Subcutaneous injection technology: placement sites. Subcutaneous injection technique: execution algorithm Intradermal subcutaneous intramuscular intravenous injections

- a method of administering drugs, in which the drug enters the body by injecting an injection solution through a syringe into the subcutaneous tissue. When conducting a subcutaneous injection of the drug, it enters the bloodstream by absorption of the drug into the vessels of the subcutaneous tissue. Usually, most drugs in the form of solutions are well absorbed in the subcutaneous tissue and provide relatively rapid (within 15-20 minutes) absorption into the systemic circulation. Usually, the effect of the drug with subcutaneous administration begins more slowly than with intramuscular and intravenous administration, but faster than with oral administration. Most often, drugs are administered subcutaneously, which do not have a local irritant effect, and are well absorbed in the subcutaneous adipose tissue. Heparin and its derivatives are administered exclusively subcutaneously or intravenously (due to the formation of hematomas at the injection site). Subcutaneous injection is used when it is necessary to introduce into the muscle both an aqueous and an oily solution of drugs, or a suspension, in a volume of not more than 10 ml (preferably not more than 5 ml). Vaccinations against infectious diseases are also carried out subcutaneously by introducing a vaccine into the body.

Application

Subcutaneous injection is a fairly common type of parenteral administration of drugs due to the good vascularization of the subcutaneous tissue, which contributes to the rapid absorption of drugs; and also due to the simplicity of the administration technique, which makes it possible to apply this method of administration to persons without special medical training after mastering the relevant skills. Most often, patients self-administer at home subcutaneous insulin injections (often with a syringe pen), and subcutaneous injection of growth hormone can also be performed. Subcutaneous administration can also be used to administer oily solutions or suspensions of medicinal substances (subject to the condition that the oily solution does not enter the bloodstream). Usually, drugs are administered subcutaneously when there is no need to obtain an immediate effect from the administration of the drug (absorption of the drug during subcutaneous injection disappears within 20-30 minutes after administration), or when it is necessary to create a kind of depot of the drug in the subcutaneous tissue to maintain the concentration of the drug in the blood at constant level for a long time. Solutions of heparin and its derivatives are also injected subcutaneously due to the formation of hematomas at the injection site during intramuscular injections. Local anesthetics may also be administered subcutaneously. When administered subcutaneously, it is recommended to administer drugs in a volume of not more than 5 ml in order to avoid tissue overstretching and the formation of an infiltrate. Do not administer subcutaneously drugs that have a locally irritating effect and can cause necrosis and abscesses at the injection site. For the injection, it is necessary to have sterile medical equipment - a syringe, and a sterile form of the drug. Intramuscularly, drugs can be administered both in a medical institution (inpatient and outpatient departments) and at home by inviting a medical worker home, and when providing emergency medical care - in an ambulance.

Execution technique

Subcutaneous injection is most often given to the outer surface of the shoulder, the anterior thigh, the subscapularis, the lateral surface of the anterior abdominal wall, and the area around the navel. Before subcutaneous injection, the drug (especially in the form of an oily solution) must be warmed up to a temperature of 30-37 ° C. Before starting the injection, the health worker treats the hands with a disinfectant solution and wears rubber gloves. Before the introduction of the drug, the injection site is treated with an antiseptic solution (most often ethyl alcohol). Before the injection, the skin at the puncture site is taken into a fold, and after that the needle is set at an acute angle to the skin surface (for adults - up to 90 °, for children and people with a mild subcutaneous fat layer, injection at an angle of 45 °). After piercing the skin, the syringe needle is inserted into the subcutaneous tissue approximately 2/3 of the length (at least 1-2 cm), to prevent needle breakage, it is recommended to leave at least 0.5 cm of the needle above the skin surface. After puncturing the skin, before administering the drug, it is necessary to pull the plunger of the syringe back to check that the needle has entered the vessel. After checking the correct location of the needle, the drug is injected under the skin in full. After the end of the administration of the drug, the injection site is re-treated with an antiseptic.

Advantages and disadvantages of subcutaneous drug administration

The advantages of subcutaneous use of drugs is that the active substances, when introduced into the body, do not change at the site of contact with tissues, therefore, drugs can be used subcutaneously, which are destroyed by the action of the enzymes of the digestive system. In most cases, subcutaneous administration provides a rapid onset of action of the drug. If prolonged action is required, drugs are usually administered subcutaneously in the form of oily solutions or suspensions, and should not be done with intravenous administration. Some drugs (in particular, heparin and its derivatives) cannot be administered intramuscularly, but only intravenously or subcutaneously. The rate of absorption of the drug is not affected by food intake and much less influenced by the characteristics of the biochemical reactions of the organism of a particular person, the intake of other drugs, and the state of the enzymatic activity of the body. Subcutaneous injection is relatively easy to perform, which makes it possible to carry out this manipulation if necessary, even for a non-specialist.

The disadvantages of subcutaneous administration are that often with the introduction of drugs intramuscularly, pain and the formation of infiltrates at the injection site (less often, the formation of abscesses) are observed, and with the introduction of insulin, lipodystrophy can also be observed. With poor development of blood vessels at the injection site, the absorption rate of the drug may decrease. With subcutaneous administration of drugs, as with other types of parenteral use of drugs, there is a risk of infection of the patient or health worker with blood-borne pathogens. With subcutaneous administration, the likelihood of side effects of drugs increases due to the higher rate of entry into the body and the absence of biological filters of the body along the route of the drug - the mucous membrane of the gastrointestinal tract and hepatocytes (although lower than with intravenous and intramuscular use) .. With subcutaneous application, it is not recommended to inject more than 5 ml of the solution once due to the likelihood of overstretching of muscle tissue and reducing the likelihood of infiltrate formation, as well as drugs that have a locally irritating effect and can cause necrosis and abscesses at the injection site.

