BASIC NURSING CARE

PARENTERAL DRUG
ADMINISTRATION

Objectives; at the end of this lesson the student midwife should be able to;
 Define parenteral drug administration.
 Explain the advantages and disadvantages of parenteral drug administration.
 Identify the various routes of parenteral drug administration.
 Understand how to promote safety, comfort, avoid injury and prevent
complications.
 Be able to administer injection through all the various routes of parenteral and
noting the various sites and name of the muscle involve.
Definition
Parenteral refers to the path by which medication comes in contact with the body. Parenteral
medications enter the body by injection through the tissue and circulatory system. Injection
medications are absorbed more quickly and are used with patients who are nauseated, vomiting,
restricted from taking oral fluids, or unable to swallow. Parenteral medications can be effective
and safe when prepared and administered correctly. However, because they are invasive and
absorbed readily and quickly into the body, there are numerous risks associated with
administering them.
Types:
1. Intra venous
2. Inramuscular
3. Intraperitoenal
4. Subcutaneous
5. Intradermal
6. Intrathecal
7. Epidural
8. Intraosseous
9. Intra-arterial
10. Intra-articular
1. Intavenous injection: This route delivers drug directly into the blood veins. The
formulation is given as a single lump or slowly by drip over a period of hours.
In most cases, the superficial veins are selected for injection. It is route which shows
fastest action compared to all others. This route is regularly used in times of emergency
and critical care.
2. Intramuscular: Here the drug is given directly into the large skeletal muscles.
The drug is released slowly from the sites of injection as the blood flows through. Since
the muscle has less sensory nerves, irritant drugs can be given without pain. Also the
drug formulation can be in suspension or oily form.
3. Intra-peritoneal: Administration of drugs into the peritoneal cavity is called intra-
periotneal injection. This method is less used in humans but widely used in research
animals used for drug testing. The injection is done at the abdominal region below the
skin into peritoneal cavity.
4. Subcutaneous: Here drug is injected just below the skin. This route is used for
vaccines, disease diagnosis etc. The drug is deposited into the loose subcutaneous
tissue which has many nerves. So irritant drug must be avoided as it can be painful. The
rate of drug absorption is slower than that from intramuscular injection. It is of different
types like
a) Dermojet: Here a delivery system devoid of needle is used. It has very fine orifice and
drug solution is projected by shot such that it reaches just below the subcutaneous
tissue. The method is painless and suitable for mass inoculations.
b) Pellet implantation: Here a solid pellet containing drug is implanted subcutaneously.
The drug is released slowly over a period of few months. Especially steroids like
deoxycorticosterone, testoserone are given.
c) Subcutaneous injection: Here a syringe with fine needle is used to administer the drug
in loose skin tissue. The injection can be very painful and used in cases like anti-rabies
injection etc.
5. Intra-dermal injection: Here drug is given into the skin so it form a small bulge. Used
for vaccincation and drug allergy testing.
6. Intrathecal: Here drug is administered into the spinal cord.
7. Epidural: The drug is injected near the spinal cord such that it affects the local
nerves. Mostly used in anesthesia during surgery, delivery etc.
8. Intraosseous: The injection is done directly into the bone marrow. The needle has to
pass through the solid bone and reach the marrow. This is route is possible in children
as the large bones are not completely hardened and are a bit soft to allow the
penetration of the needle.

Advantages of parenteral drug administration:

1. For emergency: When the drug has to start acting immediately in case of emergency
this is best. For example in case of heart failure, digoxin or adrenalin can be directly
administered.
2. For unconscious patient: When patient is unconscious, he cannot swallow the
medicine, then injection is best.
3. Avoid first pass metabolism: When a drug is taken by mouth, it has to pass through
the liver. Here most drugs undergo metabolism and may get destroyed before they
show their effect. This is called first pass metabolism. For drugs which are destroyed by
liver first pass metabolism, injection helps to avoid it.
4. Minimal wastage of drugs: When the drug is given by tablet form, it may not be
completely absorbed from the gut and even some of it may be metabolized in the liver
before it reaches blood. So more quantity of drug is required to produce desired effect.
Here, the drug is directly released into blood stream by injection so minimum drug is
needed to produce the effect as there is no wastage.
5 .Uncooperative and unreliable patients. Patients with vomiting and diarrhoea.
6. It is suitable for Irritant drugs. Drugs with high first-pass metabolism.
7. Drugs not absorbed orally.
8. Drugs destroyed by digestive juices.
9. Dose required is very less, so systemic toxicity is minimized.
10. Amount of drug administered can be regulated
Disadvantages of parenteral administration:
1. Expensive method of drug administration: Inject able drugs are expensive as they
need the instruments like syringe,
2. Needs a skilled help for injection:
3. Risky route:  Drug once given cannot be controlled if there are adverse effects or
poisoning. Whereas if given by oral route, the chances of risk are reduced due to
digestion or metabolism.
Also drug absorption can be stopped by timely administration of charcoal. This is not
possible in injection route. Hence we see anaphylactic shock on giving few drugs and it
is difficult to control adverse effects leading to death.
4. Increase chances of pain and injury at site of injection. . Can cause local tissue injury to
nerves, vessels, etc
5. Effective sterilization is required. The formulation and syringe needs sterilization else
can lead to infections. Hence we see transmission of HIV-AIDS through contaminated
needles.
6. Local irritation may cause increased respiratory secretions and bronchospasm.
Injections

7. Preparations should be sterile and is expensive.

8. Requires invasive techniques that are painful.
9. Cannot be usually self-administered.
THE FOUR MAIN TYPES
There are four routes for parenteral medications. Each type of injection requires a specific skill
set to ensure the medication is prepared properly and administered into the correct location (Perr.
The four types of injections are:
1. Subcutaneous (SC): This injection places medication/solution the loose connective
tissue just under the dermis.
2. Intradermal (ID): This injection places the medication into the dermis just under the
epidermis.
3. Intramuscular (IM): This injection places the medication into the body of a muscle.
4. Intravenous (IV): This injection places the medication/solution into a vein through an
existing IV line or a short venous access device (saline lock). Medications given by the
intravenous route can be given as an IV bolus, as an intermittent (piggyback) medication,
or in a large volume continuous infusion.
Figure 7.1: Insertion angles
To administer parenteral medications safely, it is imperative to understand how to prevent an
infection, prevent medication errors, prevent a needle-stick injury, and prevent discomfort to the
patient. Tables 7.1 to 7.4 address specific practices to eliminate safety hazards to patients and
health care workers.
Preventing Infection during an Injection
Unsafe injection practices have resulted in patient exposure to infections leading to outbreaks of
infectious diseases. These unnecessary exposures where the result of deficient health care
practices. Injectable medications must be given in a safe manner to maintain sterility of
equipment and prevent the transmission of infectious diseases between patients and health care
workers. Table 7.1 summarizes how to prevent an infection during an injection.
Table 7.1 Preventing Infection During an Injection 
Safety consideration:
 Always follow the principles of sterile technique when preparing injections.
Principle  Additional Information
Always perform hand hygiene before administration and after removing gloves. For
hygiene with alcohol.

Perform hand
hygiene.

Hand hygiene with alcohol

Prevent Keep sterile parts of the needle and syringe sterile. Avoid letting the needle touch un
needle/syringe surfaces such as the outer edges of the ampule or vial, surface of the needle cap, or c
contamination. Always keep the needle covered with a cap when not in use, and use the scoop-cap m
avoid needle-stick injuries. Avoid touching the length of the plunger. Keep the tip o
syringe sterile by covering with a cap or needle.
 Parts of a syringe and needle
Wash the patient’s skin with soap and water when it is soiled with dirt, drainage, or
matter/urine. Follow agency policy for skin preparation. When using an alcohol swa
Prepare patient’s skin.
circular motion to rub the area for 15 seconds, and then let the area dry for 30 secon
cleaning a site, move from the centre of the site outward in a 5 cm (2 in.) radius.
Use single-dose vials/ampules whenever possible. Do not keep multi-dose vials in p
Prevent
treatment area. Discard if sterility is compromised or questionable. Do not combine
contamination of
administer medications from single-dose vials or ampules for later use. Ampules sho
solution.
open and should be used immediately, then discarded appropriately.
Use new, sterile Single use syringe and needle must be used with each patient. Always inspect packa
sterile equipment intactness; inspect for dryness, rips, torn corners and expiry date. If single use equip
with each injection. available, use syringes and needles designed for steam sterilization.
Safe Medication Administration
Medication errors have a substantial impact on health care in Canada (Butt, 2010). When
preparing and administering medication, and assessing patients after receiving medication,
always follow agency policy to ensure safe practice. Review Table 7.2 for guidelines for safe
medication administration.
Table 7.2 Guidelines for Safe Medication Administration
Safety consideration:
 Agency policy on medication administration and on the medication administration record (MAR) m
Always receive the required training on the use of each agency’s medication system to avoid preve
errors.
Principle  Additional Information
Be vigilant when preparing Avoid distractions. Some agencies have a no-interruption zone (NIZ), w
medications. care providers can prepare medications without interruptions.
Check for allergies. Always ask patient about allergies, types of reactions, and severity of rea
Use two patient identifiers at all
Use at least two patient identifiers before administration AND compare a
times. Always follow agency
medication administration record (MAR).
policy for patient identification.
All medications require an assessment (review of lab values, pain, respir
Assessment comes before
cardiac assessment, etc.) prior to medication administration to ensure the
medication administration.
receiving the correct medication for the correct reason.
Be diligent in all medication Errors in medication calculations have contributed to dosage errors, espe
calculations. adjusting or titrating dosages.
Slips in memory are caused by lack of attention, fatigue, and distractions
Avoid reliance on memory; use
are often referred to as attentional behaviours, and they account for most
checklists and memory aids.
health care. If possible, follow a standard list of steps for every patient.
Communicate with your patient Provide information to patient about the medication before administering
before and after administration. questions regarding usage, dose, and special considerations. Give the pa
 opportunity to ask questions. Include family members if appropriate.
A workaround is a process that bypasses a procedure, policy, or problem
system. For example, nurses may “borrow” a medication from another p
Avoid workarounds.
waiting for an order to be filled by the pharmacy. These workarounds fa
agency policies that ensure safe medication practices.
Ensure medication has not
Medication may be inactive if expired.
expired.
Always ask for help whenever you are uncertain or unclear about an ord
Always clarify an order or
with the pharmacist, charge nurse, or other health care providers and be
procedure that is unclear.
resolve all questions before proceeding with medication administration.
Bar-code scanning (eMAR) has decreased errors in administration by 51
Use available technology to computerized physician orders have decreased errors by 81%. Technolog
administer medications. potential to help decrease errors. Use technology when administering me
but be aware of technology-induced errors.
Report all near misses, errors, Reporting allows for analysis and identification of potential errors, whic
and adverse reactions. to improvements and sharing of information for safer patient care.
High-alert medications are those that are most likely to cause significant
when used as intended. The most common high-alert medications
Be alert to error-prone situations
are anticoagulants, narcotics and opiates, insulins, and sedatives. The typ
and high-alert medications.
most commonly associated with these medications include hypotension,
depression, delirium, bleeding, hypoglycemia, bradycardia, and lethargy
If a patient questions or expresses
If a patient questions a medication, stop and explore the patient’s concer
concern regarding a
the physician’s order, and, if necessary, notify the practitioner in charge
medication, stop and do not
patient.
administer it.
Promoting Safety and Comfort of a Patient during an Injection
Injections can be given safely and effectively, and harm can be prevented if proper injection
technique is used. Most complications related to injections are associated with intramuscular
injections, but may occur with any route. Complications can occur when an incorrect site is used,
or with an inappropriate depth or rate of injection (Malkin, 2008). To promote patient safety and
comfort during an injection, review the guidelines in Table 7.3.
Table 7.3 Promoting Patient Safety and Comfort During an Injection 
Principle  Additional Information
For injections, use a sharp, beveled needle and place bevel side up.
Change the needle if liquid coats the shaft of the needle. Correct needle
length allows for correct delivery of medication into the correct site and
can reduce complications such as abscesses, pain, and bruising. Needle
selection should be based on size of patient, gender, injection site, and
Correct needle
amount of medication injected. Women tend to have more adipose tissue
around the buttocks and deltoid fat pad, which means more than half the
injections given do not reach the proper IM depths in women. Large bore
needles have been found to reduce pain, swelling, and redness after an
injection, as less pressure is required to depress the plunger.
Proper angle of Inserting the needle at the proper angle (depending on the type of
insertion and removal injection) and entering the skin smoothly and quickly can reduce pain
(see Figure 7.1) during injection. Hold the syringe steady once the needle is in the tissue to
prevent tissue damage. Withdraw the needle at the same angle used for
insertion. The angle for an IM injection is 90 degrees. With all injections,
the needle should be inserted all the way up to the hub. Holding the
syringe like a dart prevents the medication from being injected during
 insertion of needle. Removing residue (medication on the tip of the needle)
has been shown to reduce pain and discomfort. To remove residue from
the needle, change needles after preparation and before administration.
The patient’s position may affect their perception of pain. Proper position
will also facilitate proper landmarking of the site. For IM injections, for
Patient position
example, the ventrogluteal site has the greatest muscle thickness and is
free of nerves and blood vessels, with a small layer of fat.
Position the patient’s limbs in a relaxed, comfortable position to reduce
muscle tension. For example, lying prone may help a patient relax prior to
an IM injection. If giving a deltoid IM injection, have the patient relax the
Relaxation technique
arm by placing the hand in the lap. If a patient is receiving an IM injection
and distraction
in the vastus lateralis or ventrogluteal site, encourage the patient to gently
methods
point toes outwards to relax the muscle. Relaxation skills of the health care
provider will help decrease the patient’s anxiety-heightened pain. If
possible, divert the patient’s attention away from the injection procedure.
To decrease pain upon insertion, a vapocoolant spray, topical anesthetic,
or wrapped ice may be placed on the insertion site for a minute prior to
Pre-medication, if
injection. For IM injections, two studies found that applying pressure to
required
the injection site for 10 seconds before the injection reduced pain. This
data supports the gate theory of pain control.
Some research shows that the Z-track technique results in reduced pain
and complications, and fewer injection lesions. However, other research
Z-track method for IM
shows that Z-track injections result in more pain and bleeding at the
injections
injection site. (See 7.4 Intramuscular Injections for more on the Z-track
method.)
Research has found that administrating medications at 10 seconds per ml
is an effective rate for IM injections. Increasing the rate to 20 seconds per
Administration rate
ml did not show any reduction in pain. Always review drug administration
rate as per pharmacy or manufacturer’s recommendations.
Gentle touch with Gently apply a dry sterile gauze to the site after the injection. Rotate
insertion sites injection sites to prevent the development of indurations and abscesses.
Review the latest research regarding the utility of aspirating IM injections.
Aspiration with IM
There is lack of strong evidence to support the technique of aspiration with
injections
IM injections.
Data source: Ağac & Günes, 2011; Canadian Agency for Drugs and Technologies in Health,
2014; Cocoman & Murray, 2008; Greenway, 2014; Hunter, 2008; Malkin, 2008; Mitchell &
Whitney, 2001; Nisbit, 2006; Ogston-Tuck, 2014a; Perry et al., 2014; Rodgers & King, 2000;
Sisson, 2015; Workman, 1999
Preventing Needle-Stick Injuries
Health care providers can be at risk for needle-stick injuries in any health care setting. The most
common places for needle-stick injuries to occur are in the operating room and patient rooms.
Tasks that place the health care provider at risk include recapping needles and mishandling IV
lines. Table 7.4 provides guidelines to prevent needle-stick injuries.
Table 7.4 Recommendations for Prevention of Needle-Stick Injuries 
Principle  Additional Information
Avoid recapping Recapping needles has led to the transmission of infection. If possible,
needles. always use devices with safety features — i.e., safety shield.
Dispose of the needle
Immediately dispose of used needles in a sharps disposal container
immediately after
(puncture-proof and leak-proof) to avoid unsafe disposal of a sharp.
injection.
Reduce or eliminate all Avoid using needles if possible. Use a needle only when performing an
hazards related to SC, ID, or IM injection. Use a needleless system and engineered safety
needles. devices for prevention of needle-stick injuries.
Plan the safe handling and disposal of needles before beginning a
Plan disposal of sharps procedure that requires a sharp needle. Bring sharps container close to the
before injection. bedside prior to injection. Sharps containers should be at eye level and
within arm’s reach.
Follow all standard
Follow all agency policies regarding infection control, hand hygiene,
policies related to
standard and additional precautions, and blood and body fluid exposure
prevention / treatment
management.
of injury.
Report all needle-stick injuries and sharp-related injuries immediately.
Data collected regarding the nature of injuries help guide needle-stick
prevention strategies for new practices and devices. Review how to
Report all injuries.
manage needle-stick injuries and follow agency policy regarding
exposure to blood-borne pathogens. Policies help decrease the risk of
contracting a blood-borne illness.
Attend training on injury-prevention strategies related to needles and
Participate in required safety devices as per agency policy. Participate in and evaluate the
training and education. selection of safety devices, and report known needle-stick hazards to
managers.
Data source: American Nurses Association, 2002; Centers for Disease Control, 2012; National
Institute for Occupational Safety and Health, 1999; Perry et al., 2014; Pratt et al., 2007; Wilburn,
2004; Wilburn & Eijkemans, 2004

