4/08 6:51:32 PM
876
❖
CHAPTER 34
PROCEDURE 34-7 Administer a Subcutaneous Injection
Objective:
To administer an injection through the subcutaneous tissue.
Equipment/Supplies:
❖ Appropriate sized needle and
syringe unit with correct medication
❖ Antiseptic wipe
❖ Gauze 2x2 sponges
PROCEDURAL STEPS
❖
❖
❖
❖
Sharps container
Disposable gloves
Medication tray
Adhesive bandage
RATIONALE
1. Wash your hands.
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment. Institute the Seven
Rights of Drug Administration.
Instituting the seven rights will help prevent errors
from occurring.
3. Identify the patient using two identifiers, identify
yourself, and explain the procedure.
Giving the medication to the wrong patient can cause
serious problems for the patient.
4. Ask the patient about drug allergies, latex allergies,
or adhesive allergies.
Giving the patient a drug or using products that the
patient is allergic to can cause an anaphylactic reaction.
5. Select the proper injection site (fatty tissue of the
arms, thighs, or stomach).
6. Cleanse the site with antiseptic and allow to air
dry completely. (Cleanse in a circular motion
working outward to an area of 2 to 3 inches.)
This prevents the possible contamination of the injection site and ensures the removal of microorganisms
from the injection site area. Wet alcohol may cause the
site to burn when you inject the medication.
7. Prepare the equipment and apply gloves.
This prevents contamination by bloodborne pathogens
during the procedure.
8. Remove the needle cap. Pull the cap straight off,
never twist.
Twisting may loosen the needle attached to the syringe.
9. Grasp or pinch the tissue lightly with one hand.
This helps to determine
the subcutaneous layer of
tissue and helps with the
needle insertion.
10. Insert the needle at a 45° angle with the other
hand, using a quick and smooth motion
(Figure 34-52).
11. Stabilize the needle within the tissue.
27187_34_c34_p835-882.indd Sec1:876
Unnecessary movement of
the syringe can cause tissue
damage and pain to the
patient.
FIGURE 34-52 The
proper angle of insertion for a subcutaneous
injection
9/4/08 6:51:32 PM
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
PROCEDURAL STEPS
❖
877
RATIONALE
12. Aspirate to ensure the needle is not in a blood
vessel.
If the needle has inadvertently been inserted into a
vessel, there will be a bloody return into the syringe.
Do not inject, but remove the needle immediately.
Depositing medication into a blood vessel could cause
harm to the patient.
13. Inject the medication slowly and steadily.
Injecting the medication too quickly can cause discomfort to the patient and not allow the medication to be
absorbed properly.
14. Remove the needle quickly at the same angle of
insertion.
This helps to prevent trauma to the tissue.
15. Place a cotton ball or gauze sponge over the injection site and gently massage the area, if applicable.
This helps ease the discomfort caused from the injection and accelerates absorption of the medication
(unless massaging is contraindicated).
16. Properly engage the needle’s safety device and
dispose of the needle and syringe into the sharps
container. Apply a bandage to the site to prevent
the patient’s clothes from becoming contaminated
with blood.
Engaging the safety device helps to reduce the possibility of a needlestick.
17. Remove gloves and wash your hands.
This prevents contamination and the spread of
infection.
18. Give proper patient educational materials and
waiting instructions.
19. Perform post-check of the patient and site 20 to
30 minutes following the procedure.
Allergic reactions usually occur within 20 to 30 minutes of the procedure.
20. Chart the procedure correctly on the progress note
and appropriate logs.
Documentation illustrates that the procedure was
performed.
DOCUMENTATION EXAMPLE:
05-22-XX
3:15 p.m.