Possible complications of subcutaneous injection

The most common complication of subcutaneous injection is the formation of infiltrates at the injection site. Usually, infiltrates are formed when the drug is injected into the site of induration or edema that has formed after previous subcutaneous injections. Infiltrates can also form with the introduction of oil solutions that are not heated to the optimum temperature, as well as when the maximum volume of subcutaneous injection is exceeded (no more than 5 ml at a time). When infiltrates appear, it is recommended to apply a semi-alcohol compress or heparin ointment to the site of infiltrate formation, apply an iodine mesh to the affected area, and carry out physiotherapeutic procedures.

One of the complications that arise when the technique of drug administration is violated is the formation of abscesses and phlegmon. These complications most often occur against the background of incorrectly treated post-injection infiltrates, or if the rules of asepsis and antisepsis are violated during the injection. Treatment of such abscesses or phlegmon is carried out by a surgeon. In case of violation of the rules of asepsis and antisepsis during injections of imovine, infection of patients or health workers with pathogens of infectious diseases transmitted through the blood, as well as the occurrence of a septic reaction due to bacterial infection of the blood.

When injecting with a blunt or deformed needle, the formation of subcutaneous hemorrhages is likely. If bleeding occurs during a subcutaneous injection, it is recommended to apply a cotton swab moistened with alcohol to the injection site, and later - a half-alcohol compress.

If the injection site is chosen incorrectly during subcutaneous administration of drugs, damage to the nerve trunks can be observed, which is most often observed as a result of chemical damage to the nerve trunk, when a depot of the drug is created close to the nerve. This complication can lead to the formation of paresis and paralysis. Treatment of this complication is carried out by a doctor, depending on the symptoms and severity of this lesion.

With subcutaneous administration of insulin (more often with prolonged administration of the drug in the same place), there may be a site of lipodystrophy (a site of resorption of subcutaneous fatty tissue). Prevention of this complication is the alternation of insulin injection sites and the introduction of insulin, which has room temperature, the treatment consists in administering 4-8 units of suinsulin in areas of lipodystrophy.

If a hypertonic solution (10% sodium chloride or calcium chloride solution) or other locally irritating substances are erroneously injected under the skin, tissue necrosis may occur. When this complication occurs, it is recommended to prick the affected area with a solution of adrenaline, 0.9% sodium chloride solution and novocaine solution. After chipping the injection site, a pressure dry bandage and cold are applied, and later (after 2-3 days) a heating pad is applied.

When using an injection needle with a defect, when the needle is inserted too deep into the subcutaneous tissue, as well as when the injection technique is violated, the needle may break. With this complication, it is necessary to try to independently obtain a fragment of the needle from the tissues, and if the attempt fails, the fragment is removed surgically.

A very serious complication of subcutaneous injection is drug embolism. This complication occurs rarely, and is associated with a violation of the injection technique, and occurs in cases where the health worker, when performing a subcutaneous injection of an oily solution of the drug or suspension, does not check the position of the needle and the possibility of getting this drug into the vessel. This complication can be manifested by bouts of shortness of breath, the appearance of cyanosis, and often ends in the death of patients. Treatment in such cases is symptomatic.

Subcutaneous injections are a highly demanded medical procedure. The technique for its implementation differs from the method of administering drugs intramuscularly, although the preparation algorithm is similar.

The injection should be made subcutaneously less deeply: it is enough to insert the needle inside only 15 mm. Subcutaneous tissue has a good blood supply, which leads to a high rate of absorption and, accordingly, the action of drugs. Just 30 minutes after the administration of the drug solution, the maximum effect of its action is observed.

The most convenient places for the introduction of drugs subcutaneously:

• shoulder (its outer region or middle third);
• anterior surface of the thighs;
• lateral part of the abdominal wall;
• subscapular region in the presence of pronounced subcutaneous fat.

Preparatory stage

The algorithm for performing any medical manipulation, as a result of which the integrity of the patient's tissues is violated, begins with preparation. Before giving an injection, you should disinfect your hands: wash them with antibacterial soap or treat with an antiseptic.

Important: In order to protect their own health, the standard algorithm for the work of medical personnel in all types of contact with patients provides for the wearing of sterile gloves.

Preparation of instruments and preparations:

• sterile tray (ceramic plate clean and disinfected by wiping) and waste tray;
• a syringe with a volume of 1 or 2 ml with a needle 2 to 3 cm long and not more than 0.5 mm in diameter;
• sterile wipes (cotton swabs) - 4 pcs.;
• prescribed drug;
• alcohol 70%.

Everything that will be used during the procedure should be on a sterile tray. You should check the expiration date and the tightness of the packaging of the medicine and the syringe.

The place where the injection is planned to be inspected for the presence of:

1. mechanical damage;
2. edema;
3. signs of dermatological diseases;
4. manifestation of allergy.

If the selected area has the above problems, the intervention site should be changed.

Medication withdrawal

The algorithm for taking the prescribed drug into the syringe is standard:

• checking the compliance of the medicine contained in the ampoule prescribed by the doctor;
• clarification of the dosage;
• disinfection of the neck at the point of its transition from a wide part to a narrow one and notching with a special nail file supplied in one box with the medicine. Sometimes ampoules have specially weakened places for opening, made in a factory way. Then on the vessel in the indicated area there will be a mark - a colored horizontal stripe. The removed tip of the ampoule is placed in the waste tray;
• the ampoule is opened by grabbing the neck with a sterile swab and breaking it away from you;
• the syringe is opened, its cannula is combined with the needle, after which the case is removed from it;
• the needle is placed in the opened ampoule;
• the syringe plunger is retracted with the thumb, fluid is taken;
• the syringe is raised with the needle up, the cylinder should be lightly tapped with a finger to force out the air. Squeeze the medicine with a piston until a drop appears on the tip of the needle;
• put on the needle case.

Before making subcutaneous injections, it is necessary to disinfect the operating field (side, shoulder): with one (large) swab dipped in alcohol, a large surface is treated, the second (middle) place where the injection is directly planned. Technique of sterilization of the working area: moving the swab centrifugally or from top to bottom. The injection site should be dry with alcohol.

