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C H A P T E R 34Administration of Parenteral Medications Chapter OutlineAdministration 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

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

Essential Termsampuleaqueousaspirateboluscannulacartridge unitcubic centimeter (cc) diluentextravasationgaugehypodermicinfiltrationintra-articularintradermalintramuscular (IM)Luer-Lokocclusionparenteralpatencyphlebitisprecipitateprimary drugsecondary drug

continues

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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 impor-tance 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 intrave-nous medications.

10. List several complications that may occur when administering IV medications.

11. List instances in which IV therapy should be discontinued.

IntroductionMedical assistants are often responsible for the administration of parenteral medi-cations. 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

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


A D M I N I S T R A T I O N O F P A R E N T E R A L M E D I C A T I O N S ❖ 837

safety checks along the way to ensure that the entire procedure is performed with absolute accuracy.

Failure to institute safety measures can result in seri-ous 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 medica-tion, it means to deliver medication via a route other than through the digestive tract. The most com-mon 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 injec-tion and intravenous routes; refer to Chapter 32 for all enteral and parenteral routes.

Common parenteral routes by injection include intradermal, subcutaneous, intramuscular, and intra-

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, usu-ally within minutes. The following list provides infor-mation 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 disadvan-tages of parenteral administration.

Parenteral Equipment and SuppliesThere 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 medica-tion, and the amount of medication to be given.

ADVANTAGES DISADVANTAGES

Effective route when other routes would be difficult to Unsanitary equipment or mishandling of the equip-use. For example, if the patient is unconscious or ment could cause microorganisms to be introducedunresponsive. into the patient.

Medications administered by injection do not cause An allergic reaction to a parenteral drug may occurirritation to the patient’s digestive system, nor are more rapidly and may be more severe than an allergicthey altered by gastric acids. 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 Improper injection procedures could cause damage toby injection. the patient’s nerves, tissue, veins, and other vessels.

Effects of the medication take place much more Veins could be traumatized by an intravenousrapidly than the oral route, so a patient that is in injection.excessive pain would receive faster relief from a parenteral pain reliever than an oral pain reliever.

TABLE 34-1 Advantages and Disadvantages of the Parenteral Route of Administration


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SyringesSyringes (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 cavi-ties, drawing large amounts of blood, and for aspirat-ing fluid from a patient’s joint or body cavity. Syringe selection is primarily based on the amount of medica-tion to be administered.

Syringes are packaged in hard plastic containers or peel-apart packages and are sealed to ensure steril-ity. 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.

NeedlesNeedles 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 typ-ically 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.

60 mL syringe

30 mL syringe

10 mL syringe

5 mL syringe

3 mL syringe

Tuberculin

Insulin syringe with needle

Luer-Lok tip

TipBarrel Rubber

stopperRubberstopper

Plunger

Plunger

3 mL syringeseparated

5 mL syringe separatedand together

Flange Flange

FIGURE 34-1 Syringes can range from 1 mL to 60 mL.

FIGURE 34-2 The parts of a syringe

FIELD SMARTSIn 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 con-nects to the needle.

TOOL BOX

FIGURE 34-3 Examples of different needle gauges and lengths



Table 34-3 provides specific details for selecting the appropriate gauge based on the route and the viscos-ity 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 certifi-cation 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. Intra-muscular (IM) injections will require a longer needle

than a subcutaneous or intradermal injection because muscles are deeper than the other two types of tis-sue. 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

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 medi-cation 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 34-2 Description of the Components of a Syringe

FIGURE 34-4 Slip-tip

FIGURE 34-5 Luer-Lok tip

GAUGE OF VISCOSITY OFNEEDLE 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 Aqueous-based medications Sub-Q Used when repeated injections are given,(usually such as insulinultra-fine point)

TABLE 34-3 Common Gauge Sizes Based upon the Route of Administration and Viscosity of the Medication


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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 lon-ger 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 chap-ter 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 nee-dles that are used for various routes and Figure 34-7 shows the different parts of a needle.

INTRADERMAL INJECTIONS

Patients of all sizes 3⁄8� to 1⁄2�

SUBCUTANEOUS INJECTIONS

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�

INTRAMUSCULAR INJECTIONS

Deltoid: Adult with an underdeveloped or atrophied deltoid muscle and very little adipose tissue (i.e., frail adult) 5⁄8�

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).

TABLE 34-4 Common Needle Lengths Based upon the Route of Administration, Location of the Injection, and Size of the Patient (Adult Chart)

F IELD SMARTSMany 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 med-ical assistant will stock a wide variety of needle gauges and lengths to accommodate patients of all sizes and medications of all viscosities.

TOOL BOX

The parts of a needle include the following:

❖ Point: The sharpened end of the needle, cut in a slanted edge called the bevel



❖ 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 attach-ment 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)

CRITICAL THINKING CHALLENGE

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 mus-cle 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.

TOOL BOX


Mrs. Sims in room 2 is waiting for an ACTH injec-tion. 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 3⁄8�, 25 G 5⁄8�, 22 G 1�, 21 G 11⁄2�, and 20 G 2�. 1. Which needle would work best under

these conditions? List your reasons.

TOOL BOX

Intramuscular Subcutaneous

Intradermal

Intracathetersfor intravenoususe Butterfly needle and tubing for

infusions of medications i.v.over a period of time

Lumen Shaft

Lumen

Shaft

Point

Plastic sheath

Point

Hilt

Hub

Bevel

FIGURE 34-6 Different needles used for various routes of administration

FIGURE 34-7 The parts of a needle

FIELD SMARTSEven though most injection equipment looks very similar, you should refrain from mixing one man-ufacturer’s equipment with another manufactur-er’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.