TECHNIQUES AND EQUIPMENT

Before giving an injection of any kind the health care provider is obliged to undertake the
following when administering an injection:

    • Inform and educate the patient on the need and effect of the medication being delivered
    • Ensure the correct identification and verification procedures are followed
    • Provide privacy for the patient during the procedure
    • Understand the theory behind selecting appropriate injection sites
    • Ensure that the proper equipment and dosage is selected
    • Clean the site with an alcohol swab or other cleansing agent
    • Demonstrate correct technique when undertaking the procedure
    • Monitor for complications
    • Document all relevant information and ensure safe disposal of equipment

The technique will vary depending on the route and site used; however, the angle of the needle
entry is important to understand as it relates to reducing the pain for the patient. For example, IM
injections should be given at a 90 degree angle to ensure the needle reaches the muscle. A study
by Katsma and Smith (1997) revealed that nurses did not always ensure needle entry to the skin
at 90 degrees and they speculated that this would cause more pain for the patient due to the
needle shearing through the tissues. The following is a review of the most common injections
and the proper technique to administer them:

1. To give an ID injection, a 25-gauge needle is inserted at a 10-15 degree angle, bevel up, just
under the epidermis, and up to 0.5 mL is injected until a wheal appears on the skin surface. If it
is being used for an allergen testing, the area should be labeled indicating the antigen so that an
allergic response can be monitored after a specific time lapse.
2. Traditionally, SC injections have been given at a 45 degree angle into a raised skin fold.
However, with the introduction of shorter insulin needles (5, 6, or 8 mm), the recommendation
for insulin injections is now an angle of 90 degrees. The skin should be pinched up to lift the
adipose tissue away from the underlying muscle, especially in thin patients. It is no longer
necessary to aspirate after needle insertion before injecting subcutaneously as studies have
shown that piercing a blood vessel in a SC injection is very rare.

3. To administer an IM injection, prepare the syringe by removing the needle cover, inverting the
syringe, and expelling any excess air. Approximately 0.1-0.2 mL of air should be left in the
syringe which will assist in forcing the entire amount of medication to be delivered. When ready
to inject, spread the skin using the fingers of the non-dominant hand. Holding the syringe with
the thumb and forefinger of the dominant hand, quickly pierce the skin at a 90 degree angle and
enter the muscle. It is no longer necessary to aspirate after needle insertion when administering
an IM injection. If the person administering the injection is at the correct anatomical location and
is educated about where the major vessels lie, there should be no reason to aspirate. Continue to
slowly inject the medication at a constant rate until all medication has been delivered. Withdraw
the needle and syringe quickly to minimize discomfort. Depending on the medication given, the
site may be massaged although it is sometimes not recommended by the manufacturer. Check the
site at least once more a short time after the injection to ensure that no bleeding, swelling, or
other signs of a reaction to the medication are present.

4. Z- Track technique for IM injections was initially introduced for drugs that stained the skin or
were particularly irritant. It is now used more universally for IM injections as it is believed to
reduce pain as well as the incidence of leakage into the subcutaneous tissue or skin. The gluteal
muscle is the recommended site for this technique. Select a long needle (2-3 inches; 5-7.5 cm)
depending on the size of the patient with a 21-or 22-gauge in order to place the medication
deeply within the muscle. To give a Z- track injection, begin using the non-dominant hand to
move and to hold the skin and subcutaneous tissue about 1-1.5 in (2.5-3.75 cm) laterally from the
injection site. Alert the patients when the medication is about to be injected. Ask them to breathe
through their mouth and to try to relax the muscle to avoid muscle resistance. Continue holding
the displaced skin and tissue until after the needle is removed. Dart the syringe rapidly into the
displaced skin at a 90 degree angle. Aspirate on the syringe to be sure that a blood vessel has not
been penetrated. Inject the medication slowly into the muscle. Never inject more than 5ml of
medication at a time when using the Z-track method. If a larger dose is ordered, divide it and
inject it into two separate sites. Be sure that the syringe is completely empty, including air,
before withdrawing it. Upon withdrawal of the syringe, immediately release the skin and
subcutaneous tissue.

5. Air bubble technique arose historically from the use of glass syringes which required an added
air bubble to ensure an accurate dose was given, and was also intended to seal the medication
after injection. Since plastic syringes are calibrated more accurately than glass ones, it is no
longer recommended by manufacturers as a technique to use. There are also issues related to the
accuracy of the dose when using this technique as it may significantly increase the dosage. There
have been studies to compare the Z-track and the air bubble techniques with regards to which
one is more successful at preventing leakage (Quart ermine &Taylor 1995, and MacGabhann
1998) with the former study finding the air bubble more effective, and the later findings were
inconclusive.

6 pressure behind it, pull it out and apply direct pressure as you hit an artery. This is unlikely
except when you are going for deep veins. If the blood is dark you connected with the vein. Rem.
7. Intraosseous injection is a process of injection directly into the marrow of the bone. This
technique is used in emergency situations to provide fluids and medication when an IV line
cannot be used. The needle is injected through the bone’s hard cortex and into the soft marrow
interior which allows immediate access to the vascular system. Often the antero-medial aspect of
the tibia is used as it lies just under the skin and can be easily palpated and located. The anterior
aspect of the femur, the superior iliac crest and the head of the humerus are other sites that can
be used. Although intravascular access is still the preferred method for medication delivery in the
prehospital area, advances in IO access (such as the F.A.S.T. 1 and the EZ-IO system) have
made IO more common in emergency medical services (EMS) systems around the world.

In conclusion, giving an injection safely is considered to be a fundamental nursing activity, and

yet it requires knowledge of anatomy and physiology, pharmacology, psychology,
communications skills and practical experience. Nurses are encouraged to review the current
research-based practices and incorporate the best ones into their everyday practice.

Preparing Medications from Ampules and Vials

Specific equipment, such as syringes and needles, is required to prepare and administer
parenteral medications. The selection of the syringe and needle is based on the type and location
of injection; amount, quality, and type of medication; and the body size of the patient. Many
syringes come with needleless systems or needles with safety shields to prevent injuries. Aseptic
technique is paramount to the preparation and administration of these medications.
Parenteral medications are supplied in sterile vials, ampules, and prefilled syringes. Ampules are
glass containers in 1 ml to 10 ml sizes that hold a single dose of medication in liquid form. They
are made of glass and have a scored neck to indicate where to break the ampule (see Figure 7.2).
Medication is withdrawn using a syringe and a filter needle. A blunt fill needle with filter (see
Figure 7.3) must be used when withdrawing medication to prevent glass particles from being
drawn up into the syringe (see Figure 7.4). Never use a filter needle to inject medication.

Figure 7.2 Breaking open an ampule

Figure 7.3 Blunt fill needle with filter

Figure 7.4 Using a blunt fill needle with filter with an ampules
A vial is a single- or multi-dose plastic container with a rubber seal top, covered by a metal or
plastic cap (see Figure 7.5). A single-use vial must be discarded after one use; a multi-dose vial
must be labelled with the date it was opened. Check hospital policy to see how long an open vial
may be used. The vial is a closed system, and air must be injected into the vial to permit the
removal of the solution (Perry et al., 2014) (see Figure 7.6).

Figure 7.5 Preparing medications from a vial

Figure 7.6 Vial with safety needle inserted
A syringe (see Figure 7.7) is a sterile, single-use device that has a Luer lock (see Figure 7.8) or
non-Luer lock tip, which influences the name of the syringe. Syringes come in various sizes from
0.5 ml to 60 ml. Syringes may come with or without a sterile needle and will have a safety shield
on the needle.

Figure 7.7 Labelled syringe

Figure 7.8 Luer lock needle

Insulin is only given using an insulin syringe (see Figure 7.9). Insulin is ordered in units. It is
important to use the correct syringe and needle for the specific injection. Always examine the
measurement scale on the syringe to determine that you have the correct syringe (Lynn, 2011).