Manipulation algorithm:

• the syringe is taken in the right hand. The index finger is placed on the cannula, the little finger is placed on the piston, the rest will be on the cylinder;
• with the left hand - thumb and forefinger - grab the skin. You should get a skin fold;
• to make an injection, the needle is inserted with a cut up at an angle of 40-45º for 2/3 of the length into the base of the resulting skin fold;
• the index finger of the right hand maintains its position on the cannula, and the left hand is transferred to the piston and begins to squeeze it, slowly injecting the medicine;
• a swab dipped in alcohol is easily pressed against the insertion site of the needle, which can now be removed. Safety precautions provide that in the process of removing the tip, you should hold the place where the needle is attached to the syringe;
• after the injection is finished, the patient must hold the cotton ball for another 5 minutes, the used syringe is separated from the needle. The syringe is ejected, the cannula and needle break.

Important: Before injecting, you need to comfortably position the patient. In the process of performing the injection, it is necessary to continuously monitor the condition of the person, his reaction to the intervention. Sometimes it is better to inject when the patient is lying down.

When you are done giving the injection, remove your gloves if you have worn them, and disinfect your hands again: wash or wipe with an antiseptic.

If you fully comply with the algorithm for performing this manipulation, then the risk of infections, infiltrates and other negative consequences is sharply reduced.

Oil solutions

It is forbidden to make intravenous injections with oily solutions: such substances clog blood vessels, disrupting the nutrition of adjacent tissues, causing their necrosis. Oil emboli may well end up in the vessels of the lungs, clogging them, which will lead to severe suffocation, followed by death.

Oily preparations are poorly absorbed, therefore, infiltrates are not uncommon at the injection site.

Tip: To prevent the occurrence of infiltration to the injection site, you can put a heating pad (make a warm compress).

The algorithm for introducing an oil solution provides for preheating the drug to 38ºС. Before injecting and administering the medicine, you should insert the needle under the patient's skin, pull the plunger of the syringe towards you and make sure that the blood vessel has not been damaged. If blood has entered the cylinder, lightly press the needle insertion site with a sterile swab, remove the needle and try again in another place. In this case, safety precautions require replacing the needle, because. already used is not sterile.

How to inject yourself: rules of procedure

Article 498. Workman B (1999) Safe injection techniques. Nursing standard. 13, 39, 47-53.

In this article, Barbara Workman describes the correct technique for intradermal, subcutaneous, and intramuscular injections.

Objectives and expected learning outcomes

As knowledge of nurses' daily practice routines grows, it is prudent to review some of the routine procedures.

This publication provides an overview of the principles of intradermal, subcutaneous and intramuscular injections. It is shown how to choose the right anatomical injection site, anticipate the possibility of drug intolerance, as well as the special needs of the patient, which may affect the choice of injection site. Aspects of patient and skin preparation, as well as equipment features, and ways to reduce patient discomfort during the procedure are highlighted.

The main purpose of the article is to encourage the nurse to critically review their own injection technique, based on the principles of evidence-based medicine, and to provide the patient with effective and safe care.

After reading this article, the nurse should know and be able to:

• Determine safe anatomical areas for intradermal, subcutaneous and intramuscular injections;
• Identify muscles - anatomical landmarks for performing intramuscular injections, and explain why they are used for this;
• Explain what this or that method of processing the patient's skin is based on;
• Discuss ways to reduce patient discomfort during an injection;
• Describe the nurse's actions aimed at preventing injection complications.

Introduction

Giving injections is a routine and perhaps the most frequent job of a nurse, and good injection technique can make this manipulation relatively painless for the patient. However, technical proficiency without understanding the manipulation exposes the patient to unnecessary risk of complications. Initially, giving injections was a medical procedure, but with the invention of penicillin in the 1940s, the duties of the nurse were greatly expanded (Beyea and Nicholl 1995). Currently, most nurses perform this manipulation. automatically. Since nursing practice is now becoming evidence-based, it is logical reconsider this fundamental procedure from the standpoint of evidence-based medicine.

Drugs are administered parenterally because they are usually absorbed faster than from the gastrointestinal tract, or, like insulin, are destroyed by digestive enzymes. Some drugs, such as medoxy-progesterone acetate or fluphenazine, are released over a long period of time and require a route of administration that ensures continued absorption of the drug.

There are four main characteristics of an injection: injection site, route of administration, injection technique, and equipment.

intradermal route of administration

The intradermal route of administration is intended to provide local rather than systemic drug action, and is generally used primarily for diagnostic purposes, such as allergy and tuberculin tests, or for the administration of local anesthetics.

To perform an intradermal injection, a 25G needle with a cut up is inserted into the skin at an angle of 10-15°, exclusively under the epidermis and injected up to 0.5 ml of the solution until the so-called “lemon peel” appears on the skin surface (Fig. 1). This route of administration is used to perform allergy tests, and the injection site must be marked in order to track the allergic reaction after a certain period of time.

Intradermal injection sites are similar to those for subcutaneous injections (Figure 2), but can also be performed on the inside of the forearm and under the collarbone (Springhouse Corporation 1993).

When performing allergy testing, it is very important to ensure that an anti-shock kit is readily available if the patient has a hypersensitivity reaction or anaphylactic shock (Campbell 1995).

Rice. 1. "Lemon peel", which is formed during intradermal injection.

IMPORTANT (1):
Review the symptoms and signs of anaphylactic reactions.
What will you do in case of anaphylactic shock?
What medications are you taking that can trigger an allergic reaction?

Subcutaneous route of administration

The subcutaneous route of administration of drugs is used when slow, uniform absorption of the drug into the blood is necessary, while 1-2 ml of the drug is injected under the skin. This route of administration is ideal for drugs such as insulin, which require a slow steady release, are relatively painless, and are suitable for frequent injections (Springhouse Corporation 1993).

On Fig. 2 shows sites suitable for performing subcutaneous injections.