TOOL BOX


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Needle Safety when Using Parenteral EquipmentNeedle 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 inci-dent to a supervisor. An incident report should be completed and the employee should receive counsel-ing 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

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 cor-rect 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.)

FIGURE 34-9 Various medication containers: (a) ampule; (b) cartridge unit; (c) vial

(a) (b) (c)



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 cali-brations 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 stimu-late a biological effect. The biological effect that one unit of medication has upon body tissue is decided upon by the International Conference for the Unifica-tion of Formulas. Unit increments are commonly used for substances such as insulin and particular vitamins and are specific to the individual substance or medi-cation 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 VialWhen medication is stored in a vial, it may be in a single- dose vial (containing an individual dose of medication) or a multiple-dose vial (containing several doses). The

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

FIELD SMARTSAlways 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 mate-rial 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 medi-cation should be stored, both before and after opening.

TOOL BOX

FIELD SMARTSThere is no need to clean the stopper on a medi-cation vial immediately after removing the seal. The stopper is sterile at this point unless you con-taminate it when removing the seal. Once the first dose of medication has been removed, the stop-per is no longer considered sterile and will need to be cleansed with an alcohol wipe with each subsequent use.

TOOL BOX

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

(c)

(a)

(b)


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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 with-drawn, insert the needle into the vial. With the vial still in an upright position, push the plunger for-ward 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).

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


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?

TOOL BOX

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.



F IELD SMARTSIt 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.

TOOL BOX

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 medi-cation 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, mean-ing 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-

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

FIGURE 34-14 Cover the neck of the ampule with gauze and snap the neck off away from you.

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 par-ticles 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 inject-ing the patient. Refer to Procedure 34-2 for the proper steps to follow when withdrawing medication from an ampule.


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Reconstituting Medications for InjectionCertain 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 lon-ger shelf life than liquid forms. A diluent (liquid) is used to reconstitute the powder. Normally this solu-tion is sterile saline (NaCl), sterile water (H2O), or lidocaine. The diluent may be supplied with the medi-cation or may need to be drawn up separately. The medical assistant must always follow the manufactur-er’s instructions when reconstituting a medication.

Once the diluent is removed from its original con-tainer, 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 dilu-tion (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 some-times 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 medica-tions are not compatible and may cause problems if combined.

When combining two medications, the medical assistant must determine which medication is the

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 cloud-ier 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 car-tridges that hold a single dose of medication. Depo-Provera, penicillin G benzathine, Phenergan, and interferon are examples of medications that are avail-able in cartridges. The prefilled cartridge–needle units require no mixing, no special calculations, and are eas-ily 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 interchange-able with many brands of cartridges. Procedure 34-5 lists steps that are performed when using a cartridge injector device.

General Guidelines for Parenteral MedicationsIn 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 adminis-tering all types of injections:

FIELD SMARTSChanging 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 sub-stances 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.

TOOL BOX

Plunger

Rubber collar

Plunger rod

Disposable sterilecartridge-needleunit

FIGURE 34-16 A cartridge–needle unit and a reusable injec-tor device



❖ 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.

❖ 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 subcutane-ous injections, the medical assistant should aspirate to make certain that the needle is not in a blood ves-sel. 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. Med-ical 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 InjectionAt 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 particu-lar 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 contra-indicated 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.

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, Lovo-nox, 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.

TABLE 34-5 General Guidelines for Aspiration


848 ❖ C H A P T E R 3 4

Following the ProcedurePatients should be monitored for anaphylaxis (life-threatening allergic reaction) for 20 to 30 minutes fol-lowing 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 expe-riencing any breathing difficulties or any other unusual symptoms. If the patient experiences anything out of the ordinary, check with the provider before dismiss-ing 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 document-ing medications. Medications such as immunizations and narcotics should also be documented in designated log. Figure 34-17 shows a hospital medication log.

ROUTES OF ADMINISTRATIONThe route that is selected for parenteral delivery will be primarily based on the manufacturer’s recommenda-tion 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



that may make it harmful to surrounding tissue. Alter-ing 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).

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-

FIELD SMARTSPatients 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 epineph-rine should be stocked in any room where injec-tions are administered.

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EMR A PPL ICAT IONMany EMR software applications have a “Logs” section integrated within the software. Medica-tion 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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FIGURE 34-18 The needle is inserted at a 10° to 15° angle for an intradermal injection.

FIGURE 34-19 A wheal should appear on the surface of the arm following an intradermal injection.


850 ❖ C H A P T E R 3 4

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 con-nective 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 posi-tion 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.

NEEDLE SIZE 26–27 G, 3⁄8�–5⁄8�

SYRINGE SIZE 1 mL

ANGLE OF INSERTION 10°–15°

ASPIRATE No

COMMON MEDICATIONS OR Allergy extract, TB extractEXTRACTS GIVEN THIS ROUTE

MAXIMUM AMOUNT OF ML 0.1 mLPER LOCATION

MASSAGE No

TABLE 34-6 Intradermal Injection Summary Chart

FIGURE 34-20 Sites for an intradermal injection include the inner forearm and the upper portion of the back.



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 abdo-men, 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.

Intramuscular InjectionsThe term intramuscular (IM) means within the mus-cle. 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 sub-cutaneous tissues and deep into the muscular tissue; otherwise, the medication will seep into the subcuta-neous tissue and may cause a sterile abscess or malab-sorption of the medication.