27187_34_c34_p835-882.indd Sec1:877
Varivax #1, 0.5 mL, sub-q, right arm per Dr. Sullivan. Manf.–Kline Beecham, Lot number–K449, exp. date
– 12/XX. Pt. tolerated well, instructions given to pt. for site care and VIS sheet provided—consent form
signed and filed in chart.. Post injection follow-up, –complications. Sherri Jones, CMA (AAMA)
9/4/08 6:51:33 PM
878
❖
CHAPTER 34
PROCEDURE 34-8 Administer an Intramuscular Injection
Objective:
To administer an injection within the muscular tissue.
Equipment/Supplies:
❖ Appropriate sized needle and
syringe unit with correct medication
❖ Antiseptic wipe
❖ Gauze 2x2 sponges
PROCEDURAL STEPS
❖
❖
❖
❖
Medication tray
Sharps container
Disposable gloves
Adhesive bandage
RATIONALE
1. Wash your hands.
This prevents the spread of infection and contamination during the procedure.
2. Assemble the equipment. Institute the Seven
Rights of Drug Administration.
Instituting the seven rights will help prevent errors
from occurring.
3. Identify the patient using two identifiers, identify
yourself, and explain the procedure.
This prevents the wrong patient from receiving the
medication.
4. Ask the patient about drug allergies, latex allergies,
or adhesive allergies.
Giving the patient a drug or using products that the
patient is allergic to can cause an anaphylactic reaction.
5. Locate the proper injection site (deltoid, dorsogluteal, ventrogluteal, or vastus lateralis).
The right site must be selected in order for the drug to
be absorbed properly.
6. Cleanse the site with antiseptic and allow to air
dry completely. (Cleanse in a circular motion
working outward to an area of 2 to 3 inches.)
This prevents the possible contamination of the injection site and ensures the removal of microorganisms
from the injection site area. Wet alcohol may cause the
site to burn when you inject the medication.
7. Prepare the equipment and apply gloves.
This prevents contamination by bloodborne pathogens
during the procedure.
8. Remove the needle cap. Pull the cap straight off,
never twist.
Twisting may loosen the needle attached to the syringe.
9. Stretch the tissue to hold the skin taut with your
nondominant hand.
10. Using your dominant hand, insert the needle at
a 90° angle using a quick and smooth motion
(Figure 34-53).
This helps with the needle
insertion.
11. Stabilize the needle within the tissue.
Unnecessary movement
of the hand holding the
syringe can cause tissue
damage and pain to the
patient.
12. Aspirate to ensure the needle is not in a blood
vessel. If blood enters the syringe, do not inject,
but remove the needle immediately. If there is no
bloody return into the needle, proceed with the
injection process.
Depositing the medication
into the bloodstream could
cause great harm to the
patient.
27187_34_c34_p835-882.indd Sec1:878
FIGURE 34-53 The
proper angle of insertion for an intramuscular
injection
9/4/08 6:51:34 PM
A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
PROCEDURAL STEPS
❖
879
RATIONALE
13. Inject the medication slowly and steadily.
Injecting the medication too quickly can cause discomfort to the patient and not allow the medication to be
absorbed appropriately.
14. Remove the needle quickly at the same angle of
insertion.
This helps to prevent trauma to the tissue.
15. Place a cotton ball or gauze sponge over the injection site and gently massage the area, if applicable.
Massaging the area helps to disburse the medication,
unless contraindicated.
16. Engage the safety device on the needle, and
dispose of the needle–syringe unit in the sharps
container.
This protects you from an accidental needlestick from
a contaminated needle.
17. Place an adhesive bandage over the site and
remove gloves and wash your hands.
This prevents contamination and the spread of infection.
18. Give related patient educational materials and
proper waiting instructions.
19. Perform post-check of the patient and site 20 to
30 minutes following the procedure.
Allergic reactions usually occur within 20 to 30 minutes
of the procedure.
20. Chart the procedure correctly on the progress note
and appropriate logs.
Documentation illustrates that the procedure was
performed.
DOCUMENTATION EXAMPLE:
05-22-XX
3:15 p.m.