Traditionally, subcutaneous injections are performed by inserting a needle at a 45-degree angle into a skin fold (Thow and Home 1990). However, with the introduction of shorter insulin needles (5, 6, or 8 mm), insulin injections are now recommended to be performed with a 90-degree needle (Burden 1994). It is imperative to take the skin in a fold in order to separate the adipose tissue from the underlying muscles, especially in thin patients (Fig. 3). Some studies using computed tomography to track the direction of the injection needle have shown that sometimes the drug is inadvertently injected into the muscle when administered subcutaneously, especially when injected into the anterior abdominal wall in lean patients (Peragallo-Dittko 1997).

Insulin administered intramuscularly is absorbed much faster and this can lead to unstable glycemia and possibly even hypoglycemia. Hypoglycemic episodes can also be observed if the anatomical injection site changes, since insulin is absorbed from different sites at different rates (Peragallo-Dittko 1997).

For this reason, a constant change of injection sites should be carried out, for example, the area of ​​\u200b\u200bthe shoulder or abdomen is used for several months, then the injection site is changed (Burden 1994). When a patient with diabetes is admitted to the hospital, one should look for signs of inflammation, swelling, redness, or lipoatrophy at the insulin injection sites, and be sure to note this in the medical record.

Aspiration of the contents of the needle during subcutaneous injection is currently recognized as inappropriate. Peragallo-Dittko (1997) reports that blood vessel puncture prior to subcutaneous injection is very rare.

Educational materials for patients with diabetes do not contain information about the need for aspiration. It has also been noted that aspiration prior to heparin administration increases the risk of hematoma formation (Springhouse Corporation 1993).

Intramuscular route of administration

When administered intramuscularly, the drug is in a well-perfused muscle, which ensures its rapid systemic effect, and the absorption of sufficiently large doses, from 1 ml from the deltoid muscle to 5 ml in other muscles in adults (for children, these values ​​\u200b\u200bshould be divided in half). The choice of injection site should be based on the general condition of the patient, his age and the volume of drug solution to be injected.

The proposed injection site should be examined for signs of inflammation, swelling and infection, and injection of the drug into areas of skin lesions should be avoided. Similarly, 2-4 hours after the manipulation, the injection site should be examined to ensure that there are no adverse events. If injections are frequently repeated, then it is necessary to mark the injection sites in order to change them.

This reduces patient discomfort and reduces the chance of developing complications such as muscle atrophy or sterile abscesses due to poor drug absorption (Springhouse Corporation 1993).

IMPORTANT (2):
When diabetic patients are hospitalized, special medical records should be maintained.
How do you mark injection rotation sites?
How do you monitor the suitability of the injection site?
Discuss this with your colleagues.

Rice. 2. Anatomical areas for intradermal and subcutaneous injections. Red dots are sites for subcutaneous and intradermal injections, black crosses are sites for performing only intradermal injections.

Rice. 3. Capturing a skin fold when performing a subcutaneous injection.

Elderly and malnourished people have less muscle mass than younger, more active people, so before performing an intramuscular injection, it is necessary to assess whether muscle mass is sufficient for this. If the patient has little muscle, the muscle can be folded before the injection (Fig. 4).

Rice. 4. How to take the muscle in the fold in malnourished or elderly patients.

There are five anatomical regions suitable for intramuscular injections.

On Fig. 5(a-d) shows in detail how to determine the anatomical landmarks of all these areas. These anatomical regions are:

• The deltoid muscle on the shoulder, this area is used mainly for the administration of vaccines, in particular the hepatitis B vaccine and the ATP toxoid.
• The gluteal region, the gluteus maximus (upper outer quadrant of the buttock), is the traditional site for intramuscular injections (Campbell 1995). Unfortunately, there are complications when using this anatomical region, damage to the sciatic nerve or superior gluteal artery is possible if the needle insertion point is incorrectly determined. Beyea and Nicholl (1995) in their publication cite data from several researchers who used computed tomography and confirmed the fact that even in patients with moderate obesity, injections into the gluteal region more often lead to the fact that the drug is in adipose tissue, and not in muscle, which certainly slows down the absorption of the drug.
• Anterior-gluteal region, gluteus medius is a safer way to perform intramuscular injections. It is recommended because there are no large nerves and vessels, and there are no reports of complications due to damage to them (Beyea and Nicholl 1995). In addition, the thickness of adipose tissue is more or less constant here, at 3.75 cm compared to 1-9 cm in the gluteus maximus, suggesting that a standard 21 G intramuscular needle (green) will end up in the gluteus medius.
• Lateral head of the quadriceps femoris. This anatomical region is most commonly used for injections in children and carries the risk of inadvertent injury to the femoral nerve with subsequent muscle atrophy (Springhouse Corporation 1993). Beyea and Nicholl (1995) suggested that this area is safe in children up to seven months of age, then the upper outer quadrant of the buttock is best used.

Rice. 5a. Determination of the position of the deltoid muscle.

The densest part of the muscle is defined as follows: a line is drawn from the acromial process to a point on the shoulder at armpit level. The needle is inserted approximately 2.5 cm below the acromion to a depth of 90º.

The radial nerve and brachial artery should be avoided (Springhouse Corporation 1993).

You can ask the patient to put the hand on the thigh (as models do during the shows), which makes it easier to find the muscle.

To identify the gluteus maximus: the patient may lie on their side with the knees slightly bent, or with the big toes pointing inward. If the legs are slightly bent, then the muscles are more relaxed and the injection is less painful (Covington and Trattler 1997).

Rice. 5b. Definition of the outer upper quadrant of the buttock.

Draw an imaginary horizontal line from the beginning of the intergluteal gap to the greater trochanter of the thigh. Then draw another imaginary line vertically in the middle of the previous one, and at the top laterally will be the upper outer quadrant of the buttock (Campbell 1995). The muscle that lies in it is the gluteus maximus muscle. If you make a mistake during the injection, you can damage the superior gluteal artery and sciatic nerve. The typical volume of fluid to be administered in this area is 2-4 ml.