Subcutaneoustissue

Subcutaneous

45-degreeangle

Intravenous

25-degreeangle

Muscle

Dermis

Intramuscular(IM)

Subcutaneous(SC)

Intravenous(IV)

Intradermal(ID)

Intramuscular

90-degreeangle

Epidermis

Intradermal

10- to 15-degree angle

FIGURE 34-21 Angles for injection into the correct layer of skin or muscle

FIGURE 34-22 Common sites for a subcutaneous injection


852 ❖ C H A P T E R 3 4

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 Allergy injections, insulin injections, heparin, Lovonox, MMR vaccine, EXTRACTS GIVEN THIS ROUTE small pox vaccine, IPV vaccine, VAR vaccine

MAXIMUM AMOUNT OF ML 1 mLPER LOCATION

MASSAGE Yes, except in a select few medications (read manufacturer’s instructions)

TABLE 34-7 Subcutaneous Injection Summary Chart

Body areas normally used for intramuscular injec-tion 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 sub-cutaneous tissue. Table 34-8 provides facts regarding IM injections. Procedure 34-8 lists specific steps for administering IM injections.

DorsoglutealThe dorsogluteal site is used to administer injections in adults and older children. Viscid or thicker medi-cations or medications greater than 1 mL are usually injected into this muscle. Extreme caution is to be used

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,

NEEDLE SIZE 20–23 G, 1�–3�

SYRINGE SIZE 3–6 mL

ANGLE OF INSERTION 90°

ASPIRATE Yes

COMMON MEDICATIONS OR Most vaccines, analgesics, antibiotics, steroids, hormonesEXTRACTS GIVEN THIS ROUTE

MAXIMUM AMOUNT OF ML Deltoid: l mL; large muscles such as the dorsogluteal and vastus lateralis: PER LOCATION 3 mL

MASSAGE Generally: yes; Z-Track: no

TABLE 34-8 Intramuscular Injection Summary Chart

F IELD SMARTSAsk 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.

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F IELD SMARTSWhen 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 loca-tions. Always check with physician for approval prior to dividing.

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FIELD SMARTSTo assist with relaxation of the dorsogluteal mus-cle, place the patient in a prone position with the toes turned inward.

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Iliac crest

Gluteus medius muscle

Posterior superior iliac spine

Gluteus minimusmuscle

Gluteus maximusmuscleIliotibial tract

Sciatic nerve

Greater trochanterof femur

FIGURE 34-23a The dorsogluteal site

FIGURE 34-23b The landmark for dorsogluteal injections

emaciated, thin, or elderly patients due to a lack of suf-ficient muscle tissue.

VentroglutealThe 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 assis-tant 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 LateralisThe vastus lateralis is part of the quadriceps group of the thigh and is the preferred site for administer-ing 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

FIELD SMARTSTo 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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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 consid-ered acceptable for this site.

The danger involved with using this site is the acci-dental 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


854 ❖ C H A P T E R 3 4

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.

DeltoidThe deltoid is a smaller muscle than the other intra-muscular sites, but can be used for thinner, less viscid medications with a limited volume, such as immuniza-tions. 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 plac-ing two fingers on the acromion process and measur-ing 1 to 2 inches below it (Figure 34-26). The injection should be administered in the most prominent portion of the muscle.

FIELD SMARTSTo assist with relaxation of the deltoid muscle, have the patient drop the arm against the side of the body.

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Tubercle ofiliac crest

Gluteus mediusmuscleAnterior superioriliac spine

Greater trochanter of femur

Gluteusmaximusmuscle

Tensor fasciae lataemuscle

Gluteus minimusmuscle

FIGURE 34-24a The ventrogluteal site

FIGURE 34-24b The landmark for ventrogluteal injections

Femoralnerve

Anterior superioriliac spine

Tensor fasciaelatae muscle

Femoral artery andvein

Sartoriusmuscle

Vastus lateralismuscle

Patella

FIGURE 34-25a The adult vastus lateralis site

FIGURE 34-25b The landmark for vastus lateralis injections



F IELD SMARTSWhen administering an immunization in the deltoid muscle, use the patient’s dominant arm. Increased muscle use will promote better circula-tion and will help to work out the soreness from the injection much faster.

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Acromion

Clavicle

Deltoid muscle

Brachial arteryand vein

Cephalic vein

Humerus

FIGURE 34-26a The deltoid site

FIGURE 34-26b The landmark for deltoid injections

FIGURE 34-27 Remove the hand holding the Z-track immedi-ately after withdrawing the needle.

Z-Track Method of InjectionThe 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-

cutaneous tissue over the dorsogluteal tissue are dis-placed 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 aspira-tion, 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 medica-tion or discoloration of the skin from occurring. Do not massage Z-track injections. Procedure 34-9 provides fur-ther details on how to perform this procedure. Com-mon medications given by the Z-track method include iron preparations and medications that are irritating to superficial tissue, such as Vistaril®.

Skin pulled taut Skin released


856 ❖ C H A P T E R 3 4

INCORRECT TECHNIQUE CONSEQUENCES EFFECTS

Failure to change the needle Tissue irritation or discoloration Local reaction to the skin or musclebetween the vial and patient Excess pain to the patient Discoloration of the skin Increased amount of pain because of the

needle’s dullness

Using a needle that is too Medication will be deposited Medication will not be absorbed theshort into incorrect tissue way the manufacturer intended it to be

absorbed, thus changing the desired effects of the medicationAbscessTissue degeneration

Using a needle that is too Medication will be deposited Medication will not be absorbed thelong into incorrect tissue way the manufacturer intended it to be

absorbed, thus changing the desired effects of the medicationCould cause damage to the periosteum resulting in infection and bone retardationNeedle could break off into the bone

Failing to aspirate on Deposition of medication Shock: Medication was not intendedmedications that should directly into a vein or artery to go directly into the bloodstream. be aspirated May cause patient’s heart to beat faster,

respiration rate to increase, blood pres-sure to drop. Patient may become unconscious.

