battlefield medications

Battlefield Medications:Administer Injections

C168W243DEPARTMENT OF COMBAT MEDIC TRAINING

Given a patient requiring an injection and the necessary medical equipment,

administer medications by injection,

IAW the Textbook of Basic Nursing, 7thEdition, Rosdahl, Lippincott,

Chapter 63.

Terminal Learning Objective

Safety Note*Everyone wears exam gloves and goggles.

*Place ALL needles in Sharp Containers after use.

Needles do not pierce skin unless an instructor is present. If unsure, WAIT!

*Inform instructors if you suffer a needlestick Injury.

*No one gets in trouble, the concern is your safety.

*OSHA says, “Needlestick injuries are wounds caused by needles that accidentally puncture the skin.”

Whether the puncture was with a clean needle or a used needle,

if the puncture was accidental, let an instructor know right away.

Look at Your Needle in the Package

Using your student handout, circle the sterile parts of the needle.

All parts of the needle are considered sterile.

Only the protective cover should be touched.

Identify Your Needle

Hub Shaft Lumen Bevel

Identify the following parts of a needle…

Measure Your Needle

How is length and gauge determined?Length – tip of the needle to junction of shaft and hub

Gauge – diameter of the lumen

The smaller the number the larger the gauge

What is the length and gauge of this needle?

Pick the Right Needle for the Job

Four factors to considered when selecting the right needle for the job

Type of injection being givenSize of the patient (thin or not so thin) Where the injection is given (arm or butt)Thickness of the medication given

To determine needle length

To determine gauge

Identify Your Syringe

Using the picture in your student handout, identify the following parts of a syringe.

Plunger Barrel Needle Adapter Calibrated Scale

Touch Your Syringe

Sterile parts of the syringe

Plunger Needle AdapterInside of the Barrel

Measure your Syringe

The total volume of the syringe is measured in

Millimeters (ml)

Pick the Right Syringe for the Job

General Rule:

The syringe should be large enough to hold the entire dose and the calibration small enough to draw up an

accurate dose.

10.0 ml

3.0 ml

1.0 ml

Check On Your Learning

Q: What parts of the are needle sterile?

Q: What factors influence the length of the needle?

Type of injection – Size of the patient – Injection site

All parts of the needle (but not the protective cover)


Q: Which parts of the syringe are sterile?

Q: How do you know which syringe to select?

Needle Adapter - Inside the Barrel - Plunger

The syringe should be large enough to hold the entire dose and the calibration small enough to

draw up an accurate dose.

The VERY First Time They Meet…Assembling the Needle and Syringe

Inspect all packaging

Unpack the syringe

Inspect the syringe

Unpack the needle

Assemble the needle and syringe

Inspect the needle

Recap the needle using the “scoop” method


While preparing to administer an injection, the needle is removed from the flexible wrapper.

Ooopps, you drop the needle on the floor. The protective cap was in place when the needle

touched to floor. Can the needle still be used? Why or why not?

No, the needle should not be used. All parts of the needle are considered sterile, including the hub. If the sterile hub touches to floor, it is no longer sterile. The

contaminated hub could cause an infection.


If the plunger of the syringe does not move smoothly, why should it be

discarded and a new syringe used?

If the syringe does not move freely, drawing the medication may be impossible.

Additionally, administering the injection may be difficult or cause additional harm to the

patient.

The Right Medication

How many times should the medication label be verified and when?

Three Times

1. When obtained from storage

2. When the medication is drawn

3. When returning the medication to storage

The Medication is Vial

You have the “right” medication, but is the medication safe to administer? How would you know?

Check the Rubber Stopper

Check the Fluid, Any Floaties?

Check the Expiration Date (Multidose Vials are Special).

Ensure the Medication was Stored Properly

Things You Should Know Before Medication is Drawn

How do you know if you have the right amount of medication in the syringe?

The forward edge of the plunger is exactly on the prescribed ml mark of the syringe.