Rice. 5c. Definition of the anterior-gluteal region.

Place the palm of your right hand on the greater trochanter of the patient's left thigh (and vice versa). With your index finger, feel for the superior anterior iliac crest and move your middle finger back to form a V (Beyea and Nicholl 1995). If you have small hands this may not always work, so simply move your hand towards the comb (Covington and Trattler 1997).

The needle is inserted into the gluteus medius in the middle of the V at a 90º angle. A typical volume of drug solution for administration in this area is 1-4 ml.

Rice. 5d. Definition of the lateral head of the quadriceps femoris and rectus femoris.

In adults, the lateral head of the quadriceps femoris can be located a hand below and lateral to the greater trochanter, and a hand above the knee, in the middle third of the quadriceps femoris. The rectus femoris muscle is located in the middle third of the anterior surface of the thigh. In children and the elderly, or in malnourished adults, this muscle may sometimes need to be folded in order to provide sufficient depth of injection (Springhouse Corporation 1993). The first solution of the drug is 1-5 ml, for infants - 1-3 ml.

The rectus femoris is part of the anterior quadriceps femoris and is rarely used for injections by nurses, but is often used in self-administered drugs or in infants (Springhouse Corporation 1993).

IMPORTANT (3):
Learn to identify anatomical landmarks for each of these five intramuscular injection sites.
If you are accustomed to injecting drugs only in the upper-outer quadrant of the buttocks, then learn to use new areas and regularly improve your practice.

Methodology

The pain from the injection depends on the angle of the needle insertion. The needle for intramuscular injection should be inserted at an angle of 90 ° and make sure that the needle reaches the muscle - this allows you to reduce the pain of the injection. A study by Katsma and Smith (1997) found that not all nurses insert the needle at a 90° angle, believing that this technique makes the injection more painful, as the needle quickly passes through the tissues. Stretching the skin reduces the chance of needle injury and improves the accuracy of drug administration.

To correctly insert the needle, place the non-working hand and stretch the skin over the injection site with the index and middle fingers, and place the wrist of the working hand on the thumb of the non-working hand. Hold the syringe between the pads of your thumb and forefinger, this is how you can insert the needle accurately and at the right angle (Fig. 6).

Rice. 6. Technique for performing intramuscular injection, needle insertion angle 90º, anterior-gluteal region.

There has been little research on this topic in the UK, so nurses may have very different injection skills and techniques (MacGabhann 1998). The traditional technique for performing intramuscular injections was to stretch the skin over the puncture site to desensitize the nerve endings (Stilwell 1992) and quickly prick the needle at a 90° angle to the skin.

However, a review of the literature by Beyea and Nicholls' (1995) indicated that the use of the Z-technique resulted in less discomfort and fewer complications compared to the conventional technique.

Z—method

This technique was originally proposed for the administration of drugs that color the skin or are strong irritants. It is now recommended for the intramuscular administration of any medication (Beyea and Nicholl 1995) because it is believed to reduce soreness and the likelihood of drug leakage (Keen 1986).

In this case, the skin at the injection site is pulled down or to the side (Fig. 7). This shifts the skin and subcutaneous tissue by about 1-2 cm. It is very important to remember that the direction of the needle changes and you may not get to the right place.

Therefore, after determining the injection site, you need to find out which muscle is under the surface tissues, and not what skin landmarks you see. After injecting the drug, wait 10 seconds before removing the needle so that the drug is absorbed into the muscle. After removing the needle, release the skin. The tissue over the injection site will close the deposit of the drug solution and prevent leakage. It is believed that if the limb moves after the injection, the absorption of the drug will be accelerated, since blood flow will increase at the injection site (Beyea and Nicholl 1995).

Rice. 7. Z-method.

Air bubble technique

This technique was very popular in the USA. Historically, it was developed in the days of glass syringes, which required the use of an air bubble to ensure that the dose was correct. Dead space in a syringe is no longer considered necessary because plastic syringes are more accurately calibrated than glass syringes and this technique is no longer recommended by manufacturers (Beyea and Nicholl 1995).

Recently, two studies have been carried out in the UK on dummy (slow release oil solution) (MacGabhann 1998, Quartermaine and Taylor 1995) comparing the Z-method and the air bubble technique designed to prevent leakage of the solution after injection.

Quartermaine and Taylor (1995) suggested that the air bubble technique was more effective than the Z technique in preventing leakage, but the results of MacGabhann (1998) were inconclusive.

There are questions about dosing accuracy when using this technique, since the dose of the drug in this case can be significantly increased (Chaplin et al 1985). Further research is required on this technique as it is considered relatively new in the UK. However, if it is used, the nurse must ensure that she is administering the correct dose to the patient and that the technique is being used exactly as recommended.

Aspiration technique

Although the aspiration technique is not currently recommended for control of subcutaneous injections, it should be used for intramuscular injections. If the needle is mistakenly inserted into a blood vessel, the drug can be inadvertently injected intravenously, sometimes resulting in an embolism due to the specific chemical properties of the drugs. With intramuscular injection of the drug, aspiration of the contents of the needle should be carried out within a few seconds, especially if thin long needles are used (Torrance 1989a). If blood is visible in the syringe, then it is removed and a fresh preparation is prepared for injection in another place. If there is no blood, then the drug can be injected, at a rate of about 1 ml per 10 seconds, this seems a little slow, but allows the muscle fibers to move apart for the correct distribution of the solution. Before removing the syringe, you must wait another 10 seconds, and then remove the syringe and press the injection site with a napkin with alcohol.

Massaging the injection site is not necessary, as this may cause leakage of the drug from the injection site and skin irritation (Beyea and Nicholl 1995).

Leather processing

Although it is known that cleaning the skin with an alcohol wipe prior to parenteral manipulation reduces the number of bacteria, in practice there are contradictions. Rubbing the skin for subcutaneous insulin administration predisposes to skin hardening under the influence of alcohol.

