By Greg Dix Begin Welcome to this interactive learning pack on injection technique. You are required to complete this package before attending the practical.

ByBy

Greg DixGreg Dix

Begin

Welcome to this interactive learning pack on injection Welcome to this interactive learning pack on injection technique. You are required to complete this package before technique. You are required to complete this package before attending the practical skill session, it should take you attending the practical skill session, it should take you approximately 60 minutes. There will be a knowledge test at approximately 60 minutes. There will be a knowledge test at the beginning of the practical session to review your learning.the beginning of the practical session to review your learning.

GOOD LUCK!GOOD LUCK!

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IntroductionIntroduction

Learning OutcomesLearning Outcomes

Discuss the usage of commonly used needles and syringesDiscuss the usage of commonly used needles and syringes

Identify the differences between the intramuscular and Identify the differences between the intramuscular and subcutaneous routessubcutaneous routes

Identify and locate the anatomical sites for intramuscular Identify and locate the anatomical sites for intramuscular and subcutaneous injectionsand subcutaneous injections

Describe the procedure for preparation and administration Describe the procedure for preparation and administration of intramuscular andof intramuscular and subcutaneous injectionssubcutaneous injections

Describe the method used to administer intramuscular Describe the method used to administer intramuscular injections using the Z-track techniqueinjections using the Z-track technique

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Contents Page ( )Contents Page ( )

NeedlesNeedles SyringesSyringes Intramuscular InjectionsIntramuscular Injections Quiz (IM)Quiz (IM) Subcutaneous InjectionsSubcutaneous Injections Quiz (SC)Quiz (SC)

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Types of NeedleTypes of Needle Needles come in a variety of colours and sizes. For Needles come in a variety of colours and sizes. For

intramuscularintramuscular injectionsinjections (in adults) a green needle (in adults) a green needle should be used, unless the patient is extremely thin, with should be used, unless the patient is extremely thin, with little muscle mass. In such cases a blue needle would be the little muscle mass. In such cases a blue needle would be the needle of choice. However each patient should be assessed needle of choice. However each patient should be assessed individually. Very rarely are children given intramuscular individually. Very rarely are children given intramuscular injections. injections.

An orange needle should be used for An orange needle should be used for subcutaneous subcutaneous injectionsinjections, although some drugs by this route are already , although some drugs by this route are already assembled in pre-wrapped syringes with needles attached.assembled in pre-wrapped syringes with needles attached.

21g (Green)21g (Green) 23g (Blue)23g (Blue) 25g (Orange25g (Orange

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Types of SyringesTypes of Syringes Syringes come in a variety of sizes from 1ml to 50 mls, however Syringes come in a variety of sizes from 1ml to 50 mls, however

for injection purposes you will only use the following four:for injection purposes you will only use the following four:

1ml1ml 2ml2ml 5ml5ml Insulin SyringeInsulin Syringe

Depending on the amount of fluid to be injected, would influence Depending on the amount of fluid to be injected, would influence your choice as to what size syringe to use. For example, if you your choice as to what size syringe to use. For example, if you are injected 2mls of fluid you would use a 2ml syringe, rather are injected 2mls of fluid you would use a 2ml syringe, rather than a 5 ml syringe. than a 5 ml syringe. Please note that insulin syringes are Please note that insulin syringes are marked in international units and not millilitres!marked in international units and not millilitres!

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Intramuscular InjectionsIntramuscular Injections

The Intramuscular route is used to deposit a drug into the The Intramuscular route is used to deposit a drug into the muscle layer, which lies beneath the subcutaneous muscle layer, which lies beneath the subcutaneous tissue. The rate of absorption is quicker by this route than tissue. The rate of absorption is quicker by this route than via the subcutaneous route, because of the rich blood via the subcutaneous route, because of the rich blood supply within the muscle fibressupply within the muscle fibres

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Skin

Subcutaneous Layer

Muscle Layer

Intramuscular Injections…Intramuscular Injections… If two drugs are to be administered, check compatibility. If the If two drugs are to be administered, check compatibility. If the

drugs are incompatible, separate syringes and sites must be used drugs are incompatible, separate syringes and sites must be used for each drugfor each drug

The intramuscular route may be contraindicated for some The intramuscular route may be contraindicated for some patients. For example, those with blood clotting disorders.patients. For example, those with blood clotting disorders.

