Giving injections

Attention

• To prevent needle stick injuries, always carry injections in plastic tray or kidney dish and have sharps container close by

Before giving injection

• Always check file notes, ask person about allergies or adverse reactions
• Remember the RIGHTS before giving any medicine
• Always check manufacturer's instructions
• If injection site dirty or bloody — wash with soap and water

Preparing injection

• Draw up solution, put drawing up needle in sharps container
• Put on fresh, sterile needle to give injection except insulin syringes — needles can't be removed

To stop injection stinging

• Before giving — clean site with Chlorhexedine 2% in isopropyl alcohol 70% wipes, let dry completely
• After giving — use gauze or cotton wool to press down firmly on site

Angle and depth of injections — Figure 6.7

Injection sites

Subcutaneous (subcut) or intramuscular (IM) injection sites

• Anterolateral (outside) thigh (vastus lateralis), baby or toddler — Figure 6.8
• Anterolateral (outside) thigh (vastus lateralis), child or adult — Figure 6.9
• Deltoid (upper arm) — Figure 6.10
  
• Do not use for children under 12 months
• Best site for small injections in adults

IM injection sites

• Ventrogluteal 
• Better than gluteal (buttock) as less risk of damage to nerves or blood vessels
• Best site for large injections in adults
• Child — lie over carer’s knee, upper leg flexed — Figure 6.11
• Adult — Figure 6.12 OR lie on side, upper leg flexed and forward
• Gluteal (buttock) — Figure 6.13
  
• Do not use for babies, toddlers, small preschool children

Intradermal injections

Attention

• Used for Mantoux test or Mycobacterium bovis (Bacillus Calmette and Guerin [BCG] strain) vaccine
• First check person’s Mantoux status
• Only give Mantoux test or BCG immunisation if authorised to do so
• Mantoux test — usually given in inner forearm — Figure 6.14
• BCG immunisation
• Give in deltoid area (upper arm)
• ​Check regional guidelines to see if right or left arm used
• Do not cover Mantoux test or BCG immunisation injection site with dressing

What you need

• Injection tray
• Insulin syringe
• Gauze swab
• Injection solution

What you do

• Choose injection site, clean if needed, let dry completely
• Draw up solution
• Hold syringe with needle lying flat to skin and bevel edge facing up
• Slide needle under skin until it disappears, then a little further so it goes into intradermal tissue. Keep level with skin — Figure 6.14
• Slowly inject solution until you see wheal (raised area)
• If wheal is not appearing — do not repeat dose —  adjust needle position and continue injection
• Do not put pressure on site after taking out needle. Ask person to blow on area until it dries
• Do not rub site or put on sticking plaster. Leave open to air

Subcutaneous injections

Attention

• If person has daily injections (eg insulin for diabetes) — change injection site often

What you do

• For angle and depth of injection — Figure 6.7
• For injection sites — see Figure 6.8, Figure 6.9
  
• Fatty pad below umbilicus can also be used in diabetes

Subcutaneous cannula

Attention

• Used for people in palliative care or who can't swallow medicines
• More comfortable than repeated IM or IV injections
• Less likely to become infected
• Do not use metal butterfly needles. Less comfortable and site needs to be changed more often
• Subcut catheter system (eg Intima)— Figure 6.15 allows regular administration of medicine by
• Injecting into side portal
• OR Continuous infusion through syringe driver
• If catheter system not available use 22–24G cannula
• Rotate sites. Make a plan using sites that allow person the most movement

What you do

Choose site

• Do not use
• Breast tissue or skin folds
• Portacath or CVC sites
• Stoma sites
• Tumour masses, tumour nodules, oedematous areas
• Scar tissue, mastectomy sites
• Bony areas

• Consider these sites
• Intercostal spaces on anterior chest wall
• Above pectoralis muscle
• Anterior abdominal wall — do not use if ascites, abdominal disease, oedema
• Upper arm — do not use if bed-bound and needs frequent turning
• Outer thigh
• Above shoulder blades — good if person restless or disorientated

Put in subcut catheter system or cannula

• Trim hairs if needed
• Clean site with Chlorhexedine 2% in isopropyl alcohol 70% wipes, allow to dry
• Prime line with sterile water or normal saline
• Lift fold of skin between forefinger and thumb, put in full length of cannula at 30° angle
• Tape down butterfly flaps with transparent film dressing
• Remove metal insert, put in sharps container
• Attach injectable bungs to outlets (if not already there)

Follow-up

• Label site with date of insertion, record site in file notes
• Check site regularly and before giving medicine for swelling, redness, leakage
  
• If present — change site straight away
• If not present — change site in 7–10 days

Intramuscular injections

Attention

• Using small bore needle causes more pain, as more pressure needed
• Usually use 25mm long needle, may need larger if obese. Use 16mm for small babies

What you do

• Choose site — Figure 6.8 — Figure 6.12
  
• If repeat injection — use different site to last time
• Position limb so muscle being injected into is relaxed
• Ventrogluteal
• Child — lie over carer’s knee, upper leg flexed
• Adult — lie on side, upper leg flexed and forward
• Gluteal (buttock) — stand bent forward with hands on bed OR lie on stomach (prone) with foot on same side turned inward
• If person large or tall — suggest lying down, won't hurt themself or you if they faint
• Outside thigh — lie on back (supine) with toes pointing straight up
• Upper arm — sit with elbow bent and forearm supported
• Clean site if needed, let air dry
• Pull skin tight, or use Z-track method — put in needle quickly at 90° to skin
• If giving in gluteal (buttock) — pull back plunger a little to make sure you are not in blood vessel. If blood seen — change site
• Slow steady injection
• Remove needle quickly, apply pressure to injection site

To lessen pain of thick injections — (eg Bicillin L-A) (benzathine benzypenicillin, penicillin G), procaine benzylpenicillin (procaine penicillin)

• These injections are very painful. Best to have helper, person may try to grab syringe
• Consider individualised strategies for managing pain, fear and distress
• Mix well by shaking
• OR Warm and mix by rolling syringe in your hands for 1 minute
• Use needle provided with pre-loaded syringe
• Do not change to smaller bore needle, more likely to get blocked
• Do not pre-load needle — leave hollow part of needle empty
• Before injecting
• Put ice pack on site
• Press hard on site with thumb and count to thirty (30–60 seconds)

Z-track injections

Attention

• Use for
• Thick injection fluids (eg Bicillin L-A) — can leak out through large bore needle track
• Iron injections — can permanently stain skin if solution leaks out

What you do

• Choose site
• Larger/older children and adults — IM into
• Ventrogluteal — Figure 6.11
• OR Buttocks — Figure 6.12
• Small children — IM into
• Anterolateral (outside) thigh — Figure 6.8, Figure 6.9
• OR Ventrogluteal — Figure 6.11
• Pull skin down from chosen site, hold in this spot — Figure 6.16
• Put needle into muscle and give injection slowly
• When finished, leave needle in place for about 10 seconds. This stops medicine solution leaking out onto skin surface
• Take needle out, let go of skin — this will make Z-track — Figure 6.17