Figure 7.9 Insulin syringe with safety shiel

Needles are made of stainless steel, are sterile and disposable, and come in various lengths and
sizes. The needle is made up of the hub, shaft, and bevel. The bevel is the tip of the needle that is
slanted to create a slit into the skin. The hub fits onto the tip of the syringe. All three parts must
remain sterile at all times. The length of the needle will vary from 1/8 in. to 3 in., depending on
the injection. The gauge of a needle is the diameter of the needle. Gauges can vary from very
small diameter (25 to 29 gauge) to large diameter (18 to 22 gauge). A needle will have its gauge
and length marked on the outer packaging; choose the correct gauge and length for the injection
ordered (see Figures 7.10, 7.11, and 7.12)

Figure 7.10 Variety of needles with different gauges and lengths

Figure 7.11 Types of needles with safety shields

Figure 7.12 Needle with safety cap
Critical Thinking Exercises
1. What are three strategies that can be implemented to reduce distractions while preparing
medication?
2. What are two ways to prevent needle-stick injuries?

INTRAMUSCULAR INJECTION (IM)

An intramuscular (IM) injection is a shot of medicine given into a muscle. Certain medicines
need to be given into the muscle for them to work correctly.
There are 3 parts to a syringe: the needle, the barrel, and the plunger. The needle goes into your
muscle. The barrel holds the medicine and has markings on it like a ruler. The markings are in
milliliters (mL). The plunger is used to get medicine into and out of the syringe.
INTRAMUSCULAR INJECTION
Intramuscular (IM) injections are used to promote rapid drug absorption and to provide
an alternate route when the drug is irritating to subcutaneous tissue. The IM route enhances the
absorption rate because there are more blood vessels in the muscles than in subcutaneous tissue;
however, the absorption rate may be affected by the client’s circulatory status.
The nurse should determine the maximum volume to inject on the basis of the site and the
client’s muscle development:
• 4 ml for a large muscle (gluteus medius) in a well-developed adult
• 1 to 2 ml for less developed muscles in children, elderly, and thin clients
• 0.5 to 1.0 ml for the deltoid muscle
When more than 4 ml is ordered, the medication can be divided into two different sites.
There are four common sites for administrating IM injections (see the accompanying
display). Injection sites are identified by using appropriate anatomic landmarks (Figure 29-22).
 The primary site for administering an IM injection in clients over 7 months old is the
ventrogluteal (VG) site. The gluteus medius is a well-developed muscle, free of major nerves
and large blood vessels. Research shows that injuries—including fibrosis, nerve damage,
abscess, tissue necrosis, muscle contraction, gangrene, and pain—have been associated with all
the common sites (dorsogluteal, deltoid, and vastus lateralis, for example) except the VG site .
The nurse should avoid using the deltoid and dorsogluteal sites in infants and children.
There is a risk of striking the sciatic nerve when using the dorsogluteal site. The deltoid muscle
is not well developed in infants and children.
 Z-TRACK INJECTION
The Z-track (zigzag) technique refers to a method used in administering IM injections
(see Procedure 29-7). This technique was traditionally used when administering imferon, an iron
preparation, which can cause permanent discoloration in the subcutaneous tissue. Today, the
technique is used commonly when administering ventrogluteal and dorsogluteal injections.
When administering a Z-track injection, the nurse should place the client in the prone
position (Figure 29-25A); then pull the skin to one side (Figure 29-25B), insert the needle at a
90° angle and administer the medication (Figure 29-25C). Spreading the skin, a common method
formerly used for IM injections, increases the risk that medication will leak into the needle track
and the subcutaneous tissue; this risk is virtually eliminated using the Z-track technique, making
it the technique of choice. The nurse waits 10 seconds and withdraws the needle at the same
angle of insertion; the site should not be massaged because massaging could cause tissue
irritation.
Where can I give an intramuscular injection?
Thigh: Look at your thigh and divide it into 3 equal parts. The middle third is where the
injection will go. The thigh is a good place to give yourself an injection because it is easy to see.
It is also a good spot for children younger than 3 years old.
Hip: Have the person getting the injection lie on his or her side. To find the correct location,
place the heel of your hand on the upper, outer part of the thigh where it meets the buttocks.
Point your thumb at the groin and your fingers toward the person's head. Form a V with your
fingers by separating your first finger from the other 3 fingers. You will feel the edge of a bone
along the tips of your little and ring fingers. The place to give the injection is in the middle of the
V. The hip is a good place for an injection for adults and children older than 7 months.
Upper arm muscle: Completely expose the upper arm. You will give the injection in the
center of an upside down triangle. Feel for the bone that goes across the top of the upper arm.
This bone is called the acromion process. The bottom of it will form the base of the triangle. The
point of the triangle is directly below the middle of the base at about the level of the armpit. The
correct area to give an injection is in the center of the triangle, 1 to 2 inches below the acromion
process. This site should not be used if the person is very thin or the muscle is very small.
Deltoid Injection
Buttocks: Expose one side of the buttocks. With an alcohol wipe draw a line from the top of
the crack between the buttocks to the side of the body. Find the middle of that line and go up 3
inches. From that point, draw another line down and across the first line, ending about halfway
down the buttock. You should have drawn a cross. In the upper outer square you will feel a
curved bone. The injection will go in the upper outer square below the curved bone. Do not use
this site for infants or children younger than 3 years old. Their muscles are not developed
enough.
You can administer an I.M. injection into the muscles shown below. In these illustrations,
specific injection sites are shaded.
Deltoid site
 Locate the lower edge of the acromial process.
 Insert the needle 1" to 2" below the acromial
process at a 90-degree angle.
 The deltoid muscle is recommende for injections
with smaller volumes usually equal to or less
than 1ml including vaccines.this site is not
recommended for repeated injections due to its
small area ,difficult to rotate the injection site

Deltoid muscle
Diagram showing the deltoid site for intramuscular injection

 
Dorsogluteal site
 Draw an imaginary line from the posterior
superior iliac spine to the greater trochanter.
 Insert the needle at a 90-degree angle above and
outside the drawn line.
 You can administer a Z-track injection through
this site. After drawing up the drug, change the
needle, displace the skin lateral to the injection
site, withdraw the needle, and then release the
skin.
 
Ventrogluteal site
 With the palm of your hand, locate the greater
trochanter of the femur.
 Spread your index and middle fingers
posteriorly from the anterior superior iliac spine
to the furthest area possible. This is the correct
injection site.
 Remove your fingers and insert the needle at a
90-degree angle.
with its base at the acromion process and its midpoint in
line with the axilla.
The ventrogluteal site (hip) is recommended for injections requiring a larger volume to be
administered, greater than 1 ml, and for medications known to be irritating, viscous or oily. It is
also given for narcotic, antibiotic, sedative and anti-emetic medications.To locate the
ventrogluteal site, place the palm of your hand over the greater trochanter, with the fingers
facing the patient's head. The right hand is used for the left hip and left hand is used for the right
hip. Place the index finger on the anterior superior iliac spine and run the middle finger back
along the iliac crest. The injection is given in the center of the triangle that is formed.

Ventrogluteal site

Ventrogluteal site

 
Vastus lateralis and rectus femoris sites
 Find the lateral quadriceps muscle for the vastus
lateralis, or the anterior thigh for the rectus
femoris.
 Insert the needle at a 90-degree angle into the
middle third of the muscle, parallel to the skin
surface.
Vastus lateralis muscle

Vatus lateralis site for intramuscular injection

The vastus lateralis site is the recommended site for infants less than 7 months old and those
unable to walk, with loss of muscular tone.To locate the site, divide the front thigh into thirds
vertically and horizontally to make nine squares and inject in the outer middle square.
How do I choose the best place for an intramuscular injection? Keep track of where the
injections are given: Make a list of the sites you use. Write down the date, time, and the site each
time you give an injection.
Change sites for the injections: It is important to use a different site each time you give an
injection. This helps prevent scars and skin changes. The sites where injections are given should
be at least 1 inch away from each other. Ask your healthcare provider if you need to inject the
medicine in a certain site.
What items do I need to give an injection?

One alcohol wipe

One sterile 2 x 2 gauze pad

A new needle and syringe that are the correct size
Disposable gloves
How do I get rid of used syringes and needles?
It is important to dispose of your needles and syringes correctly. Do not throw needles into the
trash. You may receive a hard plastic container made especially for used syringes and needles.
You can also use a soda bottle or other plastic bottle with a screw lid. Make sure that both the
syringe and needle fit into the container easily and cannot break through the sides. Ask your
healthcare provider or a pharmacist what your state or local requirements are for getting rid of
used syringes and needles.
What are the risks of an intramuscular injection?
An intramuscular injection could cause an infection, bleeding, numbness, or pain.
When should I contact my healthcare provider?
A fever, sneezing, or coughing develops after the injection.
There is a lump, swelling, or bruising where the injection was given that does not go away.
 You have questions about how to give an injection.
When should I seek immediate care
A rash or itching develops after the injection is given.
Shortness of breath develops after the injection is given.
The mouth, lips, or face swells after the injection is given.

INTRAVENOUS INJECTION
Injection of fluid directly into a vein. Allows larger amounts of fluid to be administered and
provides means for rapid absorption of medication.

Intravenous injection an injection made into a vein. Intravenous injections are used when rapid
absorption is called for, when fluid cannot be taken by mouth, or when the substance to be
administered is too irritating to be injected into the skin or muscles. In certain diagnostic tests
and x-ray examinations a drug or dye may be administered intravenously.

Intravenous route injection uses a hypodermic injection into a vein for the purpose of
instilling a single dose of medication, injecting a contrast medium, or beginning an IV
infusion of blood, medication, or a fluid solution, such as saline or dextrose in water
Intravenous injection technique is considerably more complicated and more dangerous than
other types of injection. That said, proper technique can at least minimize the possible damage.

Administering an intravenous injection is something that’s usually easiest

with at least rudimentary medical training, but almost anyone can get good
results with the right equipment and an eye for precision. Intravenous
injections, sometimes also called simply “IV injections,” work by delivering
drugs or needed fluids directly into the bloodstream. One of the first things
you’ll need to do is to prepare the site, commonly in the arm. You’ll need to
look for a vein, clean the area, and apply pressure. When you’re ready to
start the line, you’ll want to firmly but evenly insert the needle into the vein,
usually at an angle, and secure it. You’ll also need to monitor the flow of
fluids to make sure they aren’t moving too quickly or too slowly. Rare but
serious complications can arise when air gets trapped in the line, as well;
knowing what to watch for can help you avoid administration errors that
could jeopardize the patient’s health.

IV Basics

An intravenous injection is a means of therapy and routine treatment for

many different conditions, and a variety of drugs are given intravenously. In
some cases, water, saline, or other fluids are used to address dehydration. IV
injections are an important way of administering medical fluids, though
getting the procedure right can be something of an art. In general, the
substance or medication to be injected is stored in a clean syringe or bag
that’s attached to the needle with thin plastic piping. The needle is then
inserted into the patient's vein, most commonly on the top of the hand, on
the wrist, or just inside the elbow.
Identifying a strong vein and getting the line going is the first step. Your job
doesn’t end there, though; in most cases, IV administration also includes
monitoring. You’ll need to be sure that the drip is going at the right speed
and that it doesn’t contain air bubbles, and you’ll also need to swap bags or
replenish fluids as needed.

Prepare the Site

Making sure that the area is clean and sterile is one of the easiest ways to
prevent infection and other complications. It’s usually a good idea to start by
cleaning the patient’s skin with alcohol or some other disinfectant. You’ll also
want to apply pressure to help the veins fill with blood, which can make
them more visible. A tourniquet is a common choice. Tying the tourniquet to
the patient’s upper or mid-arm region can make the veins in the lower arm,
wrist, and hand more evident, which can make insertion easier and also less
painful.

Insert the Needle

Getting the needle inserted and the line started is usually the hardest part,
and it often takes a bit of practice to get the motions right. In general, you’ll
want to stick the patient with the needle in a swift, confident motion. Aim for
a shallow angle of somewhere around 30°. With your other hand, pull the
patient’s skin gently in the opposite direction from the needle insertion. A
small amount of blood should enter the needle, which indicates that it is in
the vein. Only then should you attach the IV fluids to the line, or turn them
on if they’re on a valve system.

Monitor the Flow

If you have to administer an injection containing drugs or other fluids

intravenously, the substance you will be injecting may be stored in a bag
that is attached to a pole and hung slightly above the patient. The flow of the
substance can usually be controlled by clips that are connected to the tube.
If the clips are not manipulated, gravity will naturally force the liquid down
and the substance will drip slowly toward the vein. If the clip is loosened, the
flow will be increased, and the drugs or fluids can be administered more
quickly.

Paying attention to the flow is really critical, since too much or too little can
have negative consequences. It’s usually a good idea to check up on the
patient from time to time, too, to be sure that everything is progressing as it
should and also to see that the placement of the needle hasn’t shifted or
loosened. In some cases it’s necessary to secure the needle with medical
tape or a splint. This is particularly true with children and others who have a
hard time staying still.