The local code of practice for drug administration and the The local code of practice for drug administration and the standards for the administration of medications (NMC 2002)standards for the administration of medications (NMC 2002)http://www.nmc-uk.orghttp://www.nmc-uk.org must be adhered to at all times. must be adhered to at all times.

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http://www.nmc-uk.org/

Intramuscular InjectionsIntramuscular InjectionsSitesSites

There are five sites commonly used for There are five sites commonly used for intramuscular injections:intramuscular injections:

DeltoidDeltoid

DorsoglutealDorsogluteal

Rectus FemorisRectus Femoris

Vastas LateralisVastas Lateralis

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Locating the deltoid siteLocating the deltoid site

This is located by drawing an This is located by drawing an imaginary horizontal line, 2-3 finger imaginary horizontal line, 2-3 finger breadths (2.5-5cms) below the breadths (2.5-5cms) below the lower edge of the acromion process.lower edge of the acromion process.

The injection should be given into an The injection should be given into an imaginary triangle, whose base is imaginary triangle, whose base is the central half of this horizontal line the central half of this horizontal line and whose apex is formed inverted and whose apex is formed inverted on the midpoint of the lateral aspect on the midpoint of the lateral aspect of the arm in line with the axillaof the arm in line with the axilla

Due to the small area of this site, Due to the small area of this site, the number and volume of injections the number and volume of injections (not usually more than 1ml) which (not usually more than 1ml) which can be given into this site is limited. can be given into this site is limited. For example, vaccines which are For example, vaccines which are usually small in volume are often usually small in volume are often given in thegiven in the deltoid muscle deltoid muscle

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www.drugguide.com/muscleinjection.asp

Locating the dorsogluteal siteLocating the dorsogluteal site

Often referred to as the upper outer Often referred to as the upper outer quadrant, the method of dividing the quadrant, the method of dividing the buttock into four equal areas by buttock into four equal areas by drawing imaginary lines, to bisect it drawing imaginary lines, to bisect it vertically and horizontally has been vertically and horizontally has been utilised by many nurses over the utilised by many nurses over the years to locate this injection site.years to locate this injection site.

This site is better located by This site is better located by palpating the greater trochanter and palpating the greater trochanter and posterior iliac spine, then injecting posterior iliac spine, then injecting laterally and superior to the laterally and superior to the midpoint of an imaginary line joining midpoint of an imaginary line joining these pointsthese points

The presence of major nerves and The presence of major nerves and blood vessels, and the relatively blood vessels, and the relatively slow uptake of medication from this slow uptake of medication from this site (because of a thick layer of site (because of a thick layer of adipose tissue) makes this site less adipose tissue) makes this site less favourablefavourable..

Please check hospital policy Please check hospital policy prior to using this siteprior to using this site

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Located midway between the Located midway between the patella (knee) and superior patella (knee) and superior iliac crest on the mid-anterior iliac crest on the mid-anterior aspect of the thigh.aspect of the thigh.

The uptake of drugs from this The uptake of drugs from this region is slower than from the region is slower than from the arm, but faster than from the arm, but faster than from the buttocks.buttocks.

This site is often utilised by This site is often utilised by patients who administer their patients who administer their own medication, as it is own medication, as it is readily available in the sitting readily available in the sitting or lying position. or lying position.

Injections into this site may Injections into this site may cause considerable discomfortcause considerable discomfort

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Locating the rectus femoris site

(Workman 1999)

Rectus femoris

Locating the vastus lateralis Locating the vastus lateralis sitesite

This is located on the lateral This is located on the lateral aspect of the thigh between the aspect of the thigh between the greater trochanter of the femur greater trochanter of the femur and the lateral femoral condyle of and the lateral femoral condyle of the knee. Divide into thirds with the knee. Divide into thirds with the middle third being the the middle third being the injection site.injection site.

One of the advantages of this site One of the advantages of this site is that it is easy to access, but is that it is easy to access, but most importantly there are no most importantly there are no major blood vessels or significant major blood vessels or significant nerve structures in the vicinity of nerve structures in the vicinity of the site.the site.