Break in sterile technique The introduction of micro- Blood infection organisms into the muscle, An abscess in the subcutaneous tissue, subcutaneous tissue, or blood muscle tissue, or surrounding tissue stream Tissue degeneration

Choosing a muscle that is May cause injury to the nearby Tinglingunderdeveloped nerves Excruciating pain Paralysis

Injecting a patient with a May cause injury to the Burningsmall-gauge needle when surrounding tissue Tissue degenerationadministering a viscid Increased pain to the patientsolution

TABLE 34-9 Possible Parenteral Complications

PARENTERAL COMPLICATIONSTo 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 immu-nizations, 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 immuniza-tions for adults.




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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Recommended Adult Immunization ScheduleNote: Thes ons must be read with the footnotes that follow.

VACCINE AGE GROUP 19–49 years 50–64 years > 65 years

Tetanus, diphtheria,pertussis (Td/Tdap)1,*

Human papillomavirus (HPV)2,*

Measles, mumps, rubella (MMR) 3,*

In uenza 5,*

Pneumococcal (polysaccharide) 6,7

Hepatitis A 8,*

Hepatitis B 9,*

Meningococcal 10,*

Zoster 11

Varicella 4,*

1 or 2 doses

1 dose annually

3 doses (0, 1–2, 4– 6 mos)

1 or more doses

2 doses (0, 4– 8 wks)

1 dose

1–2 doses

1 dose Td booster every 10 yrs

2 doses (0, 6–12 mos or 0, 6–18 mos)

1 dose

1 dose

*Covered by the Vaccine Injury Compensation Program.

Substitute 1 dose of Tdap for TdSubstitute 1 dose of Tdap for Td3 doses females

(0, 2, 6 mos)

Figure 1. Recommended adult immunization schedule, by vaccine and age group United States, October 2007 – September 2008

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 at www.vaers.hhs.gov or by telephone, 800-822-7967.

Information on how to le a Vaccine Injury Compensation Program claim is available at www.hrsa.gov/vaccinecompensation 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.

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)

CS11

5143

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.

Contraindications and Precautions in Vaccine AdministrationsThere are many misconceptions regarding immuniza-tions 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.


858 ❖ C H A P T E R 3 4

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 immu-nizing agents to verify prior history of sensitivity or allergic reaction. The CDC has a great deal more infor-mation regarding immunization contraindications on their Web site at http://www.cdc.gov.

BASICS OF INTRAVENOUS THERAPYIntravenous (IV) therapy is the administration of flu-ids 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 admin-istered 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 blood-stream immediately. IV therapy is drug specific, mean-ing 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 medi-cal 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.

Equipment and Supplies Employed in Intravenous TherapyEquipment and supplies available for use in IV therapy are continually being updated to com-

ply with federal and state laws regarding safe work practices and for patient comfort. Containers for IV fluids have changed from glass containers to pli-able 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 infu-sion and are filled with ready-to-use medications at the time of manufacturing. The pharmacy will add addi-tional 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.)



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 dur-ing 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. Administra-tion 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.

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 Restores fluid and electrolyte balance, used when patients have lactoseNa 147 mEq/L, K 4 mEq/L, intolerance, may be used as a blood replacement for a short timeCl 155 mEq/L

TABLE 34-10 Common Fluids Used for IV Therapy

Flashbackarea

Catheterhub

Protectivecap

Catheter

Needle

Injection port

Piercing pin

Drip chamber

Flange

Drop orifice

Slide clampOpenClose

Luerslip

Flow controlclamp

Open

Close Open

Close

OpenClose

FIGURE 34-32 A catheter and needle

FIGURE 34-30 An IV administration tubing set FIGURE 34-31 Tubing clamps

Basic IV Administration SetsEach 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 regu-late the flow of fluids through the IV tubing.

❖ IV cannula or catheter (Figure 34-32): A flex-ible tube that is used to insert medication within


860 ❖ C H A P T E R 3 4

a body cavity or blood vessel. It has a trocar (a sharp-pointed needle) attached to it that punc-tures 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 admin-istration, 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 (Fig-ure 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 TherapyThe 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, swell-ing, 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.

(a) (b) (c)

(d) (e)

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 dress-ing to tubing; (d) secure with tape; (e) when removing, use alcohol to loosen tape. (Courtesy of ConMed Corp.)



Risks, Complications, and Adverse Reactions of IV TherapyIntravenous therapy can have numerous inherent risks and complications associated with this type of medica-tion administration procedure. The medical assistant must be knowledgeable in recognizing the complica-tions, 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 irrita-tion at the insertion site, cannula dislodgement, cathe-ter or needle occlusion, and phlebitis (inflammation of the vein). Other complications may involve hematoma

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 intoler-ance 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 effective-ness 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

Pressure HistoryGraphically displayspressure trend forlast two hours.

Rapid Rate, On-LineTitrationFacilitates rapid rateadjustments withoutinterrupting flow.

ProgrammableStart TimeCan automatically startmultiple infusions atspecified times.

All Fluids Air-In-LineDetectorSignificantly reducesthe chance ofaccidental administrationof air.

Multi-DosingEnables the automaticdelivery of a series ofinfusions, from thesame IV container, atspecified times.

Dual-RatePiggybackingAutomatically switchesto primary parametersupon completion ofsecondary (piggyback)infusion.

Volume/TimeDosingAutomatic calculationof rate by programmingvolume and time.

Automatic DrugCalculationCalculates drug dose orrate automatically for allstandard units of measure.

Flo-Stop DeviceProvides disposable-based protectionagainst accidental IVfree-flow.