Previous studies suggest that such rubbing is not necessary and that lack of skin preparation does not lead to infection (Dann 1969, Koivisto and Felig 1978).

Some experts now believe that if the patient is clean, and the nurse strictly follows all hygiene and asepsis standards during the procedure, then disinfection of the skin when performing an intramuscular injection is not necessary. If skin disinfection is practiced, then the skin must be rubbed for at least 30 seconds, then allowed to dry for another 30 seconds, otherwise the whole procedure is ineffective (Simmonds 1983). In addition, injecting before the skin dries not only increases the soreness of the skin but also allows live bacteria from the skin to enter the tissue (Springhouse Corporation 1993).

IMPORTANT (4):
What are the guidelines for pre-injection skin preparation at your facility?
Find out what recommendations are there for insulin injections.
Are these recommendations consistent with the research data in the article?
What will you do?

IMPORTANT (5):
Imagine that you are watching a student who is about to perform his first injection. What prompts or tips will you use in this case to ensure that the trainee develops proper injection skills?

Equipment

Needles for intramuscular injections should be long enough to reach the muscle, while at least a quarter of the needle should remain above the skin. The most commonly used intramuscular injections are 21G (green) or 23 (blue) gauge needles, 3 to 5 cm long. If the patient has a lot of adipose tissue, then longer needles are required for intramuscular injections to reach the muscle. Cockshott et al (1982) found that the thickness of subcutaneous fat in women in the gluteal region can be 2.5 cm more than in men, so a standard 21 G injection needle 5 cm long reaches the gluteus maximus muscle in only 5% of women and 15 % men!

If the rubber cap of the vial has already been pierced with a needle, then it becomes blunt, in which case the injection will be more painful, since the skin has to be pierced with great effort.

The size of the syringe is determined by the volume of the injected solution. For intramuscular administration of solutions in volumes less than 1 ml, only small volume syringes are used to accurately measure the desired dose of the drug (Beyea and Nicholl 1995). For administering solutions of 5 ml or more, it is best to divide the solution into 2 syringes and inject at different sites (Springhouse Corporation 1993). Pay attention to the tips of the syringes - they have different purposes.

Gloves and accessories

In some institutions, regulations require the use of gloves and aprons during injections. It should be remembered that gloves protect the nurse from patient secretions, from the development of drug allergies, but they do not provide protection from damage from needles.

Some nurses complain that it is inconvenient for them to work with gloves, especially if they initially learned to perform this or that manipulation without them. If a nurse works without gloves, then care must be taken to ensure that nothing gets into her hands - neither medicines nor patients' blood. Even clean needles must be disposed of immediately, in no case should they be re-capped, the needles are discarded only in special containers. Be aware that needles can fall from injection trays onto the patient's bed, which can cause injury to both patients and staff.

Clean disposable aprons can be used to protect workwear from splashes of blood or injection solutions, and this is also useful in cases where a special sanitary epidemiological regime is needed (to prevent the transfer of microorganisms from one patient to another). It is necessary to carefully remove the apron after the procedure so that the dirt that has fallen on it does not come into contact with the skin.

IMPORTANT (6):
Make a list of all the things that help reduce the pain of injections. Compare with Table 1.
How can you use more ways to reduce injection pain in your practice?

Table 1. Twelve steps to make injections less painful

1	Prepare the patient, explain to him the essence of the procedure, so that he understands what will happen and clearly follows all your instructions
2	Change the needle after you have taken the drug from the vial or ampoule and make sure it is sharp, clean and long enough
3	In adults and children over seven months of age, the anterior gluteal region is the injection site of choice.
4	Position the patient so that one leg is slightly bent - this reduces pain during the injection
5	If you are using alcohol wipes, make sure the skin is completely dry before injecting.
6	Ice or freezing spray can be used to numb the skin, especially for young children and patients who are phobic of injections.
7	Use the Z-method (Beyea and Nicholl 1995)
8	Change sides of injections and note this in medical records
9	Puncture the skin gently, at an angle close to 90 degrees, to prevent soreness and tissue displacement
10	Gently and slowly inject the solution, at a rate of 1 ml in 10 seconds, so that it is distributed in the muscle
11	Before withdrawing the needle, wait 10 seconds and pull the needle out at the same angle as it was inserted.
12	Do not massage the injection site after it is completed, just press the injection site with a gauze pad

Pain Reduction

Patients are very often afraid of performing injections because they assume that it hurts. Pain usually results from irritation of pain receptors in the skin, or pressure receptors in the muscle.

Torrance (1989b) lists factors that can cause pain:

• The chemical composition of the drug solution
• Injection technique
• The rate of administration of the drug
• The volume of the drug solution

Table 1 lists ways to reduce pain from the injection of the drug.

Patients may have a strong fear of injections and needles, fear, anxiety - all this greatly increases the pain during injections (Pollilio and Kiley 1997). Good procedure technique, adequate information to the patient and a calm, confident nurse are the best way to reduce the pain of manipulation and reduce the patient's reaction. Behavior modification techniques can also be used, especially when the patient has long courses of treatment and sometimes requires the use of needle-free systems (Pollilio and Kiley 1997).

Anesthetizing the skin with ice or cold sprays prior to injection has been suggested to reduce pain (Springhouse Corporation 1993), although there is currently no research evidence to support this technique.

Nurses should be aware that patients may even experience syncope or fainting after conventional injections, even if they are otherwise perfectly healthy. It is necessary to find out if this has happened before, and it is desirable that there is a couch nearby on which the patient can lie down - this reduces the risk of injury. Most often, such fainting occurs in adolescents and young men.

Complications

Complications that develop as a result of infection can be prevented by strict observance of asepsis measures and thorough hand washing. Sterile abscesses can result from frequent injections or poor local blood flow. If the injection site is edematous or this area of ​​the body is paralyzed, then the drug will not be absorbed well, and such sites should not be used for injection (Springhouse Corporation 1993).