This muscle, like the rectus This muscle, like the rectus femoris is associated with the femoris is associated with the quadriceps femoris group of quadriceps femoris group of muscles and has similar muscles and has similar absorptive propertiesabsorptive properties

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Located by the nurse placing the Located by the nurse placing the heel of his/her opposing hand (i.e heel of his/her opposing hand (i.e right hand for left hip) on the right hand for left hip) on the patients greater trochanter. The patients greater trochanter. The index finger of the hand is placed index finger of the hand is placed on the patients anterior superior on the patients anterior superior iliac spine and the middle finger iliac spine and the middle finger stretched dorsally towards but stretched dorsally towards but below the iliac crest. The triangle below the iliac crest. The triangle formed by the index finger, the formed by the index finger, the third finger and the crest of the third finger and the crest of the ilium is the injection siteilium is the injection site

This site is free of penetrating This site is free of penetrating nerves and blood vessels and has nerves and blood vessels and has attracted significant attention in attracted significant attention in the nursing literature. It is the the nursing literature. It is the opimum site for IM injections.opimum site for IM injections.

The extent to which this muscle is The extent to which this muscle is used in the United Kingdom is used in the United Kingdom is unknown.unknown.

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Ventrogluteal Site


Preparing the InjectionPreparing the Injection

Injections should be drawn up Injections should be drawn up in a clean, designated area. in a clean, designated area. Always check that the Always check that the packaging of all equipment is packaging of all equipment is intact prior to use and check intact prior to use and check expiry date.expiry date.

Check the drug to be Check the drug to be administered against the administered against the patients prescriptionpatients prescription

Wash hands. Prepare the Wash hands. Prepare the equipment- syringe and equipment- syringe and 21g/23g needle (check 21g/23g needle (check hospital policy). Check that hospital policy). Check that the plunger of the syringe the plunger of the syringe moves freely in the syringe moves freely in the syringe barrel.barrel.

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Preparing the InjectionPreparing the Injection

The drug may be contained The drug may be contained within an ampoule or a vial. If within an ampoule or a vial. If drawing up a drug from an drawing up a drug from an ampoule, tap the stem of the ampoule, tap the stem of the ampoule while holding it ampoule while holding it vertically. Using a snapping vertically. Using a snapping motion, break off the top of motion, break off the top of the ampoule along the scored the ampoule along the scored line at its neck.line at its neck.

Draw up the drug into the Draw up the drug into the syringe. Holding the syringe syringe. Holding the syringe with the needle uppermost, with the needle uppermost, tap the side of the syringe to tap the side of the syringe to allow any air bubbles to rise allow any air bubbles to rise and expel the air gently. and expel the air gently. Change the needle.Change the needle.

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Drawing up from a vial

Take the receiver and the Take the receiver and the prepared drug and prepared drug and prescription chart to the prescription chart to the patient. Check the patient’s patient. Check the patient’s identity with the prescription identity with the prescription chart and identity band.chart and identity band.

Ensure privacy, then assist Ensure privacy, then assist the patient into a comfortable the patient into a comfortable position and expose the site position and expose the site to be injected. Clean skin as to be injected. Clean skin as per hospital protocol.per hospital protocol.

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Preparing the patientPreparing the patient

Stretch the skin to one side Stretch the skin to one side around the injection site (Z-around the injection site (Z-track technique). Holding the track technique). Holding the barrel of the syringe firmly barrel of the syringe firmly between thumb and index between thumb and index finger, plunge the needle into finger, plunge the needle into the skin at an angle of 90 the skin at an angle of 90 degrees leaving a third of the degrees leaving a third of the needle exposed (just in case the needle exposed (just in case the needle snaps).needle snaps).

Steady the barrel and pull back Steady the barrel and pull back gently on the plunger to gently on the plunger to observe if blood is aspirated. If observe if blood is aspirated. If blood is present discontinue the blood is present discontinue the procedure and reassure the procedure and reassure the patient. Dispose of the drug and patient. Dispose of the drug and all equipment and repeat as all equipment and repeat as appropriate.appropriate.