Pump/ControllerModesEliminates time-consuming instrumentexchanges (based onhospital infusionprotocols). Can switchbetween pump andcontroller modes withthe press of a singlekey.

Micro/Macro InfusionCapabilityDelivers precise infusionsat rates from 0.1 to99.9 mL/hr in 0.1 mL/hrincrements and from 1 to999 mL/hr in 1 mL/hrincrements.

RS-232 Data PortEnables communicationwith a variety ofinformation andremote monitoringsystems.

Dual-ChannelDeliveryPermits simultaneousdelivery of two separateinfusions at independentrates.

Large Backlit CenterDisplay(Scratch Pad)Facilitates programming.

®

FIGURE 34-34 An IV infusion pump (Courtesy of Alaris Medical Systems.)


862 ❖ C H A P T E R 3 4

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 danger-ous and can be life threatening. The medical assistant should become familiar with symptoms that may indi-cate 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 TherapyWhen the physician determines the patient no lon-ger 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

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.

TABLE 34-11 Guideline Questions for Patient Pain Assessment

COMPLICATIONS AND RISKS DESCRIPTION SYMPTOMS

Infiltration or Medication fluid leaks from the Redness, severe swelling, hardness at theextravasation cannula or from the vein into the site, pain, and edema tissues surrounding the site.

Catheter and needle Rednessdisplacement

Occlusion The cannula becomes blocked and Blood in IV tubing allows blood to back up into the IV tubing.

Loss of patency Occurs when the vein wall has Blood in IV tubing(the openness of been damagedthe vein)

Phlebitis Bacteria can form as a normal Vein may be hard, red streak along vein,(inflammation of immune response due to the death inflammation, and swellingthe vein wall) of leukocytes and other tissue cells.

Thrombosis Blood clots form, causing slow or Slow or stopped infusion 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 Redness, red streak at the site of the needle to surrounding tissues or nearby

TABLE 34-12 Complications and Risks of Intravenous Therapy



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 press-ing 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. Docu-ment 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 toler-ated procedure well. No swelling, no bruising, or other complications noted.”).

Intravenous therapy is a concise procedure and should be performed only by specially trained individu-als. 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

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

TABLE 34-13 Signs and Symptoms of Systemic Complications

FIGURE 34-35 Inspect the cannula following withdrawal from the patient’s vein.


864 ❖ C H A P T E R 3 4

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 INJECTIONSThe term intra-articular means within a joint. Some injections are given within a joint to help reduce inflam-mation 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.


You work in an urgent care center and the phy-sician 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 per-form this procedure. All of the rest of the medi-cal 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?

TOOL BOX

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

PROCEDURAL STEPS

1. Wash your hands and apply gloves.

2. Assemble the equipment.

3. Work in a quiet and well-lit area.

4. Select the correct medication from the storage area and check the drug label (Medication Check #1).

5. Check the expiration date.

RATIONALE

This prevents the spread of infection and contamina-tion during the procedure.

Distractions and poor lighting may lead to medication errors.

This assists in making certain you have the correct medication.

Using a medication beyond the expiration date may decrease the effectiveness of the drug.

❖ Gauze 2x2 sponges

❖ Sharps container

❖ Medication tray



PROCEDURAL STEPS

6. Compare the medication with the physician’s order (Medication Check #2).

7. Calculate the correct dose to be given, if needed. Verify the correct calculations with the physician if necessary.

8. Open the syringe and attach the needle to the syringe.

9. Open the antiseptic wipe and clean the vial stopper (Figure 34-36).

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.

11. Check to make sure the needle is firmly attached to the syringe and remove the cap from the needle.

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.

14. Invert the vial while holding onto the syringe and plunger. Hold the vial and syringe without con-taminating the needle or hub of the syringe. These parts of the syringe must remain sterile.

15. Hold the syringe at eye level and withdraw the proper amount of medication (Figure 34-38).

16. Keep the tip of needle below the fluid level.

17. Remove any air bubbles in the syringe by tap-ping or flicking the side of the syringe where the bubbles are located (Figure 34-39).

RATIONALE

This alleviates the possibility of mistakes and wasting of valu-able medication.

Giving the correct dose helps to obtain the desired effects and avoid complications.

This prevents contamination of the vial and the needle when preparing the injection.

This keeps the pressure in the vial at atmospheric pressure.

If the needle is not firmly attached to the syringe, it may become disconnected and cause an injury to the person prepar-ing the medication or to the patient during the procedure.

Forcing air into the medication can cause the fluid to break down or bubble, thus creating more bubbles in the medication vial.

This helps prevent microorgan-isms from entering the vial and the patient from obtaining an infection.

This ensures that you are reading the calibration lines correctly.

This prevents air microorgan-isms from entering the vial and from being drawn into the syringe.

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 34-36 Cleanse the stopper of the vial.

FIGURE 34-37 Insert the needle through the rubber stopper.

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


866 ❖ C H A P T E R 3 4

PROCEDURAL STEPS

18. Remove any air remaining in the tip of the syringe. Check to make certain that you still have the cor-rect 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.

20. Replace the needle cap on the syringe (Figure 34-40) or replace with a new needle and cap setup.

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.

RATIONALE

Removing air bubbles and expelling any air could change the volume of medication in the syringe.

Replacing the nee-dle unit reduces the risk of a local reac-tion if the needle used to withdraw the medication is changed between the vial and patient. Pushing the needle through the rub-ber stopper dulls the needle; a new needle pierces the skin much easier.

Three checks help to ensure you have the correct medi-cation and prevents errors from occurring.

continued

FIGURE 34-40 Replace the needle cap.

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



❖ Medication tray



PROCEDURAL STEPS







7. Calculate the correct dose to be given, if needed.

8. Open the syringe and filter needle and assemble, if necessary.

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.