• Verify Drug and Check the Container• Remove the Vial’s Protective Cap

• Clean the Rubber Stopper• Remove Needle’s Protective Cover

• Draw Air Into the Syringe• Insert Needle Into the Stopper

• Inject Air Into the Vial• Draw the Medication

• Withdraw the Needle from the Stopper• Expel Air Still in the Syringe• Verify the Correct Dosage

• SCOOP the Needle Into the Protective Cover• Return the Vial or Discard

Drawing Medication from a VialDemonstration


Q: When should the medication be compared to the doctors orders and why?

Q: How do you determine the correct amount of medication has been drawn?

When obtained from the place of storage, when drawn, when returned storage.

To avoid administering the wrong medication to the wrong patient.

Ensure the forward edge of the plunger is actually on the prescribed ml mark.


Q: How are clean needles recapped?

Q: Should you recap “dirty” needles?

Place protective cover on work surface.

With the dominate hand holding the syringe, “SCOOP” the needle into the cover.

DO NOT hold the protective cover with the non-dominant hand.

No

Dr. Cooper has assessed a patient and ordered you to draw up medication for him.

Doctor’s Orders:Draw 0.1 ml of 0.9% Sodium Chloride

in a 1.0 ml syringe

with a 25 gauge needle.

Drawing Medication from a VialPractical Exercise

• Verify Drug and Check the Container• Remove the Vial’s Protective Cap

• Clean the Rubber Stopper• Remove Needle’s Protective Cover

• Draw Air Into the Syringe• Insert Needle Into the Stopper

• Inject Air Into the Vial• Draw the Medication

• Withdraw the Needle from the Stopper• Expel Air Still in the Syringe• Verify the Correct Dosage

• SCOOP the Needle Into the Protective Cover• Return the Vial or Discard

Drawing Medication from a VialPractical Exercise

Reconstituting Medication

Some medications are placed in a vial in POWDERED

form and must be reconstituted with a liquid

(diluent) before administration.

Preparing these medications is as simple as injecting the

diluent into the medication vial, mixing and drawing to

required amount.

Reconstituting MedicationDemonstration

• Verify Drug and Check the Containers

• Withdraw Correct Amount of Diluent

• Reconstitute the Medication

• Invert Reconstituted Medication Vial to Dissolve Powder

• Inspect Solution to Ensure it is Well-Mixed

• Change Needle (and Syringe)

• Withdraw Proper Amount of Medication

• Administer


While attempting to reconstitute a powdered medication, the diluent is difficult to inject.

What should you do?If the vial with the powdered medication contains air,

some air may have to be withdrawn to allow the diluent to be injected.

How do you determine if the reconstituted medication should be inverted gently or if

vigorous mixing is required?Check the medication label or the package insert.

Dr. Mayer has assessed a patient and ordered you to draw up medication for him.

Doctor’s Orders:Drawn 0.5 ml of 0.9% Sodium Chloride

in a 3.0 or 5.0 ml syringe


Reconstituting MedicationPractical Exercise

Reconstituting MedicationPractical Exercise

• Verify Drug and Check the Containers

• Withdrawn Correct Amount of Diluent

• Reconstitute the Medication

• Invert Reconstituted Medication Vial to Dissolve Powder

• Inspect Solution to Ensure it is Well-Mixed

• Change Needle (and Syringe)

• Withdrawn Proper Amount of Medication

• Administer

Ampules

It is made entirely of glass.The medication you need is inside.

There are NO openings, caps, rubber stoppers or lids.

THIS IS AN AMPULE

Impossible Mission Made Easy

Located on the neck of every ampule is a

break line.

Once cleansed, the neck can easily be broken by hand.

But Wait…

What if glass gets in the ampule…

and then glass gets in the syringe…

and then glass gets into me?

Use a filter needle!!

Draw Medication from an Ampule Demonstration

• Tap Ampule to Force Medication out of the Neck

• Clean the Neck of the Ampule

• Break the Neck of the Ampule

• Inspect the Ampule for Glass

• Withdraw Proper Amount of Medication(Do Not inject air into the ampule – you will get a shower)

• Recap and Remove Filter Needle and Replace• Administer


You have snapped the neck and currently inspecting an ampule.

What are you inspecting for? Small glass particles.

What do you do if you find something in the ampule?