Hepivax 0.5 mL, IM, R. Deltoid per Dr. Jones. Manf. – Kline Beecham, Lot number–K449, exp. date – 12/XX.
Pt. tolerated well, instructions given to pt. for site care and VIS sheet provided and consent form signed
and filed. No problems during post check. Sherri Jones, CMA (AAMA)
PROCEDURE 34-9 Administer a Z-Track Medication
Objective:
To administer an injection by the Z-track method
Equipment/Supplies:
❖ Appropriate sized needle and syringe unit
with correct medication
❖ Antiseptic wipe
❖ Gauze 2x2 sponges
❖
❖
❖
❖
PROCEDURAL STEPS
RATIONALE
1. Wash your hands.
Medication tray
Sharps container
Disposable gloves
Adhesive bandage
This prevents the spread of infection and contamination during the procedure
2. Assemble the equipment. Perform the Seven
Rights of Drug Administration.
3. Identify the patient using two identifiers, identify
yourself, and explain the procedure.
This ensures that you do not give the wrong patient the
medication.
continues
27187_34_c34_p835-882.indd Sec1:879
9/4/08 6:51:34 PM
880
❖
CHAPTER 34
continued
PROCEDURAL STEPS
4. Ask the patient about drug allergies, latex allergies,
or adhesive allergies.
RATIONALE
Giving the patient a drug or using products that the
patient is allergic to can cause an anaphylactic reaction.
5. Locate the proper injection site (usually the dorsogluteal site).
6. Cleanse the site with antiseptic and allow to air
dry completely. (Cleanse in a circular motion
working outward to an area of 2 to 3 inches.)
Cleansing the site reduces microorganisms on the skin.
Allowing the site to air dry helps to take away the sting
when inserting the needle.
7. Prepare the equipment and apply gloves.
Gloves help to prevent contamination by bloodborne
pathogens during the procedure in the event the site
bleeds.
8. Remove the needle cap. Pull the cap straight off,
never twist.
Twisting may loosen the needle attached to the syringe.
9. Using your nondominant hand, pull the tissue to
be injected laterally 1 to 2 inches away from the
injection site.
This displaces the tissue so when the tissue is released,
the tissue will return to a normal position to prevent
the medication from leaking out of the site and into surrounding tissue.
10. Using your dominant hand, insert the needle at a
90° angle with a quick and smooth motion.
11. Stabilize the needle within the tissue.
Unnecessary movement of the hand holding the syringe
can cause tissue damage and pain.
12. Aspirate using the one-hand technique to ensure
the needle is not in a blood vessel. If medication is
in a blood vessel, remove the needle and prepare a
new setup.
Using the one-hand technique when aspirating frees the
other hand to keep the tissue retracted.
13. Inject the medication slowly and steadily.
Injecting the medication too quickly can cause discomfort to the patient and not allow the medication to be
absorbed properly.
14. Wait 10 seconds before removing the needle.
This allows the medication to settle in the tissue.
15. Remove the needle quickly at the same angle of
insertion.
16. Release the tissue after removing the needle from
the site.
This allows the displaced tissue to return to a normal
position and blocks the insertion path of the needle,
preventing the medication from leaking into the surrounding tissues.
17. Place a cotton ball or gauze sponge over the
injection site. Do not massage the site for a Z-track
injection.
Massaging could possibly cause malabsorption of the
medication, discoloration to the tissue surrounding the
site, or even leakage of the medication from the injection site.
18. Properly engage the safety device and dispose of
the needle–syringe unit into the sharps container.
Apply a bandage to the site to prevent the patient’s
clothes from becoming contaminated with blood.
Engaging the safety device keeps you from accidentally
getting stuck with a contaminated needle.
19. Remove gloves and wash your hands.
This prevents contamination and the spread of
infection.
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A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
PROCEDURAL STEPS
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881
RATIONALE
20. Give related patient educational materials and
waiting instructions.
21. Perform post-check of the patient and site 20 to
30 minutes following the procedure.