10. Open the antiseptic wipe and clean the ampule container. Allow the ampule to dry completely.

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.

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.

13. Check to make sure the filter needle is firmly attached to the syringe and remove the cap from the needle.

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. Com-pletely draw up all the medication into the syringe (Figure 34-41).

15. Remove the needle from the ampule without allowing the needle to touch the edges of the ampule.

16. Dispose of the ampule into the sharps container. Check the medication label before discarding the ampule (Medication Check #3).

RATIONALE



This helps to ascertain you have the correct medication and prevents error from occurring.

No medication should be given if the drug has reached the expiration date, as it may not be effective.

This alleviates the possibility of mistakes and wasting of valuable medication.

An incorrect dose could cause great harm to the patient.

A filter needle filters out possible glass fragments that may be present from snapping the stem from the body of the ampule.

This forces the medication into the base of the ampule container.

This prevents contamination of the needle when pre-paring the injection.

This protects the fingers when breaking open the neck of the vial.

This keeps glass fragments from flying into the medical assistant’s eyes or face.

If the needle is not firmly attached it may cause injury to the person preparing the medication.

Tilting the ampule facilitates emptying the entire ampule.

This prevents contamination of the needle.

Immediately disposing of the ampule prevents injury to the person preparing the medica-tion for injection.

FIGURE 34-41 Hold the ampule at a slight angle when withdrawing medication.

continues


868 ❖ C H A P T E R 3 4

PROCEDURAL STEPS

17. Remove any bubbles in the syringe.

18. Pull back slightly on the plunger to draw the med-ication from the needle into the syringe, engage the safety device, and remove the filter needle.

19. Open a new needle for administering medication to the patient and attach it correctly to the syringe.

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.

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.

continued

RATIONALE

This helps to prevent little air bubbles from entering the patient.

This removes any medication that remains within the filter needle. Medication cannot be administered to the patient with the filter needle.

The filter needle may have glass fragments inside, so it is not used.

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.

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



❖ Medication tray

PROCEDURAL STEPS




4. Select the correct medication and diluent from the storage area, and check both drug labels (Medication Check #1).

RATIONALE



Having the wrong medication or diluent could cause harm to the patient.



PROCEDURAL STEPS

5. Check the expiration date on both labels.


7. Calculate the correct dose to be given, if needed. Verify the correct calculations with the provider if necessary.

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).

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.

11. Check to make sure the needle is firmly attached to the syringe and remove the needle cap.

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).

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.

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.


RATIONALE

Medication should not be given if the drug has reached the expiration date, because it may not be effective.


Giving the wrong dose could cause great harm to the patient.

This prevents possible contami-nation to the medication vials or the patient.

This equalizes the pressure within the vial.

If the needle is not firmly attached to the syringe, it may become disconnected and cause an injury to the person prepar-ing the medication.

This equalizes the amount of air in the vial.

If the needle tip is not inserted in the fluid, air will be drawn into the syringe.

This allows the powder to be flushed with the fluids and helps to minimize the forma-tion of clumps within the powder.

FIGURE 34-43 Inject air into the diluent vial.

FIGURE 34-44 Inject the diluent into powdered medication vial.

FIGURE 34-42 Cleanse the rubber stopper of both vials.

continues


870 ❖ C H A P T E R 3 4

PROCEDURAL STEPS

21. Roll the vial between the hands to thoroughly mix the medication (Figure 34-45).

22. Record the new date of expiration on the label of the medication vial.

23. Recheck the medication label before returning the vial to the proper storage area (Medication Check #3).

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.

continued

RATIONALE

This allows all of the particles to be sus-pended appropriately.

Once the medication has been prepared, it is only good for a certain amount of time.

A third check helps in ascertaining you have the correct medication.

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


❖ Medication tray


PROCEDURAL STEPS




4. Select the correct medications from the storage area and check their drug labels (Medication Check #1).

5. Check the expiration dates on both vials.

RATIONALE



Reading the label helps to acertain you have the correct medication.

No medication should be given if the drug has reached the expiration date, as the medication may not be as effective.



PROCEDURAL STEPS

6. Compare the medications with the physician’s order (Medication Check #2).

7. Calculate the correct doses to be given, if needed. Verify the correct calculations with the provider if necessary.

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.

10. Determine which medication is the primary medi-cation vial. Do not do anything with the primary medicine at this point.

11. Draw up an amount of air into the syringe that is equal to the amount of medication required from the second vial.

12. Check to make sure the needle is firmly attached to the syringe and remove the needle cap.

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.

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.

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.

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.

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.

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.

RATIONALE


Giving an incorrect dose could cause great harm to the patient.

This removes microbes that may be on the stoppers.

The primary medication is the first medication to be drawn up.

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.

If the needle is not firmly attached it may become detached from the syringe, causing harm to the preparer.

Pushing the needle into the medication will contaminate the needle, affecting the next vial.

This equalizes the pressure due to the fluid being removed from the vial.

Pushing air into the liquid could create bubbles in the syringe and vial.

If the needle tip is not inserted in fluid, air will be drawn into the syringe.

This expels any remaining air within the syringe and the needle and ascertains you have the correct amount of medication.

This reduces the risk of medication from the first vial carrying over to the second vial.

continues


872 ❖ C H A P T E R 3 4

PROCEDURAL STEPS

21. Smoothly insert the needle into the secondary vial.

22. Invert the vial and slowly withdraw the medica-tion 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.

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 adminis-tered.


27. Recheck the medication labels of both vials before returning the vials to the proper storage area (Medication Check #3).

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.

continued

RATIONALE

If medication from the primary vial mixes with the secondary vial it will contaminate the contents of the second vial.