Discard the ampule and get a new one.

When drawing medication from an ampule, should you draw air into the syringe?

Why or why not? No.

The contents of the ampule are not under pressure

Dr. Mabry has assessed a patient and ordered you to draw up medication for him.

Doctor’s Orders:Draw 0.5 ml of 0.9% Sodium Chloride

in a 3.0 or 5.0 ml syringe


Draw Medication from an Ampule Practical Exercise

Draw Medication from an Ampule Practical Exercise

• Tap Ampule to Force Medication out of the Neck

• Clean the Neck of the Ampule

• Break the Neck of the Ampule

• Inspect the Ampule for Glass

• Withdraw Proper Amount of Medication(Do Not inject air into the ampule – you will get a shower)

• Recap and Remove Filter Needle and Replace• Administer

Intradermal Injections

In preparing to become a 68W, each of you received an intradermal injection.

What was it and why?TB (tuberculosis) Test

Testing your exposure to the disease

Cite one more reason intradermal injections administered?Allergy Testing

Equipment

What is the standard needle length and gauge for intradermal injections?

Length - ¼ to ½ inch Gauge - 25 to 27

What is the standard syringe for intradermal injections?

Tuberculin or other 1.0 ml syringe

Read Carefully - That’s 0.1 ml NOT 1.0 ml

Intradermal Injection Sites

Inner ForearmBack of the Upper Arm

Below Shoulder Blades

What should all of these sites have in common?Free of hair, tattoos and scarsNOT over a vein or bony area

Intradermal Medication Placement

Prepare for an Intradermal Injection

What are the minimum questions a

patient should be asked before

administering any injection?

What is your name?

What are you allergic to?

What drug reactions have you experienced?

*Are you or is there a possibility you could be pregnant? *Females Only

Things to Know BEFORE it is Too Late…

Describe how the needle should be introduced into the skin?

Bevel Up at a 15-20 Degree Angle

How far should the needle be inserted into the skin?

Just until the bevel disappears.

Only This Far


What does “Aspirate” mean?

“To draw by suction”In this case:

Once the needle is in the tissue draw back the plunger.

Aspirating while administering injections

identifies if a needle is inadvertently placed INTO a blood vessel.

Should you aspirate intradermal injections?NO

Your Goal:RECREATE the “Wheal”

Intradermal InjectionsDemonstration

• Verify/Gather Equipment• Assure Emergency Equipment and Personnel Availability

• Select Site, Expose Site, Position Patient• Clean Site

• Remove Needle’s Protective Cover• Hold Skin

• Insert Needle• Inject Medication• Remove Needle

• Cover Site - Remember “Do Not Scratch, Rub or Wash”• Discard Needle and Syringe

• Watch the Patient for a Reaction• Where and when should the test be read?

• Record


At what angle should the needle be inserted to deliver a intradermal injection?

15-20 degrees

If a wheal does not appear, what is your next course of action?

Withdraw the needleDispose of the needle and syringe

Re-administer the injection

Do intradermal injections require aspiration?No.

A brand new company of Soldier medics has arrived to Fort Sam Houston.

The Doctor’s Orders:Administer 0.1 ml

of 0.9% Sodium Chloride,

ID,

to PV1 Noriega,

A very thin, 24 year old female.

Intradermal InjectionsPractical Exercise

Intradermal InjectionsPractical Exercise

• Verify/Gather Equipment• Assure Emergency Equipment and Personnel Availability

• Select Site, Expose Site, Position Patient• Clean Site

• Remove Needle’s Protective Cover• Hold Skin

• Insert Needle• Inject Medication• Remove Needle

• Cover Site - Remember “Do Not Scratch, Rub or Wash”• Discard Needle and Syringe

• Watch the Patient for a Reaction• Where and when should the test be read?

• Record

Subcutaneous (SQ) Injections

What is the absorption rate for SQ injections?

15-30 Minutes

What is the duration?Hours to Weeks

What type of medication should be given SQ?

Small Amounts – Watery - Nonirritating

Subcutaneous Medication Placement

Equipment

What is the standard needle length and gauge for subcutaneous injections?