Allergic reactions usually occur within 20 to 30 minutes of the procedure.
22. Chart the procedure correctly in the progress note
and appropriate logs.
Documentation proves that you performed the
procedure.
DOCUMENTATION EXAMPLE:
05-22-XX
3:15 p.m.
Methylcobalamin, 1.0 mL, Deep IM (Z-Track), L. Dorsogluteal per Dr. Raymond. Manf. – Kline Beecham, Lot
number–K449, exp. date – 12/XX. Pt. tolerated well, –complications during post injection check. Sherri
Jones, CMA (AAMA)
Chapter Summary
By learning the information provided in this chapter and performing the competencies, medical assistants will come
to realize the importance of performing safe and competent invasive procedures for their patients’ health care needs.
The practice of performing invasive procedures must be methodical, focused, and performed with the utmost care,
not given light thought or compromising the quality of services provided. The standard of care demands a high level
of achievement and understanding, for the protection of the patient and the provider’s practice.
FIELD APPLICATION CHALLENGE
The physician asks you to administer a hormone
shot that is very viscid and oily. As you go to withdraw the medication, you notice that you are having
a great deal of trouble pulling back on the plunger.
After preparing the medication, you go back to the
patient’s room with the medication tray. You ask
the patient where he wants to have the medication
administered. The patient replies his arm and rolls
up his sleeve. You start to administer the injection.
You notice that it is very difficult to push forward
on the plunger as you inject the medication into the
patient’s deltoid. The patient appears to be experiencing a great deal of pain. Following the injection,
the skin over the site is very reddened and a hard
knot now appears at the injection site.
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1. What are some possible causes for the difficulty
in pulling back the plunger?
2. What should you have done when the patient
asked for the injection in the arm? What would
have been a better location?
3. What would have been an appropriate sized
needle to use for this injection based on the
new location of the injection and the viscosity
of the medication?
4. Why do you suppose that the patient’s arm reddened and a knot appeared in the area where
the injection was given?
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882
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CHAPTER 34
Chapter Assessment
Web Activity
1. What is the most important aspect of administration of medication to a patient?
a. Documentation of the procedure
b. Documentation of the medication administered
to the patient
c. Proper identification of the patient
d. Proper technique in administering the
medication
1. The Centers for Disease Control and Prevention
National Immunization Program provides information on the importance of vaccinations. Go to
http://www.cdc.gov and look up this important
information. Prepare a one-page summary that
depicts why the benefits of immunizing far outweighs the risks of immunizing.
2. Tuberculin syringes come in what syringe size?
a. 1 mL syringes
b. 3 mL syringes
c. 5 mL syringes
d. 10 mL syringes
3. The gauge of the needle indicates:
a. the size of the lumen.
b. the length of the needle.
c. the length of the hub.
d. the size of the syringe.
4. A subcutaneous injection is usually given at what
degree for angle of insertion?
a. 10°
b. 15°
c. 45°
d. 90°
5. The two vaccines that are contraindicated for
pregnant women are:
a. hepatitis B and tetanus.
b. Varicella and MMR.
c. PPD and hepatitis B.
d. small pox and hepatitis A.
6. The gauge used for an injection is determined by:
a. the viscosity of the medication.
b. the site of the injection.
c. the amount of fat the patient has.
d. all of the above.
CONNECTION
Using your StudyWARE CD-ROM:
❖ Complete the Concentration activity for this
chapter.
❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK
On your StudyWARE CD-ROM,
go to the DVD Challenge for
this chapter. View the DVD clip
and respond to the following
questions:
1. Once you load the cartridge into the injector
device and lock it into place, what should
you do with the medicine in the syringe to
finalize the preparation of the syringe needle
unit?
2. After administering the injection, what steps
should you take to dispose of the cartridge
unit?
7. Parenteral routes include all but which of the
following?
a. Intramuscular
b. Intravenous
c. Oral
d. Intra-articular
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