If the incorrect dosage is in the syringe, the patient may not obtain the full effects of the medication.

Some facilities will allow recapping of clean needles, while other facilities prefer the scoop method.

Checking the label three times helps to ascertain you have the correct medication and prevents errors from occurring.

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



❖ Injection tray



PROCEDURAL STEPS






6. Compare the medication with the physician’s instructions (Medication Check #2).

7. Calculate the correct dose to be given, if needed.

8. Pick up the cartridge unit holder (the injector).

9. Turn the ribbed collar toward the open position until it stops (Figure 34-46).

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.)

12. Thread the rod of the plunger into the cartridge unit until a slight resistance is felt (Figure 34-47).

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).

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).

RATIONALE



This ascertains that you have the correct medication.

No medication should be given if the drug has reached the expiration date, as it may not be effective.

This alleviates the possibility of mistakes and wasting of valu-able medication.

There may be instances in which a patient does not need the entire dose within the cartridge.

This allows for the insertion of the cartridge into the holder.

If the cartridge is not tightened securely onto the holder, the needle unit may move during the injection procedure.

Checking the label three times ascertains you have the correct medication and prevents errors from occurring.

This prevents the fingers from being in front of the needle.

FIGURE 34-46 Turn the ribbed collar to the open position.

FIGURE 34-47 Thread the plunger onto the cartridge unit.

FIGURE 34-48 After the injection is given, disengage the plunger from the cartridge unit.

continues


874 ❖ C H A P T E R 3 4

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).

18. Cleanse the cartridge holder with an antiseptic cleanser and allow to dry.

19. Cleanse the work area and remove gloves and wash your hands.

continued

RATIONALE

This helps to prevent an acci-dental needlestick.

This prevents cross-contamination 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.

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



❖ Disposable gloves

❖ Medication tray

PROCEDURAL STEPS

1. Wash your hands.

2. Assemble the equipment. Institute the Seven Rights of Drug Administration.

3. Identify the patient using two identifiers, identify yourself, and explain the procedure

4. Ask patient about drug allergies or latex allergies.

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.)

RATIONALE


Instituting the seven rights helps to alleviate errors.

Giving the medication to the wrong patient can cause serious problems for the patient.

Giving the patient a drug or using products that the patient is allergic to can cause an anaphylactic reaction.

This prevents the possible contamination of the injec-tion 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.



PROCEDURAL STEPS

7. Prepare the equipment and apply gloves.

8. Remove the needle cap. Pull the cap straight off, never twist.

9. Stretch the skin taut at the site of administration.

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).

12. Remove the needle quickly at the same angle of insertion.

13. Do not press on or massage the injection site. Do not apply a bandage to the site.

14. Properly engage the safety device on the needle and dispose of the needle–syringe unit in the sharps container.

15. Remove gloves and wash your hands.

16. Give proper patient education for caring for the site and inform the patient to wait 20 to 30 minutes.

17. Perform post-injection observation and document the procedure in the patient’s chart and the appro-priate logs.

RATIONALE

Wearing gloves prevents contamination of bloodborne pathogens during the procedure.

Twisting may loosen the needle attached to the syringe.

This allows the needle to be inserted easier and keeps the tissue from moving during insertion.

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 injec-tion will have to be repeated.

This prevents injury to the tissue.

The medication will be dispersed into deeper tissue if pressure is applied to the area. A bandage will absorb the medication.

Engaging the safety device will help to prevent an accidental needlestick.

This prevents contamination and the spread of infection.

The 20 to 30 minute wait is to observe the patient for anaphylaxis.

Documentation illustrates that the procedure was performed.

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.

DOCUMENTATION EXAMPLE:

05-22-XX Tubersol, 0.1 mL, ID , right lower forearm, per Dr. Jones . Manf – Kline Beec ham, Lot number—K449, exp. 3:15 p.m. date – 12/XX. Pt. tolerated well, instructions given to ret urn to clinic 48–72 hours for PPD reading.

– complications during post-inject ion observation. Sherri Jones , CMA (AAMA)


876 ❖ C H A P T E R 3 4

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




❖ Medication tray

❖ Adhesive bandage

PROCEDURAL STEPS

1. Wash your hands.


3. Identify the patient using two identifiers, identify yourself, and explain the procedure.

4. Ask the patient about drug allergies, latex allergies, or adhesive allergies.

5. Select the proper injection site (fatty tissue of the arms, thighs, or stomach).




9. Grasp or pinch the tissue lightly with one hand.

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.

RATIONALE


Instituting the seven rights will help prevent errors from occurring.

Giving the medication to the wrong patient can cause serious problems for the patient.



This prevents contamination by bloodborne pathogens during the procedure.


This helps to determine the subcutaneous layer of tissue and helps with the needle insertion.

Unnecessary movement of the syringe can cause tissue damage and pain to the patient.

FIGURE 34-52 The proper angle of inser-tion for a subcutaneous injection



PROCEDURAL STEPS

12. Aspirate to ensure the needle is not in a blood vessel.

13. Inject the medication slowly and steadily.


15. Place a cotton ball or gauze sponge over the injec-tion site and gently massage the area, if applicable.

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.


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.

20. Chart the procedure correctly on the progress note and appropriate logs.

RATIONALE

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.

Injecting the medication too quickly can cause discom-fort to the patient and not allow the medication to be absorbed properly.

This helps to prevent trauma to the tissue.

This helps ease the discomfort caused from the injec-tion and accelerates absorption of the medication (unless massaging is contraindicated).

Engaging the safety device helps to reduce the possibil-ity of a needlestick.


Allergic reactions usually occur within 20 to 30 min-utes of the procedure.