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Administering the Administering the InjectionInjection

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Administering the Administering the Injection cont…Injection cont…

Inject the drug by pushing the plunger of the syringe using Inject the drug by pushing the plunger of the syringe using your thumb, with a slow continuous movement. The fingers your thumb, with a slow continuous movement. The fingers steady the syringe and act as a counterforce.steady the syringe and act as a counterforce.

Injecting slowly allows time for the tissue to be displaced and Injecting slowly allows time for the tissue to be displaced and is less painful. Inject solution at a rate of 1ml per 10 seconds.is less painful. Inject solution at a rate of 1ml per 10 seconds.

Wait a few seconds to allow diffusion through the muscle, Wait a few seconds to allow diffusion through the muscle, then withdraw the needle. Apply pressure to the site if then withdraw the needle. Apply pressure to the site if necessary.necessary.

Make the patient comfortable and dispose of sharps according Make the patient comfortable and dispose of sharps according to hospital policy.to hospital policy.

Never re-sheath the needleNever re-sheath the needle Sign the patient’s prescription chart and document the time Sign the patient’s prescription chart and document the time

the drug was given. the drug was given.

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Z – Track TechniqueZ – Track Technique

A B C

A) Using your non-dominant hand, pull the skin and subcutaneous tissue 2-3 cms sidewards

B) Pierce the skin with a quick dart-like motion at 90 degree’s. Aspirate for blood, if none, slowly inject the medication

C) Withdraw the needle and release the skin to create a disjointed pathway which locks in the medication. Note – remember to use a long enough needle to reach the target muscle so that the medication is not deposited into the subcutaneous tissue. (Rodger & King 2000)

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Complications can occur at the site of the injection following Complications can occur at the site of the injection following IM drug administration. For example, seepage of the IM drug administration. For example, seepage of the injection solution and/or bleeding from the injection site injection solution and/or bleeding from the injection site onto the skin, pain, irritation and even skin lesions. onto the skin, pain, irritation and even skin lesions.

Such complications have been widely researched and one Such complications have been widely researched and one possible cause being some degree of fault in the IM possible cause being some degree of fault in the IM injection administration technique itself.injection administration technique itself.

Complications of IM Complications of IM injectionsinjections

QuizQuizThe following quiz consists of a list of 8 multiple The following quiz consists of a list of 8 multiple choice questions pertaining to intramuscular choice questions pertaining to intramuscular injections. Please click the mouse over the sound injections. Please click the mouse over the sound symbol for the answer you believe to be the symbol for the answer you believe to be the correct one. If you hear the sound of a gun shot, correct one. If you hear the sound of a gun shot, then unfortunately, you have chosen the incorrect then unfortunately, you have chosen the incorrect answer. A round of applause indicates the correct answer. A round of applause indicates the correct answer. answer.

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Question 1Question 1

What colour needle What colour needle would you normally would you normally use to administer use to administer an intramuscular an intramuscular injection to an injection to an adult?adult?

A - BlueA - Blue

B - GreenB - Green

C - OrangeC - Orange

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When When administering an administering an intramuscular intramuscular injection, a blue injection, a blue needle is only used needle is only used when the patient when the patient is..is..

A - ObeseA - Obese

B - ThinB - Thin

C - A diabeticC - A diabetic

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A 2ml syringe is A 2ml syringe is used for every used for every intramuscular intramuscular injectioninjection

A - YesA - Yes

B - NoB - No

C - Doesn’t matterC - Doesn’t matter

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When When administering an administering an IM injection, the IM injection, the angle of the needle angle of the needle should be at…should be at…

A – 45 degreesA – 45 degrees

B – 90 degreesB – 90 degrees

C – 60 degreesC – 60 degrees

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The intramuscular The intramuscular layer lies beneath layer lies beneath the..the..