Careful selection of the injection site will avoid nerve injury, accidental intravenous injection, and subsequent embolism by drug components (Beyea and Nicholl 1995). Systematic changing of the injection site prevents complications such as injection myopathy and lipohypertrophy (Burden 1994). The appropriate length of the needle and the use of the anterior gluteal region for injections allows the drug to be injected precisely into the muscle, and not into the subcutaneous fat. The use of the Z-technique reduces pain and skin discoloration associated with the use of certain drugs (Beyea and Nicholl 1995).

Professional Responsibility

If the drug is administered parenterally, then it is no longer possible to “return” it. Therefore, it is always necessary to check the dose, the correctness of the appointment, and clarify the patient's name with the patient so as not to confuse the appointment. So: the right medicine to the right patient, in the right dose, at the right time, and in the right way - this will avoid medical errors. All drugs must be prepared exclusively according to the manufacturer's instructions, all nurses should know how these drugs work, contraindications to their use and side effects. The nurse should assess whether the drug can be used at all in this patient at this time (UKCC 1992).

conclusions

The safe administration of injections is one of the primary functions of a nurse and requires knowledge of anatomy and physiology, pharmacology, psychology, communication skills, and practical experience.

There are studies that prove the effectiveness of injection techniques to prevent complications, but there are still "white spots" that need more research. This article focuses on research-proven techniques so that nurses can incorporate these procedures into their daily practice.

Bibliography

Beyea SC, Nicholl LH (1995) Administration of medications via the intramuscular route: an integrative review of the literature and research-based protocol for the procedure. Applied Nursing Research. 5, 1, 23-33.
Burden M (1994) A practical guide to insulin injections. Nursing standard. 8, 29, 25-29.
Campbell J (1995) Injections. Professional nurse. 10, 7, 455-458.
Chaplin G et al (1985) How safe is the air bubble technique for IM injections? Not very say these experts. Nursing. 15, 9, 59.
Cockshott WP et al (1982) Intramuscular or intralipomatous injections. New England Journal of Medicine. 307, 6, 356-358.
Covington TP, Trattler MR (1997) Learn how to zero in on the safest site for an intramuscular injection. Nursing. January, 62-63.
Dann TC (1969) Routine skin preparation before injection. An procedure unnecessary. Lancet. ii, 96-98.
Katsma D, Smith G (1997) Analysis of needle path during intramuscular injection. nursing research. 46, 5, 288-292.
Keen MF (1986) Comparison of Intramuscular injection techniques to reduce site Koivisto VA, Felig P (1978) Is skin preparation necessary before insulin injection? Lancet. i, 1072-1073.
MacGabhann L (1998) A comparison of two injection techniques. Nursing standard. 12, 37, 39-41.
Peragallo-Dittko V (1997) Rethinking subcutaneous injection technique. American Journal of Nursing. 97, 5, 71-72.
Polillio AM, Kiley J (1997) Does a needless injection system reduce anxiety in children receiving intramuscular injections? Pediatric Nursing. 23:1, 46-49.
Quartermaine S, Taylor R (1995) A comparative study of depot injection techniques. Nursing Times. 91, 30, 36-39.
Simmonds BP (1983) CDC guidelines for the prevention and control of nosocomial infections: guidelines for prevention of intravascular infections. American Journal of Infection Control. 11, 5, 183-189.
Springhouse Corporation (1993) Medication Administration and IV Therapy Manual. second edition. Pennsylvania, Springhouse Corporation.
Stilwell B (1992) Skills Update. London, MacMillan Magazines.
Thow J, Home P (1990) Insulin injection technique. british medical journal. 301, 7, July 3-4.
Torrance C (1989a) Intramuscular injection Part 2. Surgical Nurse. 2, 6, 24-27.
Torrance C (1989b) Intramuscular injection Part 1. Surgical Nurse. 2, 5, 6-10.
United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992) Standards for Administration of Medicine. London, UKCC.

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Hadescription of the method of performing a simple medical service

Algorithm for performing subcutaneous drug administration

I. Preparation for the procedure.

1. Introduce yourself to the patient, explain the course and purpose of the procedure.
2. Help the patient to take a comfortable position: sitting or lying down. The choice of position depends on the condition of the patient; the administered drug. (if necessary, fix the injection site with the help of junior medical staff)
3. Treat your hands in a hygienic way, dry them, put on gloves, a mask.
4. Prepare a syringe.

Check the expiration date and tightness of the package.

1. Draw up the drug in a syringe.

A set of a drug in a syringe from an ampoule.

- Shake the ampoule so that the entire drug is in its wide part.

- Treat the ampoule with a ball moistened with an antiseptic.

- File the ampoule with a nail file. With a cotton ball moistened with an antiseptic, break off the end of the ampoule.

- Take the ampoule between the index and middle fingers, turning it upside down. Insert a needle into it and draw up the required amount of the drug.

Ampoules with a wide opening - do not turn over. Make sure that when dialing the drug, the needle is always in the solution: in this case, the ingress of air into the syringe is excluded.

- Make sure there is no air in the syringe.

If there are air bubbles on the walls of the cylinder, slightly pull the plunger of the syringe and “turn” the syringe several times in a horizontal plane. Then the air should be expelled by holding the syringe over the sink or into the ampoule. Do not expel the medicinal product into the air of the room, it is dangerous to health.

- Change the needle.

If using a reusable syringe, place it and cotton balls in the tray. When using a single-use syringe, put a cap on the needle, place the syringe with the needle, cotton balls in the package from under the syringe.

A set of medicinal product from a vial closed with an aluminum cap.

- Bend off with non-sterile tweezers (scissors, etc.) part of the bottle cap covering the rubber stopper. Wipe the rubber stopper with a cotton ball moistened with an antiseptic.

- Inject into the syringe a volume of air equal to the required volume of the drug.

- Insert the needle at a 90° angle into the vial.

- Introduce air into the vial, turn it upside down, slightly pulling the piston, draw the right amount of the drug from the vial into the syringe.

- Remove the needle from the vial.

- Change the needle.