05-22-XX Varivax #1, 0.5 mL, sub-q, right arm per Dr. Sullivan. Manf.–Kline Beec ham, Lot number–K449, exp. date3:15 p.m. – 12/XX. Pt. tolerated well, instructions given to pt. for site care and VIS sheet provided—consent form

signed and fi led in chart.. Post inject ion f ollow-up, –complications. Sherri Jones , CMA (AAMA)


878 ❖ C H A P T E R 3 4

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


❖ Medication tray




PROCEDURAL STEPS

1. Wash your hands.




5. Locate the proper injection site (deltoid, dorsoglu-teal, ventrogluteal, or vastus lateralis).




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).


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.

RATIONALE


Instituting the seven rights will help prevent errors from occurring.

This prevents the wrong patient from receiving the medication.


The right site must be selected in order for the drug to be absorbed properly.


This prevents contamination by bloodborne pathogens during the procedure.


This helps with the needle insertion.

Unnecessary movement of the hand holding the syringe can cause tissue damage and pain to the patient.

Depositing the medication into the bloodstream could cause great harm to the patient.

FIGURE 34-53 The proper angle of inser-tion for an intramuscular injection



PROCEDURAL STEPS



15. Place a cotton ball or gauze sponge over the injec-tion site and gently massage the area, if applicable.

16. Engage the safety device on the needle, and dispose of the needle–syringe unit in the sharps container.

17. Place an adhesive bandage over the site and remove gloves and wash your hands.

18. Give related patient educational materials and proper waiting instructions.


20. Chart the procedure correctly on the progress note and appropriate logs.

RATIONALE

Injecting the medication too quickly can cause discom-fort to the patient and not allow the medication to be absorbed appropriately.

This helps to prevent trauma to the tissue.

Massaging the area helps to disburse the medication, unless contraindicated.

This protects you from an accidental needlestick from a contaminated needle.


Allergic reactions usually occur within 20 to 30 minutes of the procedure.



05-22-XX Hepivax 0.5 mL, IM, R. Deltoid per Dr. Jones . Manf. – Kline Beec ham, Lot number–K449, exp. date – 12/XX.3:15 p.m. Pt. tolerated well, instructions given to pt. for site care and VIS sheet provided and consent form signed

and fi led. No problems during post chec k. 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


❖ Medication tray




PROCEDURAL STEPS

1. Wash your hands.

2. Assemble the equipment. Perform the Seven Rights of Drug Administration.


RATIONALE

This prevents the spread of infection and contamina-tion during the procedure

This ensures that you do not give the wrong patient the medication.

continues


880 ❖ C H A P T E R 3 4

PROCEDURAL STEPS


5. Locate the proper injection site (usually the dorso-gluteal site).




9. Using your nondominant hand, pull the tissue to be injected laterally 1 to 2 inches away from the injection site.

10. Using your dominant hand, insert the needle at a 90° angle with a quick and smooth motion.


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.


14. Wait 10 seconds before removing the needle.


16. Release the tissue after removing the needle from the site.

17. Place a cotton ball or gauze sponge over the injection site. Do not massage the site for a Z-track injection.

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.


continued

RATIONALE


Cleansing the site reduces microorganisms on the skin. Allowing the site to air dry helps to take away the sting when inserting the needle.

Gloves help to prevent contamination by bloodborne pathogens during the procedure in the event the site bleeds.


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 sur-rounding tissue.

Unnecessary movement of the hand holding the syringe can cause tissue damage and pain.

Using the one-hand technique when aspirating frees the other hand to keep the tissue retracted.

Injecting the medication too quickly can cause discom-fort to the patient and not allow the medication to be absorbed properly.

This allows the medication to settle in the tissue.

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 sur-rounding tissues.

Massaging could possibly cause malabsorption of the medication, discoloration to the tissue surrounding the site, or even leakage of the medication from the injec-tion site.

Engaging the safety device keeps you from accidentally getting stuck with a contaminated needle.




PROCEDURAL STEPS

20. Give related patient educational materials and waiting instructions.


22. Chart the procedure correctly in the progress note and appropriate logs.

RATIONALE

Allergic reactions usually occur within 20 to 30 min-utes of the procedure.

Documentation proves that you performed the procedure.


05-22-XX Met hylcobalamin, 1.0 mL, Deep IM (Z-Track), L. Dorsogluteal per Dr. Raymond. Manf. – Kline Beec ham, Lot 3:15 p.m. number–K449, exp. date – 12/XX. Pt. tolerated well, –complications during post inject ion chec k. Sherri

Jones , CMA (AAMA)

Chapter SummaryBy 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 CHALLENGEThe physician asks you to administer a hormone shot that is very viscid and oily. As you go to with-draw 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 experi-encing 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.

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 red-dened and a knot appeared in the area where the injection was given?


882 ❖ C H A P T E R 3 4

Web Activity1. The Centers for Disease Control and Prevention

National Immunization Program provides infor-mation 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 out-weighs the risks of immunizing.

CONNECTIONUsing your StudyWARE CD-ROM:

❖ Complete the Concentration activity for this chapter.

❖ Complete the Quiz for this chapter in Test Mode.

THE DVD LINKOn 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?

Chapter Assessment1. What is the most important aspect of administra-

tion of medication to a patient?a. Documentation of the procedureb. Documentation of the medication administered

to the patientc. Proper identification of the patientd. Proper technique in administering the

medication

2. Tuberculin syringes come in what syringe size?a. 1 mL syringesb. 3 mL syringesc. 5 mL syringesd. 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.

7. Parenteral routes include all but which of the following?a. Intramuscularb. Intravenousc. Orald. Intra-articular


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