Avoiding Complications

You must be extremely careful when you administer an intravenous injection

to avoid complications. Improper administration could result in an air
embolism, which is when a large amount of air enters the patient's
bloodstream. If IV fluids are given too quickly, the body may not be able to
absorb them, leading to serious health problems. Needles that are not clean
can sometimes lead to the transmission of diseases, including HIV and
hepatitis, as well as infection.

It’s also really important that you pay close attention to the fluid you’re
administering. Many clear bags look alike, but IVs are used for a lot of
different things. Choosing the wrong fluid can have devastating
consequences.

Determine what type of injection you are giving. Your doctor or should give you detailed
directions on the type of injection you will administer as well as the technique. When you are
ready, review the detailed instructions that come with the medication as well as the directions
given to you by your doctor, nurse, or pharmacist. If you have any questions or doubts about
how and when to administer the injection, talk to your doctor, nurse, or pharmacist. Ask
questions if you are not sure about the correct syringe, needle length, and needle gauge before
proceeding.

Some medications come ready-to-use, while others require you to fill the needle with
medication from a vial.

Be very clear on the supplies you need for the injection. Some people receive more than one
type of injection at home.

It is easy to confuse the syringes and needles needed for one injection with those intended for
use with another medication injection.

Be familiar with the product packaging. Not all injectable medication packaging is the same.
Some medications may need reconstitution before administration. Many come packaged with
everything you need including syringes and needles.

Again, it is imperative that your healthcare provider teaches you about your medication and
any preparatory steps specific to that medication. Simply reading the instructions or a "How To"
is not sufficient — you must have access to a direct link to ask questions and become educated
on your medication and the administration.

Once you have talked to your doctor, you can also review the product literature, which will give
clear step-by-step instructions on anything you need to do in order to prepare the medication
for administration.

Again, this is should not be considered a replacement for talking to your healthcare provider
about how to prepare and administer the medication.

The literature will also tell you the recommended syringe size, needle size, and needle gauge, if
those are not included in the packaging.
Give a medication packaged in a single dose vial. Common manufacturer packaging for many
injectable medications is done by putting the medication into a vial called a single dose vial.

The label on the medication vial will say either “single dose vial” or will contain the
abbreviation, SDV.

This means each vial contains only one dose. There may be fluid left in the vial after you have
prepared the dose you need to give.

The remainder of the medication in the vial is to be discarded and not saved for another dose.

The nurse confirms the type and amount of IV solution by reading the health care practitioner’s
prescription in the medical record. IV solutions are sterile and packaged in plastic bags or glass
containers. Solutions that are incompatible with plastic are dispensed in glass containers. Plastic
IV solution bags collapse under atmospheric pressure to allow the solution to enter the infusion
set. Plastic solution bags are packaged with an outer plastic bag, which should remain intact until
the nurse prepares the solution for administration. When the plastic solution bag is removed from
its outer wrapper, the solution bag should be dry. If the solution bag is wet, the nurse should not
use the solution. The moisture on the bag indicates that the integrity of the bag has been
compromised and that the solution cannot be considered sterile. The bag should be returned to
the dispensing department that issued the solution. IV solutions are usually packaged in
quantities ranging from 50 to 1,000 ml. The nurse should select a container that has the
prescribed amount of solution or select several containers that together contain the prescribed
volume.
Implementation of IV Therapy
• Know why the therapy is prescribed.
• Document client understanding.
• Select the appropriate equipment in accordance to agency policy.
• Obtain the correct solution as prescribed.
• Assess the client for allergies: tape, iodine, ointment, or antibiotic preparations to be used for
skin preparation of the venipuncture site.
• Administer the fluid at the prescribed rate.
• Observe for signs of infiltration ..
• Document implementation of prescribed IV therapy in the client’s medical record. whose
volume is greater than that prescribed. For example, if the client is to receive 600 ml of normal
(0.9%) saline, the nurse must not select a 1000 ml container, but rather two containers, 100 ml
and 500 ml (containers are not prepared in volumes of 600 ml).

Crystalloids (electrolyte solutions with the potential to form crystals) are used to replace
concurrent losses of water, carbohydrates, and electrolytes. Sodium chloride and Ringer’s lactate
are commonly used crystalloid solutions. There are three types of parenteral fluids that are
classified in accord with the tonicity of the fluid relative to normal blood plasma. As previously
discussed, an osmolar solution can be hypotonic, isotonic, or hypertonic. The type of solution is
prescribed on the basis of the client’s diagnosis and the goal of therapy. The normal osmolarity
of blood is between 280 and 295 mOsm/L, so the desired effect of the tonicity of the fluid is
determined as follows:
1. Hypotonic fluid (hypo-osmolar, less than 290 mOsm/L) lowers the osmotic pressure and
causes fluid to move into the cells; if fluid is infused beyond the client’s tolerance, water
intoxication may result.
2. Isotonic fluid (iso-osmolar, 290 mOsm/L) increases extracellular fluid volume; if fluid is
infused beyond the client’s tolerance, cardiac overload may result.
3. Hypertonic fluid (hyperosmolar, greater than 290 mOsm/L) increases the osmotic pressure of
the blood plasma, drawing fluid from the cells; if fluid is infused beyond the client’s tolerance,
cellular dehydration may result (Bul. Table 37-5 discusses the common types of intravenous
solutions in terms of their tonicity, contents, and clinical usage.
Crystalloid solutions can be;
isotonic (equal to the sodium chloride concentration of blood, 0.9%);
hypotonic (less than the sodium chloride concentration of blood); and
hypertonic (greater than the sodium chloride concentration of blood) .
Colloids (nondiffusable substances) function like plasma proteins in blood by exerting a
colloidal pressure to replace intravascular volume only. Examples of colloidal solutions are
albumin, dextran, Plasmanate, and hetastarch (artificial blood substitute). During the
administration of these solutions, the nurse should monitor the client for hypotension and allergic
reactions .

Equipment
IV equipment is sterile, disposable, and prepackaged with user instructions. The user instructions
are usually placed on the outside of the package, with a schematic that labels the parts, allowing
the user to read the package prior to opening. All intravenous
equipment must be inspected by the nurse to determine the integrity of the IV product before,
during, and after use. Product integrity refers to the sterility of the equipment. Products are
assessed for integrity by visual examination of the product and checking the expiration date on
the equipment. All products identified with a defect must be returned to the appropriate
department within the agency with a written report identifying the defect
Administration Set
The administration set (infusion set) refers to the plastic disposal tubing that provides for the
infusion of a solution. There are several types of infusion sets to accommodate the solution and
the mode of administration: primary continuous; secondary; primary intermittent; and special
tubing for certain solutions such as blood/blood components. There are several add-on devices,
such as extension sets, filters, stopcocks, PRN adaptor, and needleless devices that are used in
conjunction with the administration set and changed whenever the set is changed. Administration
sets are changed at established time intervals and immediately upon suspected contamination or
when the integrity of the set has been compromised. The administration set contains an insertion
spike with a protective cap, a drip chamber, tubing with a slide clamp and regulating (roller)
clamp, a rubber injection port, and a protective cap over the needle adapter (Figure 37-10). The
protective caps keep both ends of the infusion set sterile and are removed only just before usage.
The insertion spike is inserted into the port of the IV solution container. Infusion sets can be
vented or nonvented. The nonvented type is used with plastic bags of IV solutions and vented
bottles. The vented set is used for glass containers that are not vented (Figure 37-11). Glass
containers require an air vent so that air can displace fluid from the container into the IV tubing.

Intravenous Filters
Intravenous filters prevent the passage of undesirable substances such as particulate matter and
air from entering the vascular system. Particulate matter filters are utilized when preparing
infusion medications for administration to prevent obstruction in the vascular/pulmonary
systems, irritation and phlebitis (inflammation of a vein). Aireliminating filters are used for the
delivery of infusion therapy to decrease the potential of air emboli; the filter should be located as
close as possible to the cannula site. IV filters come in various sizes; the finer the filter, the
greater is the degree of solution filtration. Although studies have shown that IV filters reduce the
risk of bacteremia and phlebitis as much as 40%, some agencies do not use IV filters because of
cost. Many IV catheters contain an in-line filter; if the catheter has an in-line filter, it is not
necessary to add a filter to the tubing.
 Needles and Venous
Peripheral-Short Catheters
Needles and peripheral-short catheters provide access to the venous system. A variety of devices
are available in different sizes to complement the age of the client, the type and duration of the
therapy, and to protect the user from injury (Figure 37-12). As with any gauge needle, the larger
the number, the smaller the lumen. The nurse considers the client’s age, body size, and the type
of solution to be administered when selecting the gauge of the needle or catheter:
• Infants and small children, 24 gauge
• Preschool through preteen, 24 or 22 gauge

NURS I N G T I P
Age Considerations for Choosing IVs and Equipment
Neonates, infants, and children are at risk for Altered Fluid Balance: Overload, related to
rehydration. IV tubing with a microdrip and special volume control chambers is used to regulate
the amount of fluid to be administered over a specific time interval. Armboards and soft
restraints are used to stabilize peripheral infusions by immobilizing the extremity to prevent
accidental removal of infusion devices.

Preparing an Intravenous Solution

To prepare an IV solution, read the agency’s protocol and gather the necessary equipment.
Because IV equipment and solutions are sterile, check the expiration date on the package prior to
usage. The solution can be prepared at the nurses’ work area or in the client’s room (Procedure
37-2). The nurse prepares and applies a time strip to the IV solution bag to facilitate monitoring
of the infusion rate as prescribed by the health care practitioner (Figure 37- 19). The IV tubing is
tagged with the date and time to indicate when the tubing replacement is necessary. IV tubing is
changed every 48 to 72 hours in accord with the agency’s protocol. The nurse initials the time
strip and IV tubing tag.
 NURSING ALERT
Marking an IV Bag
Do not use a felt-tip pen to mark an IV bag; the ink from the pen can leak through the plastic and
contaminate the solution. Do not label bag with time strip made of adhesive/silk/paper tape, as
the adhesive will leach into the bag. Use only labels appropriate for IV bags.

Initiating IV Therapy
When initiating IV therapy, the nurse should assess for a venipuncture site. Figure 37-20
presents the common peripheral sites for starting IV therapy in pediatric, adult, and geriatric
clients (see Chapter 28, Procedure 28-1, Venipuncture). When assessing clients for potential
sites, consider their age, body size, clinical status and impairments, and the skin condition (see
the accompanying display for contraindications when selecting a site). Lowerextremity veins are
used for IV therapy only when so prescribed by the health care practitioner; circulating
Figure 37-20 Peripheral Veins Used in Intravenous Therapy. A. Armand Forearm; B. Dorsum of
the Hand; C. Dorsal Plexus of the Foot
blood in the lower extremities is likely to pool and clot, which may result in an embolism.
Because contact with blood is likely, venipuncture requires the implementation of Standard
Precautions. Select a vein for puncture at its most distal end to maintain the integrity of the vein,
because venous blood flows with an upward movement toward the heart. When a vein is
punctured with an instrument, such as a needle, fluids can infiltrate (leak from the vein into the
tissue at the site of puncture). If IV therapy has to be discontinued for any reason, such as
infiltration, it can be restarted above the initial puncture site only.

Vein Finder
A vein finder is a device used to locate hard-to-find veins. It is helpful, for example, in working
with obese clients whose superficial veins are difficult to locate. A Venoscope (Figure 37-21) is
a type of vein finder with adjustable fiberoptic arms that reveal veins. The room is dimmed, and
the disposable skids are placed flush against the skin. The nurse slowly moves the Venoscope
along the extremity until a dark, shadowy line is seen between the fiberoptic arms. Once the vein
is identified, it can also be checked to determine whether it is sclerotic. To assess for sclerotic
veins, apply a downward pressure over the fiberoptic arms and observe the vein when pressure is
applied then released. A nonsclerotic vein will disappear with pressure and reappear when
pressure is released.