A – Subcutaneous A – Subcutaneous layerlayer

B – SkinB – Skin

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The rate of The rate of absorption via the absorption via the IM rate is quicker IM rate is quicker than the SC route than the SC route because of…because of…

A – Rich blood A – Rich blood supplysupply

B – More nerve B – More nerve endingsendings

C – thick muscleC – thick muscle

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The Z track techniqueThe Z track technique A – Deposits the drug A – Deposits the drug into subcutaneous into subcutaneous tissuetissue

B – Deposits the drug B – Deposits the drug into the target muscleinto the target muscle

C – Deposits the drug C – Deposits the drug into both the into both the subcutaneous tissue subcutaneous tissue and the target muscleand the target muscle

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The Dorsogluteal The Dorsogluteal muscle can be muscle can be found…found…

A – Front of legA – Front of leg

B – ButtocksB – Buttocks

C – Side of legC – Side of leg

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Drugs that need to be absorbed steadily and slowly are given via Drugs that need to be absorbed steadily and slowly are given via the subcutaneous route. A subcutaneous injection is the subcutaneous route. A subcutaneous injection is administered beneath the epidermis into the fat and connective administered beneath the epidermis into the fat and connective tissue underlying the dermis. Examples of drugs given via this tissue underlying the dermis. Examples of drugs given via this route include insulin and low molecular weight heparin. The route include insulin and low molecular weight heparin. The majority of injections given to children is via this route.majority of injections given to children is via this route.

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Subcutaneous Injections

Skin

Subcutaneous LayerMuscle Layer

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Subcutaneous Injection Sites

Rotation of the injection sites will reduce the likelihood of local reaction and improve absorption of the drug:

•Abdomen

•Thigh

•Deltoid area

•Loins

www2.mc.duke.edu/ivf/injectio.htm

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Follow the same procedure for drawing up the drug as if Follow the same procedure for drawing up the drug as if you were drawing up an IM injection. However remember you were drawing up an IM injection. However remember that some drugs are available in pre-filled syringes.that some drugs are available in pre-filled syringes.

Expose the injection site and clean the skin according to Expose the injection site and clean the skin according to hospital policy. Grasp the skin to elevate the subcutaneous hospital policy. Grasp the skin to elevate the subcutaneous tissue. tissue.

A topical local anaesthetic can be applied to the injection A topical local anaesthetic can be applied to the injection site for children. Distraction therapy may also be necessary.site for children. Distraction therapy may also be necessary.

SC injections are normally given at an angle of 45 degrees SC injections are normally given at an angle of 45 degrees when they are more than half an inch long (an orange when they are more than half an inch long (an orange needle)needle)

If the needle is half an inch or less (pre-filled syringes), the If the needle is half an inch or less (pre-filled syringes), the needle should then be inserted at an angle of 90 degrees. needle should then be inserted at an angle of 90 degrees.

Procedure for Procedure for AdministrationAdministration of SC of SC injectionsinjections

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There is no need to pull back to aspirate as there is very There is no need to pull back to aspirate as there is very little blood supply in the subcutaneous layer.little blood supply in the subcutaneous layer.

Administer the injection at a rate of 1ml per 10 seconds.Administer the injection at a rate of 1ml per 10 seconds. Withdraw the needle and apply pressure to the site if Withdraw the needle and apply pressure to the site if

necessary.necessary. Make the patient comfortable and dispose of sharps Make the patient comfortable and dispose of sharps

according to hospital policy.according to hospital policy.

Never re-sheath the needleNever re-sheath the needle Sign the patient’s prescription chart and document the Sign the patient’s prescription chart and document the

time the drug was given. time the drug was given.

Procedure cont…1Procedure cont…1

Complications of SC Complications of SC InjectionsInjections

Complications can occur at the site of injection following SC Complications can occur at the site of injection following SC administration. For example:administration. For example:

Excessive bruising, especially following heparin Excessive bruising, especially following heparin administrationadministration

Repeated cleaning of the injection site with alcohol swabs Repeated cleaning of the injection site with alcohol swabs and/or repeated use of the same site may result in and/or repeated use of the same site may result in hardening of the skin.hardening of the skin.

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QuizQuizThe following quiz consists of a list of 7 multiple The following quiz consists of a list of 7 multiple choice questions pertaining to subcutaneous choice questions pertaining to subcutaneous injections. Please click the mouse over the sound injections. Please click the mouse over the sound symbol for the answer you believe to be the symbol for the answer you believe to be the correct one. If you hear the sound of a gun shot, correct one. If you hear the sound of a gun shot, then unfortunately, you have chosen the incorrect then unfortunately, you have chosen the incorrect answer. A round of applause indicates the correct answer. A round of applause indicates the correct answer. answer.