½ to 1 inch

23 to 25 Gauge

Also consider Patient’s:

amount of SQ tissue, age, size and general condition

What is the standard syringe for subcutaneous injections?

Will depend of the amount of medication given

Subcutaneous Injection Sites

1st Choice2nd Choice

3rd Choice

Not to exceed 0.5 ml


Per Physician’s Orders



Bevel Up at a 45 Degree Angle

How far should the needle be inserted the site?Depth depends on the condition of the patient.

Should you aspirate subcutaneous injections?Yes

Because the needle is placed deeper into the tissue, there is a better chance to hit a vessel.

Subcutaneous InjectionsDemonstration

• Identify and Screen the Patient• Verify/Gather Equipment

• Assure Emergency Equipment and Personnel Availability• Select Site, Expose Site, Position Patient

• Clean Site• Hold Skin with Non-dominate Hand

• Insert Needle• Release Skin

• Aspirate• Inject Medication

• Remove Needle and Cover Site• Massage Site

• Discard Needle and Syringe• Record

• Watch the Patient for a Reaction


What is the purpose for subcutaneous injections?

Absorption rate desired is slower than IM route. For small amounts of watery and nonirritating

medication.

What are possible sites for subcutaneous injections?

Upper arm, Vastus lateralis, Abdomen

At what angle should the needle be inserted for a subcutaneous injection?

45 degrees

The Doctor’s Orders:

Administer 0.5 ml


SQ,

to PFC Jefferson,

very thin 18 year old female.

Subcutaneous InjectionsPractical Exercise

Subcutaneous InjectionsPractical Exercise









Intramuscular (IM) Injections

What is the absorption rate for IM injections?

10-20 Minutes

What is the duration?Hours to Weeks

What type of medication should be given IM?

Viscous or Irritating – Large Volumes

Intramuscular Medication Placement

Equipment

What is the standard needle length and gauge for intramuscular (IM) injections?

Not less than 1 inch Up to 2 inches (Unless patient is extremely thin) (For obese

patients)

20-22 Gauge

What is the standard syringe for intramuscular (IM) injections?

Will depend of the amount of medication given

Intramuscular (IM) Injection Sites

1st Choice – Deltoid Muscle

Not to exceed

2.0 ml


2nd Choice - Gluteus Maximus



3rd Choice

Vastus Lateralis

Not to exceed

5.0 mlKnee

Post

eri

or

An

teri

or

Hip



Bevel Up at a 90 Degree Angle

How far should the needle be inserted?Depth depends on the condition of the patient.

Should you aspirate intramuscular injections?Yes

Because the needle is placed deeper into the tissue, there is an increased chance to hit a vessel.

Intramuscular InjectionsDemonstration









Q:When administering an intramuscular injection should you aspirate? Why or why not?

Q: At what angle should the needle be inserted for an intramuscular injection?


Yes. - If you aspirate blood, the end of the needle may be in a blood vessel. Medication delivered into the blood stream, a different route of delivery, could alter the effect of the medication and possibly injure the patient.

90 degree angle

Q: What is the purpose for IM Injections?

Q: What are the preferred injection sites for an intramuscular injection?


When rapid absorption rate & long duration is desired.

When administering viscous or irritating medications.

When large volumes of medication is needed.

Deltoid Muscle

Gluteus Maximus

Vastus Lateralis

The Doctor’s Orders:

Administer 0.5 ml


IM,

to CPT Jones,

an average sized 42 year old male.

Intramuscular InjectionsPractical Exercise

Intramuscular InjectionsPractical Exercise









Summary

What factor determines the gauge of the needle?Thickness of the medication administered

How are clean needles recapped?The Scoop Method

How are “dirty/used” needles disposed of?In a Sharps Container

When must filter needles be used?When drawing medication from an ampule

Of the three injections you have learned, which injections should you aspirate and why?

Intramuscular (IM) and Subcutaneous (SQ)

To ensure the end of the needle is in the desired type of tissue and NOT in a blood vessel.

Which injection has a faster rate of absorption in an “average” healthy person, IM or SQ?

IM

Summary

QUESTIONS?

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