Administering IV Therapy
Once the solution is prepared for administration, the nurse calculates the rate and explains the
procedure to the client (see Procedure 37-3 for the administration of IV therapy). There are three
ways to administer solutions:
1. Initiate the infusion by performing a venipuncture.
2. Use an existing IV system: catheter, heparin or PI lock, central line, or implanted port.
3. Add a solution to a continuous-infusion line.
Flushing
Flushing refers to the instillation of a solution into an intravenous cannula. Flushing is performed
to assess and maintain cannula patency and prevent the mixing of incompatible medications
and/or solutions, following the conversion of continuous IV therapy to intermittent IV therapy,
and to maintain intermittent cannula patency following IV medication administration and blood
sampling. The type of solution and frequency of flushing an intermittent intravenous cannula is
determined by the agency’s policy/protocol. According to the INS (2000), flushing a cannula at
established intervals with saline (0.9% sodium chloride injection) is the accepted solution to
ensure and maintain patency of an intermittent PI cannula, while a heparin flush solution is the
accepted solution to maintain patency of an intermittent central venous devices. The volume of
flush is equal to the volume capacity of the cannula and add-on devices times two .
Consideration is also given to the volume and frequency of heparin flush in order to prevent an
alteration in the client’s clotting factors. When flushing a cannula positive pressure within the
lumen of the catheter must be maintained to prevent the reflex of blood into the cannula lumen.
Infusion sets with macrodrip chambers are often used for adult clients, whereas microdrip
chambers are used for volume-sensitive clients, such as geriatric or pediatric clients. Pediatric
and geriatric clients usually require some type of device to regulate the fluids as a safety factor to
prevent overload. Devices such as controllers and pumps are commonly used to regulate the rate
of infusion.
Calculation of Flow Rate
The flow rate is the volume of fluid to infuse over a set period of time as prescribed by the
health care practitioner. The health care practitioner will identify either the amount to infuse per
hour (such as 125 ml per hour or 1000 ml over an 8-hour period). Calculate the hourly infusion
rate as follows:
For example, if 1000 ml is to infuse over 8 hours: Calculate the actual infusion rate (drops per
minute) as follows: For example, if 1000 ml is to infuse over 8 hours with a tubing drop factor of
10 drops per milliliter: Another way to calculate the actual infusion rate is to use the hourly
infusion rate; for the example just given:
or cartridge to deliver the fluid at a specific set rate.

Managing IV Therapy
IV therapy requires frequent client monitoring by the nurse to ensure an accurate flow rate and
other critical nursing actions; refer to Procedure 37-4. These other actions include ensuring client
comfort and positioning; checking IV solution for correct solution, amount, and timing;
monitoring expiration dates of the IV system (tubing, venipuncture site, dressing) and changing
as necessary; and being aware of safety factors. Coordinate client care with the maintenance of
IV lines. Clients with IV therapy usually require assistance with hygienic measures, such as
changing a gown (see Procedure 37-4). Change IV tubing when doing site care to decrease the
number of times the access device is manipulated, thereby decreasing the risk for infiltration and
phlebitis. PI devices are changed every 72 hours as directed by the Centers for Disease Control
and
Prevention (CDC) guidelines.

Hypervolemia
Hypervolemia (increased circulating fluid volume) may result from rapid IV infusion of
solutions. This causes cardiac overload, which may lead to pulmonary edema and cardiac failure.
Monitor the infusion rate hourly and refer to the Nursing Care Plan, Client with Fluid Volume
Excess, for the assessment and interventions for a client experiencing fluid volume excess. Total
volume
Number of hours to infuse = ml/hour
infusion rate 1000 8 = 125 ml/hour
Total fluid volume
Total time (minutes) drop factor = drops per minute
1000 ml
8(60) min10 drops/ml =
10,000 drops
480 min = 20.8 or 21
drops/min
125 ml 10 drops/ml
60 min
= 20.8 or 21 drops/min

NURSING ALERT
Catheter Sepsis
If client complains of chills and fever, check length of time that this IV solution has been
hanging and the needle or catheter has been in place; assess client’s vital signs, and assess for
other symptoms of pyrogenic reactions, such as backache, headache, malaise, nausea, and
vomiting. Unexplained fever may be related to catheter sepsis. Pulse rate increases and
temperature is usually above 100°F if IV-related sepsis occurs. Stop infusion, notify health care
practitioner, and obtain blood specimens if prescribed.
If a solution infuses at a rate greater than prescribed, decrease the rate to keep vein open (KVO)
and immediately notify the health care practitioner. Report the amount and type of solution that
infused over the exact time period and the client’s response.

Infiltration
Infiltration may be caused by inserting the wrong type of device, using the wrong-gauge needle,
or dislodgement of the device from the vein. When a drug or solution is administered under high
pressure by a pump, it may also cause infiltration or vein irritation. Infiltration results in the
leaking of fluids or medications into the surrounding tissue. The client usually complains of
discomfort at the IV site. Inspect the site by palpating for swelling, and feel the temperature of
the skin (coolness and paleness of skin are indications of infiltration). The nurse confirms that
the needle is still in the vein by pinching the IV tubing; this action should cause a flashback
(blood should rush into the tubing if the needle is still in the vein). If a flashback does not occur,
aspirate the injection port nearest the device as explained in Procedure 37-4. Discontinue the
needle or catheter if it cannot be aspirated and apply a sterile dressing to the puncture site. After
the IV has been removed, the puncture site may ooze or bleed (especially in clients receiving
anticoagulants). If oozing or bleeding occurs, apply pressure and reapply a sterile dressing until
it stops. Accurately assess and document the degree of edema. Clients may be injured by
infiltration. If the IV site becomes grossly infiltrated, the edema in the soft tissue may cause a
nerve compression injury with permanent loss of function to the extremity. If a vesicant
(medication that causes blistering and tissue injury when it escapes into surrounding tissue)
infiltrates, it may cause significant tissue loss with permanent disfigurement and loss of function.

Phlebitis
Phlebitis may result from either mechanical or chemical trauma. Mechanical trauma may be
caused by inserting a device with too large a gauge, using a vein that is too small or fragile, or
leaving the device in place for too long.
Chemical trauma may result from infusing too rapidly, or from an acidic solution, hypertonic
solution, a solution that contains electrolytes (especially potassium and magnesium), or other
medications. Phlebitis may be a precursor of sepsis. Listen for client complaints of tenderness,
the first indication of an inflammation. Inspect the IV site for changes in skin color and
temperature (a reddened area or pink or red stripe along the vein, warmth, and swelling are
indications of phlebitis). If phlebitis is present, discontinue the IV infusion. Before removing and
discarding the venous device, check the agency’s protocol to see whether the tip of the device
needs to be cultured and sent to the laboratory for a culture and sensitivity. After removing the
device, apply a sterile dressing to the site and wet warm compresses to the affected area.
Document in the nurses’ notes the time, symptoms, and nursing interventions. Hypertonic
solutions may cause irritation necessitating frequent IV site changes. Observe site for symptoms
of postinfusion phlebitis following IV removal. This may occur in response to either chemical or
mechanical factors of the preexisting IV. Postinfusion phlebitis is treated with hot compresses to
the site and elevation of the extremity.
.

Discontinuation
of Intravenous Therapy
Intravenous therapy is discontinued on health care practitioner order as determined by the
client’s need or response to therapy. The removal of a short peripheral catheter is a nursing
intervention to minimize the complication risks related to infusion therapy or to implement the
health care practitioner’s order. Peripheral catheters are removed every 48 hours and
immediately upon suspected contamination or complications. Pressure and a dry sterile dressing
are applied to the site upon removal of the catheter; refer to Procedure 37-4. The integrity of the
catheter and insertion site should be assessed with observations and actions documented to the
client’s medical record. The removal of a PICC is usually a simple procedure; however, research
suggests that, in 7% to 12% of PICC removals, difficulties can arise (Macklin, 2000). Only
nurses who have been trained in the insertion of a PICC line should remove the catheter. Since
the catheter is completely inserted in the vascular system and invisible, the nurse must feel for
resistance during removal. If resistance is felt, the nurse stops and assesses for certain
complicating factors: venous spasm, vagal reaction, phlebitis, thrombosis, and knotting of the
catheter. Prior to removal, the nurse must verify in the client’s medical record the type and the
specific length of the inserted PICC.
 Infusion
I.V. drugs can be injected into the veins therapy
of the arms and hands. The illustration at
right shows commonly used sites.
 Locate the vein using a In medicine,
tourniquet. infusion
 Insert the catheter at a slight therapy
angle (about 10-15 degrees). deals with
all aspects of
 Release the tourniquet when
fluid and
blood appears in the syringe or
medication
tubing.
infusion, via
 Slowly inject the drug into the
intravenous
vein.
or

subcutaneous application. A special infusion pump can be used for this purpose.[1] A fenestrated
catheter is most frequently inserted into the localized area to be treated.
There are a range of delivery methods for infusion of drugs via catheter:
 Electronic Pump: Drugs are often pre-mixed from vials and stored in infusion bags to be
delivered by electronic pump.
 Elastomeric pump
 Pre-Filled Infusion Therapy: with this latest technology, a unit dose can be metered to
the location from a pre-filled container.
Infusion therapy has a range of medical applications including sedation, anesthesia, post-
operative analgesic pain management, chemotherapy, and treatment of infectious diseases
Advantages of infusion therapy over other non-site-specific delivery methodologies are primarily
efficacy through precision of medication delivery.
New standards for infusible pharmaceuticals have been achieved in recent years with the advent
of pre-filled, ready-to-use, dose-specific products. Advanced aseptic presentation, with
hermetically sealed containers, allows predictable sterility, ease of use, improved control, and
lower total costs. Essentially, systematizing the delivery mechanism and standardizing the
delivery container.
Treatments
Infusion therapy involves the administration of medication through a needle or catheter.
Typically, "infusion therapy" means that a drug is administered intravenously or subcutaneously.
The term may pertain where drugs are provided through other non-oral routes of administration,
such as intramuscular injection and epidural administration (into the membranes surrounding the
spinal cord).
Until the 1980s, patients receiving infusion therapy often had to remain in an inpatient setting for
the duration of their therapy. New technologies and heightened emphasis on cost containment in
health care, as well as developments in the clinical administration of the therapy, led to strategies
to administer infusion therapy in alternate settings (at clinics and at home).

INTRADERMAL INJECTION
 Intradermal (ID) or intracutaneous injections are typically used to diagnose tuberculosis,
identify allergens, and administer local anesthetics. The site below the epidermis is the location
for administering ID injections; drugs are absorbed slowly from this site. The sites commonly
used for ID injection are the inner aspect of the forearm (if it is not highly pigmented or covered
with hair), upper chest, and upper back beneath the scapula (Figure 29-19). Only small amounts
of water-soluble medication should be used for subcutaneous injections. The drug’s dosage for
an ID injection is usually contained in a small quantity of solution (0.01 to 0.1 ml). A 1-ml
tuberculin syringe with a short bevel, 25 to 27 gauge, 3/8- to 1/2-inch needle is used to provide
accurate measurement. If repeated doses are ordered, the site should be rotated. ID injections are
administered into the epidermis layer by angling the needle 10° to 15° to the skin. See Procedure
29-5 for administering intradermal injections.
SUBCUTANEOUS INJECTION
 FIGUR
E 11-3

Injections made into the subcutaneous tissues; called also hypodermic injection. Although
usually fluid medications are injected, occasionally solid materials, such as steroid hormones,
are administered subcutaneously in small, slowly absorbed pellets to prolong their effect.
Subcutaneous injections may be given wherever there is subcutaneous tissue, usually in the
loose skin on the side of the chest or in the flank. The amount injected should not exceed 2 ml
for cats and small dogs, 5 ml for large dogs and 20 ml for horses. Cows are often given 200 ml
because of their very loose skin. The needle is held at a 45-degree angle to the skin.

Angle of needle insertion for administering a subcutaneous injection.

intradermal injection injection of small amounts of material into the corium or substance of
the skin, done in diagnostic procedures and in administration of regional anesthetics, as well as
in treatment procedures. In certain allergy tests, the allergen is injected intracutaneously.
These injections are given in an area where the skin and hair are sparse, usually on the inner
part of the forearm. A 25-gauge needle, about 1 cm long, is usually used and is inserted at a 10-
to 15-degree angle to the skin.
 Subcutaneous (SC or SQ) injections are commonly used in the administration of
medications such as insulin and heparin because these drugs are absorbed slowly, to produce a
sustained effect. SC injections place the medication into the subcutaneous tissue, between the
dermis and the muscle. Clients who administer frequent subcutaneous injections should rotate
sites regularly. An administration chart can help them keep track of the sites used..
Common sites for SC injections are the abdomen, the lateral and anterior aspects of the upper
arm or thigh, the scapular area on the back, and upper ventrodorsal gluteal areas (Figure 29-21).

The nurse should select a sterile 0.5-to 3-ml syringe with a 25- to 29-gauge, 3/8- to 1/2-
inch needle. The medication is administered by angling the needle 45° or 90° to the skin. The
client’s body weight will influence the angle used for injection. As a general rule, to reach
subcutaneous tissue, if you can grasp 2 inches of tissue between two fingers, insert the needle at
a 90° angle.
If only 1 inch of tissue can be grasped between the fingers, use a 45° angle to administer the
medication.