- Place the syringe with a needle in a sterile tray or packaging from a single-use syringe in which the drug was collected.

The opened (multi-dose) vial should be stored no more than 6 hours.

1. Select and inspect/palpate the area of ​​the proposed injection to avoid possible complications.

II. Performing a procedure

1. Treat the injection site with at least 2 balls moistened with an antiseptic.
2. Gather the skin with one hand into a triangular fold, base down.
3. Take the syringe with the other hand, holding the cannula of the needle with your index finger.
4. Insert the needle with the syringe with a quick movement at an angle of 45 ° for 2/3 of the length.
5. Pull the plunger towards you to make sure that the needle is not in the vessel.
6. Slowly inject the drug into the subcutaneous fat.

III. End of procedure.

1. Remove the needle, press the ball with a skin antiseptic to the injection site, without removing the hand with the ball, lightly massage the injection site.
2. Disinfect consumables.
3. Remove gloves, place them in a container for disinfection.
4. Treat hands in a hygienic way, dry.
5. Make an appropriate record of the results of the implementation in the medical documentation.

Additional information about the features of the implementation of the technique

Before injection, individual intolerance to the drug should be determined; lesions of the skin and fatty tissue of any nature at the injection site

When heparin is administered subcutaneously, it is necessary to hold the needle at an angle of 90 °, do not aspirate for blood, and do not massage the injection site after injection.

When prescribing injections for a long course, 1 hour after it, apply a heating pad to the injection site or make an iodine grid.

15-30 minutes after the injection, be sure to ask the patient about his well-being and about the reaction to the administered medicine (detection of complications and allergic reactions).

Places for s / c injection - the outer surface of the shoulder, the outer and anterior surface of the thigh in the upper and middle third, the subscapular region, the anterior abdominal wall, in newborns, the middle third of the outer surface of the thigh can also be used.

Medicinal substances can enter the body in different ways. Most often, drugs are taken orally, that is, through the mouth. There are also parenteral routes of administration, which include the injection method. With this method, the right amount of the substance enters the blood very quickly and is transferred to the "point" of application - the diseased organ. Today we will focus on the algorithm for performing an intramuscular injection, which is often referred to by us as an “injection”.

Intramuscular injections are inferior to intravenous administration (infusion) in terms of the rate of entry of a substance into the blood. However, many drugs are not intended for intravenous administration. Intramuscularly, you can enter not only aqueous solutions, but also oily, and even suspensions. This parenteral route is the most commonly administered drug.

If the patient is in the hospital, then there are no questions about the implementation of intramuscular injections. But when drugs are prescribed intramuscularly to a person, but he is not in the hospital, difficulties arise here. Patients may be offered to go to the clinic for procedures. However, every trip to the clinic is a health risk, which lies in the possibility of contracting infections, as well as the negative emotions of outraged patients in line. In addition, if a working person is not on sick leave, he simply does not have free time during the opening hours of the treatment room.

The skills of performing intramuscular injections are of great help in maintaining the health of the household, and in some situations, they save lives.

Advantages of intramuscular injections

• a fairly rapid entry of the drug into the blood (in comparison with subcutaneous administration);
• you can enter aqueous, oily solutions and suspensions;
• it is allowed to introduce irritating substances;
• you can enter depot drugs that give a prolonged effect.

Cons of intramuscular injections

• it is very difficult to make an injection on your own;
• soreness of the introduction of certain substances;
• administration of suspensions and oily solutions may cause pain at the injection site due to slow absorption;
• some substances bind to tissues or precipitate upon administration, which slows down absorption;
• the risk of hitting a nerve with a syringe needle, which will injure it and cause severe pain;
• the danger of a needle entering a large blood vessel (it is especially dangerous when administering suspensions, emulsions and oil solutions: if particles of a substance enter the general bloodstream, blockage of vital vessels may occur)

Some substances are not administered intramuscularly. For example, calcium chloride will cause inflammation and tissue necrosis at the injection site.

Intramuscular injections are made in those areas where there is a sufficiently thick layer of muscle tissue, and the probability of getting into the nerve, large vessel and periosteum is also low. These areas include:

• gluteal region;
• anterior thigh;
• the back surface of the shoulder (much less often used for injections, because you can touch the radial and ulnar nerves, the brachial artery).

Most often, when conducting an intramuscular injection, they “target” the gluteal region. The buttock is mentally divided into 4 parts (quadrants) and the upper-outer quadrant is selected, as shown in the figure.

Why this particular part? Due to the minimal risk of hurting the sciatic nerve and bone formations.

Choosing a syringe

• The syringe must match the volume of the injected substance.
• Syringes for intramuscular injections, together with a needle, are 8-10 cm in size.
• The volume of the drug solution should not exceed 10 ml.
• Tip: choose syringes with a needle of at least 5 cm, this will reduce soreness and reduce the risk of lumps after an injection.

Prepare everything you need:

• Sterile syringe (before use, pay attention to the integrity of the package);
• Ampoule / bottle with medicine (it is necessary that the medicine has body temperature, for this you can first hold it in your hand if the drug was stored in the refrigerator; oil solutions are heated in a water bath to a temperature of 38 degrees);
• Cotton swabs;
• Antiseptic solution (medical antiseptic solution, boric alcohol, salicylic alcohol);
• Bag for used accessories.

Injection algorithm:

Intramuscular injections can be made independently in the anterior surface of the thigh. To do this, you need to hold the syringe at an angle of 45 degrees, like a pen for writing. However, in this case, a greater likelihood of touching the nerve than in the case of gluteal insertion.

If you have never injected yourself and have not even seen how it is done, you should contact your healthcare professional. Theoretical knowledge without the help of an experienced specialist is sometimes insufficient. Sometimes it is psychologically difficult to insert a needle into a living person, especially a loved one. It is useful to practice injecting on surfaces whose resistance is akin to human tissue. Foam rubber is often used for this, but vegetables and fruits are better suited - tomatoes, peaches, etc.

Observe sterility during injections and be healthy!