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What colour needle What colour needle would you normally would you normally use to administer a use to administer a subcutaneous subcutaneous injectioninjection

A - OrangeA - Orange

B - BlueB - Blue

C - GreenC - Green

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An insulin syringe An insulin syringe is marked in…is marked in…

A - International A - International mlsmls

B - International B - International mgsmgs

C – International C – International unitsunits

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When administering When administering a SC injection with a a SC injection with a needle less than half needle less than half an inch, the angle of an inch, the angle of the needle should the needle should be..be..




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When administering When administering a SC injection with a a SC injection with a needle longer than needle longer than half an inch, the half an inch, the angle of the needle angle of the needle should be…should be…




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Aspirating for blood Aspirating for blood is required prior to is required prior to administration of a administration of a S/C drug..S/C drug..

A - SometimesA - Sometimes

B – AlwaysB – Always

C - NeverC - Never

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A common site for A common site for a SC injection is a SC injection is the…the…

AbdomenAbdomen

ShoulderShoulder

CalfCalf

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Rotating SC sites Rotating SC sites will… will…

A – Decrease painA – Decrease pain

B – Reduce B – Reduce SwellingSwelling

C – Prevent C – Prevent hardening of the hardening of the skinskin

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Further ReadingFurther Reading

It is recommended that you access It is recommended that you access the resource file for articles upon the resource file for articles upon injection technique.injection technique.

The articles in The articles in yellowyellow bold on the bold on the following page are those we following page are those we recommend you read.recommend you read.

Beyea S; Nicoll LM (1996) Back to basics. Administering intramuscular injections the right way. Beyea S; Nicoll LM (1996) Back to basics. Administering intramuscular injections the right way. American Journal of NursingAmerican Journal of Nursing.. Vol 91. No 1. P 34-35 Vol 91. No 1. P 34-35

Greenway.K (2004) Using the Ventrogluteal Site for Intramuscular Injection. Greenway.K (2004) Using the Ventrogluteal Site for Intramuscular Injection. Nursing Nursing StandardStandard. Vol18, No 25. p.39-42.. Vol18, No 25. p.39-42.

King L (2003) Subcutaneous insulin injection technique. King L (2003) Subcutaneous insulin injection technique. Nursing StandardNursing Standard. Vol 17. No 34. . Vol 17. No 34. P45-52.P45-52.

Pritchard AP; Mallett J (1994) Pritchard AP; Mallett J (1994) Manual of clinical nursing procedures.Manual of clinical nursing procedures. Blackwell Scientific Blackwell Scientific Publications. Oxford.Publications. Oxford.

Rodger MA; King L (2000) Drawing up and administering intramuscular injections: a review Rodger MA; King L (2000) Drawing up and administering intramuscular injections: a review of the literature. of the literature. Journal of Advanced NursingJournal of Advanced Nursing. Vol 31. No 3. P 574-582. Vol 31. No 3. P 574-582..

Royal College of Paediatrics and Child Health (2002) Royal College of Paediatrics and Child Health (2002) Position Statement on Injection Position Statement on Injection TechniqueTechnique. London: Royal College of Paediatrics and Child Health. . London: Royal College of Paediatrics and Child Health.

Workman. B (1999) Safe Injection Techniques. Workman. B (1999) Safe Injection Techniques. Nursing Standard.Nursing Standard. Vol13. No.39 p47-53. Vol13. No.39 p47-53.

www.2.mc.duke.edu/ivf/injectio.htm - accessed 30/5/04www.2.mc.duke.edu/ivf/injectio.htm - accessed 30/5/04 www.drugguide.com/muscleinjection.asp -accessed 30/5/04www.drugguide.com/muscleinjection.asp -accessed 30/5/04

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References

I hope you found this learning pack useful I hope you found this learning pack useful and informative. and informative.

Thank -YouThank -You

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By Greg Dix Begin Welcome to this interactive learning pack on injection technique. You are required to complete this package before attending the practical.

Documents

drugthe intramuscular

used needles

subcutaneous routesidentify

subcutaneous tissue

needle of choice

separate syringes

insulin syringes

green needle