S.C. drugs can be injected into the fat pads on the abdomen, buttocks, upper back, and lateral
upper arms and thighs (shaded in the illustrations below). If your patient requires frequent S.C.
injections, make sure to rotate injection sites.
 Gently gather and elevate or spread S.C. tissue.
 IInsert the needle at a 45- or 90-degree angle, depending on the drug or the amount of
S.C. tissue at the site.
 WOUND DRESSING
Definition
Wound;An injury to living tissue caused by a cut, blow, or other impact, typically one in which
the skin is cut or broken.
Surgical or Wound dressing
Sterile dressing covering applied to a wound or incision using aseptic technique with or without
medication.
Purposes
 To promote wound granulation and healing
 To prevent undue contamination of wound
 To decrease purulent wound drainage (dressing material absorbs the drainage)
  To provide dry environment (moist environment facilities growth and multiplication of
micro-organisms)
 To immobilize and support the wound
 To apply medication to the wound
 To provide comfort
 To promote aesthetic sense
Major principles for wound dressing
1. Use Standard Precautions at all times.
2. When using a swab or gauze to cleanse a wound, work from the clean area out toward
the dirtier area. (Example: When cleaning a surgical incision, start over the incision line,
and swab downward from top to bottom). Change the swab and proceed again on
either side of the incision, using a new swab each time.
3. When irrigating a wound, warm the solution to room temperature, preferably to body
temperature, to prevent lowering of the tissue temperature. Be sure to allow the
irrigant to flow from the cleanest area to the contaminated area to avoid spreading
pathogens.
TYPES OF DRESSING
The types of dressing is as follows
 Transparent adhesive films
 Hydrocolloids
 Collagens
 Hydrogels
 Exudate absorbers
 Polyurethane foams
 Lubricating sprays of emollients
 Enzymatic debriders
 Nonadherent dressings
 Gauze dressings
Procedure
Preliminary Assessment
o Level of consciousness and understanding of the patient
o Vital signs
o Allergy to tape or cleaning solutions
o Bleeding tendencies
o Doctor’s order
o Bleeding or drainage from wound site
o Condition of the wound
Preparation of the patient and ward
o Ensure that sweeping and mopping of ward is completed
o Explain procedure to the patient
o All articles should be assemble at patient bed side
o Proper lighting of the ward
 o Switch off fan
o Provide privacy by using screens
o Check the agency protocol about using cleaning solutions
o Fix disposable plastic bags in holders on the trolley. Place within reach for
disposal of soiled dressing.
Articles required
1. Sterile dressing set containing the following
 Dressing cup (1)
 K-basin
 Artery clamp
 Non-toothed thumb forcep
 Cotton balls
 Gauze pieces
 Pads
Other articles
 Cleaning solution prescribed
 Sterile saline
 Prescribed solution for dressing wound
 Adhesive or non-allergic tape
 Scissors
 Sterile gloves (1 pair)
 Plastic bag for waste disposal
 Pad drum with sterile dressing pads and gauze pieces
 Towel or pad and mackintosh
 Kidney tray
 Sterile scissor (if needed)
 Cheatle forceps
 Ether
Procedure of wound/surgical dressing
 Position the patient comfortably
 Expose the dressing site
 Instruct not to touch wound, equipment or dressing
 Wash hands
 Open dressing pack
 Transfer extra cotton balls and gauze pieces into the dressing pack if the
wound is large
 Pour cleaning solution into the dressing cup
 Cover the pack without contaminating the inner layer
 Place dressing mackintosh and towel under the part and place clean K-
basin over mackintosh
 Remove outer dressing
 Use ether to remove adherent adhesive
 Leave the inner dressing if it does not come out with outer dressing
  If wound drain is present, remove one layer at a time
 Do surgical hand washing
 Wear gloves if the wound is contaminated
 Flip open the dressing pack cover by inserting fingers in the inner layer of
the wrapper
 Using thump forceps, pick up cotton ball and wet it in saline
 Using artery clamp and thump forceps, soak adherent gauze squeezing
the cotton ball over the gauze
 Using the same artery clamp, remove the gauze and dispose in the plastic
bag
 Discard the artery clamp
 Observe the character and amount of drain and assess the condition of
the wound
 Use only thump forceps to pick up cotton balls
 Pick up cotton balls every time using only the thump forceps and soak in
cleaning solution
 Squeeze out excess solution from the cotton balls into the kidney basin
(sterile)
 Clean the wound (clean to dirty) with firm stroke using the artery clamp
 Discard used cotton balls into the clean K-basin
 Use only one cotton ball for each stroke
 Ensure wound is thoroughly cleaned
 Finally, clean the skin in proximity to the wound edge, with strokes away
from the wound
 Soak gauze piece in the dressing solution, squeeze out excess solution,
spread it keeping it over the sterile field
 Apply over the wound, fully covering the wound with medicated gauze
pieces
 Apply dry gauze pieces over the medicated gauze pieces
 Apply pad if the wound is large or lot of exudates is present in the wound
 Discard gloves if used
 Discard the used artery clamp and thump forceps into the clean K-basin
 Secure dressing with adhesive/bandage
After care of patient and articles
o Make the patient comfortable
o Replace equipments
o Discard the disposable items
o Wash hands
o Document the type of dressing, condition of the wound, type of exudate and
patient’s response
o Report is any abnormality is observed

Drain Management and Removal

Drains systems are a common feature of post-operative surgical management and are used to
remove drainage from a wound bed to prevent infection and the delay of wound healing. A
drain may be superficial to the skin or deep in an organ, duct, or a cavity such as a hematoma.
The number of drains depends on the extent and type of surgery. A closed system uses a
vacuum system to withdraw fluids and collects the drainage into a reservoir. Closed systems
must be emptied and measured at least once every shift and cleaned using sterile technique
according to agency protocol.

Drainage tubes consist of silastic tubes with perforations to allow fluid to drain from the
surgical wound site, or separate puncture holes close to the surgical area. The drainage is
collected in a closed sterile collection system/reservoir or an open system that deposits the
drainage on a sterile dressing. Drainage may vary depending on location and type of surgery. A
Hemovac drain (see Figure 4.3) can hold up to 500 ml of drainage. A Jackson-Pratt (JP) drain
(see Figure 4.4) is usually used for smaller amounts of drainage (25 to 50 ml). Drains are usually
sutured to the skin to prevent accidental removal. The drainage site is covered with a sterile
dressing and should be checked periodically to ensure the drain is functioning effectively and
that no leaking is occurring.

 Perform hand hygiene.

 -Check room for additional precautions.
 Introduce yourself to patient.
 Confirm patient ID using two patient identifiers (e.g., name and date of birth).
 Explain process to patient and offer analgesia, bathroom etc.
 Listen and attend to patient cues
 Ensure patient’s privacy and dignity.

Steps

Additional Information

1. Perform hand hygiene. Hand hygiene reduces the risk of infection.

2. Collect the necessary supplies. For example: drainage measurement container, non-sterile
gloves, waterproof pad, and alcohol swab

3. Apply non-sterile gloves and goggles or face shield according to agency protocols.

Personal protective equipment reduces the transmission of microorganisms and protects

against an accidental body fluid exposure.
4. Maintaining sterile technique, remove plug from pouring spout as indicated on drain. Open
plug pointing away from your face to avoid an accidental splash of contaminated fluid.Maintain
the plug’s sterility

The vacuum will be broken and the reservoir (drainage collection system) will expand.Open
drain with opening facing away from you

5. Gently tilt the opening of the reservoir toward the measuring container and pour out the
drainage. Pour away from yourself to prevent exposure to body fluids.

6. Place drainage container on bed or hard surface, tilt away from your face, and compress the
drain to flatten it with one hand.With the other hand, swab the surface of the port, then insert
the plug to close the drainage system.Gently squeezing the drain to flatten and remove all the
air prior to closing the spout will establish the vacuum system.

Expel air from JP drain and flatten it before closing

Expel air from Hemovac drain and flatten it before closing

7. Place the plug back into the pour spout of the drainage system, maintaining sterility. This
establishes vacuum suction for drainage system.

8. Secure device onto patient’s gown using a safety pin; check patency and placement of tube.

Ensure that enough slack is present in tubing, and that reservoir hangs lower than the wound.

Proper placement of the reservoir allows gravity to facilitate wound drainage. Providing enough
slack to accommodate patient movement prevents tension of the drainage system and pulling
on the tubing and insertion site.

9. Note character of drainage: colour, consistency, odour, amount.

Discard drainage according to agency policy.

Drainage counts as patient fluid output and must be documented on patient chart as per
hospital protocol.

Monitor drains frequently in the post-operative period to reduce the weight of the reservoir
and to monitor drainage.

10. Remove gloves and perform hand hygiene.

Hand hygiene must be performed after removing gloves. Gloves are not puncture-proof or leak-
proof, and hands may become contaminated when gloves are removed.
Remove gloves

Hand hygiene with disinfectant

11. Document procedure and findings according to agency policy.

Report any unusual findings or concerns to the appropriate health care professional.

This allows for an accurate recording of drainage.

Record the number the drains if there is more than one, and record each one separately.

If the amount of drainage increases or changes, notify the appropriate health care provider
according to agency policy.

If amount of drainage significantly decreases, the drain may be ready to be assessed and
removed.

Drain Removal

Removal of a drain must be ordered by the physician or NP. A drain is usually in place for 24 to
48 hours, and removal depends on the amount of drainage over the last 24 hours.

Steps for removing a wound drainage system

Always review and follow your hospital policy regarding this specific skill.

Safety considerations:

Perform hand hygiene.

Check room for additional precautions.

Introduce yourself to patient.

Confirm patient ID using two patient identifiers (e.g., name and date of birth).

Explain process to patient and offer analgesia, bathroom, etc.

Listen and attend to patient cues.

Ensure patient’s privacy and dignity.

Assess ABCCS/suction/oxygen/safety.
Additional Information

1. Confirm that the physician order correlates with amount of drainage in the past 24 hours.
Physicians should specify an amount for acceptable drainage for the drain to be removed.

2. Explain procedure to patient; offer analgesia and bathroom as required.

Taking this step decrease the patient’s anxiety about the procedure. Explain to the patient that
a pulling sensation may be felt but will stop after the procedure is complete.

Analgesia provides comfort and achieves the goal of an acceptable pain level for the procedure.

3. Assemble supplies at patient’s bedside: dressing tray, sterile suture scissors or a sterile blade,
cleansing solution, extra gauze, tape, garbage bag. Organizing supplies helps the procedure
occur as efficiently as possible for the patient.

4. Apply a waterproof drape/pad for depositing the drain once it has been removed. This
provides a place to put the drain once it is removed.

5. Perform hand hygiene.

Hand hygiene reduces the risk of infection.

Hand hygiene with disinfectant

6. Apply non-sterile gloves and face shield according to agency policy.

Personal protective equipment reduces the potential for accidental exposure to blood or body
fluids.

Apply non-sterile gloves

7. Release suction on reservoir and empty; measure and record drainage if >10 ml.

Releasing suction reduces potential for tissue damage as drain is removed.

Release suction cap

8. Remove tape and dressing from drain insertion site. Remove tape to allow for ease of
drain removal.

9. Cleanse site according to simple dressing change procedure.

This step prevents infection of the site and allows the suture to be easily seen for removal.

Cleanse drain site

10. Carefully cut and remove suture anchoring drain with sterile suture scissors or a sterile
blade.

Wound drain may be attached to the skin with one suture to keep it in place

Snip beneath the suture knot

Snip beneath the suture knot to ensure contaminated suture is not brought into the tissue. Pull
suture out. Snip or cut knot away from yourself.

11. Stabilize skin with non-dominant hand. Applying counter pressure to skin near the drain
decreases discomfort to patient.

12. Ask patient to take a deep breath and exhale slowly; remove the drain as the patient
exhales. This step helps the patient prepare for removal of the drain.

13. Firmly grasp drainage tube close to skin with dominant hand, and with a swift and steady
motion withdraw the drain and place it on the waterproof drape/pad (other hand should
stabilize skin with 4 x 4 sterile gauze around drain site).

Slight resistance may be felt.

If there is strong resistance, stop, cover site, and call physician.

Ensure the drainage tip is intact. The end of the drainage tip should be smooth. Some agencies
require that the tip be sent for lab analysis for microorganisms.

When pulling out drain, gather up the drain tubing in your hand as its being removed.

Gather drain tubing in your hand as its being removed

Gather drain tubing in your hand as its being removed

14. Place drain and tube on waterproof pad or in garbage bag to be disposed of after procedure
is complete. This step prevents the drain and tube from contaminating bed or floor.

15. Remove gloves and apply new non-sterile gloves.

This prevents contamination of the drain site.

Remove gloves

Apply new non-sterile gloves

16. Cleanse old drain site using aseptic technique according to simple dressing change
procedure. This step prevents contamination of the drain site.

17. Cover drain site with sterile dressing.

Cover drain site with sterile dressing

Cover drain site with sterile dressing

18 Assist patient back to comfortable position and lower bed. This ensures patient safety and
comfort after the procedure.

19. Discard drain in biohazard waste as per hospital policy. This prevents the spread of
microorganisms.

20. Perform hand hygiene.

Hand hygiene prevents the spread of infection.

Perform hand hygiene

Perform hand hygiene

21. Document output and drain removal. Record drainage according to agency policy.

22. Assess dressing 30 minutes after drain removal.

Monitor for excessive drainage from the drainage site.

Assess dressing 30 minutes post-drain removal

Assess dressing 30 minutes after drain removal

23. Document

BANDAGING
Definition of bandage
A strip of fabric used especially to cover, dress, and bind up wounds

A flexible strip or band used to cover, strengthen, or compress something

INDICATION FOR BANDAGING

You can use a bandage to hold a dressing in place,
To control bleeding,
To support a limb and stop it from moving.
To raise an injured limb
To reduce swelling.
There are two main types of bandage:
• Roller bandages: use these to hold dressings in place and to support injured limbs, particularly
for ankles, knees, wrists or elbows.
• Triangular bandages: use these as large dressings, as slings to support a wrist, arm or shoulder
injury, or folded as a broad-fold bandage to stop a limb from moving.
If you can’t find a bandage, then you can always improvise by using a piece of clothing or
material. For example, you could fold a headscarf diagonally in half to make a triangular
bandage for a sling.
How to put on a bandage:
If someone’s hurt themselves and you need to apply a bandage, below are the key things to
remember.
• Reassure them and explain what you’re going to do before you start.
• Make them comfortable by helping them sit or lie down in a comfortable position.
• Support the injury by holding the limb carefully, or ask them or someone else to help.
• Start bandaging from the front and from the side of the body or limb that’s injured.
• Apply bandages firmly but not so tightly that it restricts their circulation.
• Generally, wrap the bandage using spiral turns working from the inside to the outside of the
limb
 For joint injuries, make diagonal turns in a figure-of-eight above and below the joint. See below
for specific techniques.
• To immobilise a limb, make a broad-fold bandage: lay a triangular bandage flat on a clean
surface, fold it in half horizontally so the point touches the base, and then fold it in half again.
• Leave fingers and toes peeking out, if possible, so you can press them to check circulation
afterwards.
• Use pins or tape to fasten roller bandages, otherwise, tuck the bandage in as securely as you
can.
• Use reef knots to tie triangular bandages: right over left and under, then left over right and
under.
• Check their circulation: Once you’ve finished, check for circulation, by pressing one of their
finger or toe nails for five seconds until it goes pale. If the colour doesn’t come back within two
seconds, the bandage is too tight so you’ll need to loosen it and do it again. Check their
circulation every ten minutes.
GENERAL FUNCTIONS OF BANBAGING
• Aid in wound healing
• Prevent open wound contamination
Wound debridement
• Maintain moist wound environment
• Support or protect deeper body parts
Pressure
Prevent/reduce swelling or hemorrhage
Prevent weight bearing
Immobilization of tissues
Often serve multiple functions
Monitor for swelling proximal and distal Monitor for foul smelling odor.
BANDAGE CARE
Close observation and care is critical
• Change as often as necessary
• Keep clean and dry
• Cover with plastic when outside/Remove plastic inside
• Monitor for swelling proximal and distal
• Monitor for foul odor • Licking and chewing can indicate a problem
COMPLICATIONS OF Bandaging
Ineffective treatment
• Vascular compromise
• Dermatitis
• Skin and soft tissue necrosis
• Loss of range of motion
CONTRAINDICATIONS
Decompensated cardiac failure
Massive edema of legs and arms due to congestive heart failure
Known or suspected deep vein thrombosis or thrombophlebitis
Any instances where increased venous and lymphatic return is undesirable
CAUTIONS
 Cellulitis
 Acute Infection
 Active Cancer
 Renal Failure
 Heart Conditions
 Extremity Is Not Sensitive To Pain
 BLOOD TRANSFUSION
DEFINITION
A blood transfusion involves taking blood from one person (a donor) and giving it to another (a
recipient) to replace blood lost in major accidents, or during life-saving operations. In order to
make safe blood transfusions it is important to know to what blood type the patient belong to.
Mixing incompatible blood types could be dangerous and lethal. Early blood transfusions
consisted of whole blood, but modern medical practice commonly uses only components of the
blood, such as red blood cells or plasma. If you have lost blood due to an injury or surgery red
blood cells are the most commonly transfused part of the blood. Red blood cells are also used for
transfusion if you have anemia

INDICATIONS OF BLOOD TRANSFUSION

 Anaemia
 Major Surgical Operation
 Accidents resulting in considerable blood loss
 Cancer patients requiring therapy
 Women in childbirth and newborn babies in certain cases
 Patients of hereditary disorders like Haemophilia and
Thalassaemia
 Severe burn victims.
Components
Whole blood
Red blood cells
White blood cells
Plasma
platelets

Compatible blood
For a blood transfusion to be successful, AB0 and Rh blood groups must be compatible between
the donor blood and the patient blood. You primarily try to give the same blood type as the
patient herself/himself has got. However, some blood types could be rare in different parts of the
world or hospitals might be out of stock with a particular blood type. Therefore you need to
know which blood types are “compatible”, that is which other blood types fit a patient with a
certain blood type.For example, a person with blood type B Rh- has got A and Rh antibodies and
cannot receive a blood transfusion with red blood cells which have A and Rh antigens like A
Rh+ or AB Rh+.
Who can receive blood from whom?
People can happily receive blood from the same blood type as their own, but they have
antibodies against any antigens not found on their own red blood cells. Look at the "Compatible
blood chart" below!
Four blood group type exist; A, B, AB, and O.
ABO blood system
O can only receive blood from: O
A can receive blood from: A and O
B can receive blood from: B and O
AB can receive blood from: AB, A, B and O
Rh stands for rhesus factor which is a protein antigen.those whose red blood cells have it are Rh+
and those whose red blood cells donot have it are Rh-
Rh blood system
Rh+ can receive blood from: Rh+ and Rh-
Rh- can receive blood from: Rh-

This "Compatible blood chart" refers to blood transfusions with red blood cells.
People with O Rh- blood can only receive O Rh- blood.
People with O Rh+ can receive both O Rh+ and O Rh- blood.
People with blood type AB Rh+ can recieve blood from all blood types and therefore are called
Universal receivers.
Can receive red
Can donate red
Blood Type Antigens Antibodies blood cells in a
blood cells to
transfusion from

AB Rh+ A, B and Rh None AB Rh+ AB Rh+

AB Rh -
A Rh+
 A Rh -
B Rh+
B Rh -
O Rh+
O Rh -

AB Rh - A and B None AB Rh - AB Rh -
AB Rh+ A Rh -
B Rh -
O Rh -
A Rh+ A and Rh B A Rh+ A Rh+
AB Rh+ A Rh -
O Rh+
O Rh -

A Rh - A B A Rh - A Rh -
A Rh+ O Rh -
AB Rh -
AB Rh+

B Rh+ B and Rh A B Rh+ B Rh+

AB Rh+ B Rh -
O Rh+
O Rh-

B Rh - B A B Rh- B Rh -
B Rh+ O Rh -
AB Rh-
AB Rh+

O Rh+ Rh A and B O Rh+ O Rh+

A Rh+ O Rh -
B Rh+
AB Rh+
O Rh - None A and B AB Rh+ O Rh -
AB Rh -
A Rh+
A Rh -
B Rh+
B Rh -
0 Rh+
0 Rh -

 Blood donors must be at least 17-18 years old in most countries.

The fact that people with Rh- blood do not naturally have Rh antibodies in their blood plasma (as
one can have A or B antibodies, for instance) is not taken into consideration in this game. In
reality a person with Rh- blood can develop Rh antibodies in the blood plasma if he or she
receives blood from a person with Rh+ blood. The received blood cells with Rh antigens can
trigger the production of Rh antibodies in an individual with Rh- blood. In the game one has to
pretend that all patients with Rh- blood type has received Rh+ blood in previous blood
transfusions.
Also, the antibodies are here referred to as A antibodies, B antibodies and Rh antibodies. These
are also commonly referred to as anti A antibodies, anti B antibodies, and anti Rh antibodies.
NOTE: A person with blood type O Rh- blood is considered to be a "universal donor", which
means that any person, regardless what blood type you belong to, could receive O Rh- blood in a
transfusion, for instance in an emergency situation when there is no time for blood typing.
Recent research indicates that this may no longer be totally accurate, because of a better
understanding of the complex issues of immune reactions related to incompatible donor blood
cells.
What if there is no time for blood typing?
In emergencies, there are exceptions to the rule that the donor's blood type must match the
recipient's exactly. Blood type O Rh- is the only type of blood that people of all other blood
types can receive, so it is used in situations when patients need a transfusion but their blood type
is unknown. People with blood type O Rh- are called Universal donors.
What happens if you get the wrong blood in a transfusion?
Immunological reactions occur when the receiver of a blood transfusion has antibodies that work
against the donor blood cells. Then the red blood cells from the donated blood will clump, or
agglutinate. The agglutinated red cells can clog blood vessels and stop the circulation of the
blood to various parts of the body. The agglutinated red blood cells can also crack open, leaking
toxic contents out in the body, which can have fatal consequences for the patient.

What happens when blood clumps or agglutinates?

If the blood is not compatible in a blood transfusion,then the red blood cells from the donated
blood will clump or agglutinate. The agglutinated red cells can clog blood vessels and stop the
circulation of the blood to various parts of the body. The agglutinated red blood cells may also
crack and their contents leak out in the body. The red blood cells contain hemoglobin which
becomes toxic when outside the cell. This can have fatal consequences for the patient.
The antibodies' task is to act against foreign substances in the body. To a person with B blood the
A antigens is considered foreign. The A antigen and the A antibodies can bind to each other in
the same way that the B antigens can bind to the B antibodies. This is what would happen if, for
instance, a B blood person receives blood from an A blood person. The red blood cells will be
linked together, like bunches of grapes, by the antibodies. As mentioned earlier, this clumping
could lead to death.
TRANSFUSION PROCEDURES

Personnel who participate in the administration of blood

components must be trained in transfusion procedures and in
recognition and management of adverse reactions.

REQUIREMENTS FOR BLOOD TRANSFUSION

Transfusion set which consist of a tube filter and chamber

Normal saline solution

Blood in a bag

Iv stand pole

Sterile disposable gloves

Cannular

Intravenous Solutions
o Only isotonic saline (0.9%) is recommended for use
with blood components.
o Prior to blood transfusion, completely flush
incompatible intravenous solutions and drugs from
the blood administration set with isotonic saline.
Blood Warmers
Blood warmers are available from the operating rooms.

Blood warmers may be used as long as the device has a

temperature alarm and visible temperature monitor. Blood
warming devices are most appropriate for massive and rapid blood
replacement, such as exchange transfusion of the newborn.

Patient Instructions and Preparation

Blood Bank personnel will notify patient unit personnel by
telephone when ordered blood is ready for transfusion.

Informed Consent

o Informed consent for blood transfusion is a process

in which the patient is informed of the medical
indications for the transfusion, the possible risks, the
possible benefits, the alternatives, and the possible
consequences of not receiving the transfusion.
o Informed consent may be obtained by a physician, a
nurse, or a physician extender who is knowledgeable
about blood transfusion and the patient’s condition
so as to be able to explain the elements of informed
consent above.
o The risks of transfusion, including adverse symptoms
and alternatives to homologous (allogeneic)
transfusion, must be discussed with the patient well
before the transfusion. The booklet, "Blood
Transfusion, Your Options" describing transfusion
options are available from Moore. This booklet
should be provided to patients as early as possible
before transfusion.
o The patient is then given a choice to accept or
decline transfusion. Consent should be obtained
sufficiently in advance of the transfusion that the
patient can truly understand what is said and have
sufficient time to make a choice.
o Consent should be documented in the medical chart
using the form "Consent to Receive Blood
Transfusion" (available on-line or from Moore).
o A single informed consent may cover many
transfusions if they are part of a single course of
treatment.
o It may be advisable, though, to obtain a new consent
when there is a significant change in the patient's
care status, such as a transfer for care to another
service, an inpatient admission, or an outpatient
transfusion.
o In emergency situations the physician ordering the
transfusion must make a reasonable judgement that
the patient would accept the transfusion.
Transfusion should not be delayed in a life-
threatening situation if it is likely that the patient
 would agree to transfusion. After the event, the
circumstances of the transfusion decision should be
documented in the medical chart.
Post Transfusion Instructions to the Patient
o Outpatients or patients who will be leaving the
hospital within one week of transfusion should be
given written instructions regarding delayed
transfusion reactions.
o The patient handout "Post-Transfusion Instructions
for the Patient" may be used for this purpose.
o Copies of this form are available from Moore order
number 2201460.
Release and Transport of Blood Components
To reduce the potential for waste of the component, do the
following before requesting that a blood component be issued from
the Blood Bank:

1 verify the physician's order for the product, volume and transfusion rate

2 administer any pretransfusion medication

3 record the patient's vital signs

4 initiate or verify patency of an intravenous line

5 blood component ordered
6 number of units required
 

Receipt of Blood Components

The person receiving the blood being transported or opening the
tube at the receiving location must immediately upon receipt

Step Action

1 Verify
 Product is designated for a patient at the receiving location
 Name and CPI number recorded on the Transfusion Record Form
attached to the unit correspond with that of the intended recipient
 Unit has a normal appearance.

2 The person receiving the blood component should:

  the Transfusion Record Form and
 the patients attached positive patient identifier.
Two qualified individuals must
These steps must never be bypassed.

1 Ask the patient to state his or her name. Verify patient and component
identification information.

2 Verify the blood type, donor number, component name

3 Verify compatibility: a compatibility chart is on the back inside cover of

this booklet.

4. Verify the product is not outdated

5. Sign the Transfusion Record Form before blood transfusion is initiated.

6. The person who hangs the blood must record the date and time the
transfusion was started

7. Record the date, time, component and unit number on the appropriate
sheet on the patient's chart. Refer to unit policy and procedures.
DO NOT START the transfusion if there is any discrepancy.

Contact the Blood Bank.

Initiating the Transfusion

o Immediately before transfusion, mix the unit of

blood thoroughly by gentle inversion.
o Follow the manufacturer's instruction for the use of
special filters and ancillary devices. Additional
administration instructions for selected components
are printed at the end of this chapter and are
available upon request from the Blood Bank.
o If any part of the unit is transfused, the unit is
considered transfused.
Flow Rates

Initial Flow Rate Slowly at no more 1 mL/minute to allow for

recognition of an acute adverse reaction.
Proportionately smaller volume for pediatric
patients.

Standard Flow Rate - Adults If no reaction occurs in the first 15 minutes,

the rate may be increased to 4 mL/minute
Signs of blood reaction

Back pain

Dark urine

Chills

Fainting or dizziness

Fever

Flank pain(discomfort in the part of the body below the ribs and
above the illium)

Skin flushing (a feeling of warmth and rapid reddening of your

neck,upper chest or ficial region).

Shortness of breath

If a Transfusion Reaction is Suspected

o Stop the transfusion

o Maintain the IV.
o Save the bag and attached tubing
Causion to Medications

o Do not add medications directly to a unit of blood

during transfusion.
o Medications that can be administered "IV Push" may
be administered by stopping the transfusion, clearing
the line at the medication injection site with 5-10 mL
of normal saline, administering the medication,
reflushing the line with saline and restarting the
transfusion.
At the Termination of an Uncomplicated Transfusion

After the completion of each uncomplicated transfusion, the

responsible physician or nurse should verify that the "Transfusers
Must Complete" section of the Transfusion Record Form

is complete, including

 date and time transfusion was stopped

 volume of blood infused
  Check the box documenting the
presence/absence of a transfusion reaction.
Discontinue the isotonic saline solution used to initiate the
transfusion after the completion of the transfusion unless
specifically ordered.
Document the patient's response to the transfusion in the patient's
medical record.

Disposal of Blood Bags If No Reaction is Suspected

Discard empty blood bags with attached blood infusion sets on the
patient unit in a biohazard waste container such as a red bag.

Compatible IV Isotonic (0.9%) saline is the only solution compatible with stem cell
solution products

Infusion Administer through a central venous catheter. Use a standard 170 to 210
equipment micron filter. Do not administer through a microaggregate filter.

Documentation Vital signs must be documented after the first 15 minutes of the infusion, at
of Vital Signs half hour intervals during an allogeneic infusion, every 15 minutes during
an autologous infusion and then every 30 minutes for one-hour post
infusion.

LUMBA PUNCTURE
Definition

It is the introduction of a needle in the spinal cord to obtain

cerebrospinal fluid for diagnosis and therapeutic purposes.

Indications 
LP is essential or extremely useful in the diagnosis of bacterial,
fungal, mycobacterial, and viral CNS infections and, in certain
settings, for help in the diagnosis of subarachnoid hemorrhage, CNS
malignancies, demyelinating diseases, and Guillain-Barré syndrome.
Urgent — The number of definite indications for LP has decreased
with the advent of better neuroimaging procedures including CT
scans and MRI, but urgent LP is still indicated to diagnose two
serious conditions :
●Suspected CNS infection (with the exception of brain abscess or a
parameningeal process).
●Suspected subarachnoid hemorrhage (SAH) in a patient with a
negative CT scan.
The most common use of the LP is to diagnose or exclude
meningitis in patients presenting with some combination of fever,
altered mental status, headache, or meningeal signs. Examination of
the CSF has a high sensitivity and specificity for determining the
presence of bacterial and fungal meningitis.
The findings on CSF analysis also may help distinguish bacterial
meningitis from viral infections of the central nervous system.
However, there is often substantial overlap.
Nonurgent — A nonurgent LP is indicated in the diagnosis of the
following conditions.
●Idiopathic intracranial hypertension (pseudotumor cerebri)
●Carcinomatous meningitis
●Tuberculous meningitis
●Normal pressure hydrocephalus
●CNS syphilis
●CNS vasculitis
Conditions in which LP is rarely diagnostic but still useful include:
●Multiple sclerosis
●Guillain-Barré syndrome
●Paraneoplastic syndromes
LP is also required as a therapeutic or diagnostic maneuver in the
following situations
●Spinal anesthesia
●Intrathecal administration of chemotherapy
●Intrathecal administration of antibiotics
●Injection of contrast media for myelography or for cisternography
- to relieve increased intracranial pressure
Technique
 Place the patient in the lateral recumbent or prone positions or
sitting upright. The lateral recumbent or prone positions are
preferred over the upright position because they allow more accurate
measurement of the opening pressure.
Identify the highest points of the iliac crests by palpation a direct
line joining these is a guide to the fourth lumbar vertebral body. The
lumbar spinous processes of L3, L4, and L5, and the interspaces
between can usually be directly identified by palpation. The spinal
needle can be safely inserted into the subarachnoid space at the L3/4
or L4/5 interspace, since this is well below the termination of the
spinal cord.
.Clean the overlying skin with alcohol and a disinfectant such as
povidone-iodine or chlorhexidine (0.5 percent in alcohol 70 percent);
the antiseptic should be allowed to dry before the procedure is
begun.
After the skin is cleaned and allowed to dry, a sterile drape with an
opening over the lumbar spine is placed on the patient.
Use the appropriate needle size to avoid the risk of a post-LP
headache, and to avoid increase technical difficulty of the procedure.
Local anesthesia (eg, lidocaine) is infiltrated into the previously
identified lumbar intervertebral space and a 20 or 22 gauge spinal
needle containing a stylet is inserted into the lumbar intervertebral
space.    
Advance the spinal needle slowly, angling slightly toward the head,
as if aiming towards the umbilicus.
Once CSF appears and begins to flow through the needle, the patient
should be instructed to slowly straighten or extend the legs to allow
free flow of CSF within the subarachnoid space.
Fluid is then collected in sterile plastic tubes. A total of 8 to 15 mL
of CSF is typically removed during routine LP. However, when
special studies are required, such as cytology or cultures for
organisms that grow less readily (eg, fungi or mycobacteria), 40 mL
of fluid can safely be removed.
Aspiration of CSF should not be attempted as it may increase the
risk of bleeding.
The stylet should be replaced before the spinal needle is removed, as
this can reduce the risk of post-lumbar puncture headache.
Contraindications
Although there are no absolute contraindications to performing the
procedure, caution should be used in patients with:
●Possible raised intracranial pressure
●Thrombocytopenia or other bleeding diathesis (including ongoing
anticoagulant therapy)
●Suspected spinal epidural abscess

omplicationsC
 LP is a relatively safe procedure, but minor and major
complications can occur even when standard infection control
measures and good technique are used. These complications include:
●Post-LP headache
●Infection
●Bleeding
●Cerebral herniation
●Minor neurologic symptoms such as radicular pain or numbness
●Late onset of epidermoid tumors of the thecal sac
●Back pain
Post LP headache — Post-LP headache is caused by leakage of CSF
from the dura and traction on pain-sensitive structures. Patients
characteristically present with frontal or occipital headache within
24 to 48 hours of the procedure, which is exacerbated in an upright
position and improved in the supine position. Associated symptoms
may include nausea, vomiting, dizziness, tinnitus, and visual
changes.
Infection
Meningitis — Meningitis is an uncommon complication of LP. In a
review of 179 cases of post-LP meningitis reported in the medical
literature between 1952 and 2005, half of all cases occurred after
spinal anesthesia;
While some cases of post-LP meningitis due to staphylococci,
pseudomonas, and other gram-negative bacilli have been attributed
to contaminated instruments or solutions or poor technique, other
studies have suggested that post-LP meningitis could arise from
aerosolized oropharyngeal secretions from personnel present during
the procedure especially since many of the causative organisms are
found in the mouth and upper airway.
Based upon these observations, some authors have recommended the
routine use of face masks during LP and neuroradiologic imaging
procedures involving LP.
An LP through a spinal epidural abscess can result in the spread of
bacteria into the subarachnoid space.
Bleeding — The CSF is normally acellular, although up to five red
blood cells (RBCs) are considered normal after LP due to incidental
trauma to a capillary or venule. A higher number of RBCs is seen in
some patients in whom calculation of the white blood cell (WBC) to
RBC ratio and the presence or absence of xanthochromia may
differentiate LP-induced from true CNS bleeding.
Cerebral herniation — The most serious complication of LP is
cerebral herniation. Suspected increased intracranial pressure (ICP)
is a relative contraindication to performance of an LP and also
requires independent assessment and treatment.
A 1969 study of 30 patients with increased ICP who deteriorated
after LP attempted to identify the clinical features of patients who
were at greatest risk for this complication. The following findings
were noted: 73 percent had focal findings on neurologic examination
(including dysphagia, hemiparesis, and cranial nerve palsies); 30
percent had documented papilledema prior to the LP; and 30 percent
had evidence of increased ICP on plain skull films (erosion of the
posterior clinoid processes). Deterioration occurred immediately in
one-half of the patients, with the remainder declining within 12
hours.
The concern about this serious complication has resulted in routine
CT scanning prior to LP being the standard of care in many
emergency departments. At one institution, for example, 78 percent
of patients with suspected meningitis underwent CT scanning before
the LP was performed. However, this practice, when applied to
patients with suspected bacterial meningitis, delays the performance
of LP, which in turn may delay treatment or limit the diagnostic
power of CSF analysis when performed after antibiotic
administration. Moreover, CT scanning is not necessary in all
patients prior to LP and may not be adequate to exclude elevated
ICP in others. Some studies suggest that high-risk patients can be
identified, allowing the majority of patients to safely undergo LP
without screening CT. This was best illustrated in a prospective
study of 301 adults with suspected meningitis. The following
findings were noted:
●Among the 235 (78 percent) who underwent CT scan before LP, 24
percent had an abnormal finding but only 5 percent (11 patients) had
a mass effect.
●The risk of an abnormal CT scan was associated with specific
clinical features (presence of
Epidermoid tumor — The formation of an epidermoid spinal cord
tumor is a rare complication of LP that may become evident years
after the procedure is performed. Most reported Abducens
palsy — Both unilateral and bilateral abducens palsy are reported
complications of LP. This is believed to result from intracranial
hypotension and is generally accompanied by other clinical features
of post LP headache. Most patients recover completely within days
to weeks. Other cranial nerve palsies are rarely reported.
Radicular symptoms and low back pain — It is not uncommon (13
percent in one series) for patients to experience transient electrical-
type pain in one leg during the procedure. However, more sustained
radicular symptoms or radicular injury appear to be rare.
Up to one-third of patients complain of localized back pain after LP;
this may persist for several days, but rarely beyond.
SUMMARY AND RECOMMENDATIONS —
 Lumbar puncture (LP) is essential or extremely useful in the
diagnosis of bacterial, fungal, mycobacterial, and viral CNS
infections and, in certain settings, for help in the diagnosis of
subarachnoid hemorrhage, CNS malignancies, demyelinating
diseases, and Guillain-Barré syndrome.
●LP is a relatively safe procedure, but minor and major
complications can occur, including headache, infection, bleeding,
cerebral herniation, as well as minor neurologic symptoms such as
radicular pain or numbness.
●Meningitis is a relatively rare complication of LP.
•LP is contraindicated in patients with a suspected spinal epidural
abscess.
•Suspected bacteremia is NOT a contraindication to LP.
•We suggest the use of a face mask for diagnostic LP if the
procedure is expected to be prolonged or difficult or if the operator
has an upper respiratory tract infection.
●Bleeding in the epidural or subdural space following LP may occur
in up to 2 percent of patients, primarily in those patients with
thrombocytopenia or other bleeding disorders or in those who have
received anticoagulant therapy.

   

L3-L4 interspace palpation. Image

courtesy of Gil Z Shlamovitz, MD.

Open the spinal tray, change to sterile gloves, and prepare the equipment. Open the numbered
plastic tubes, and place them upright (see the image below). Assemble the stopcock on the
manometer, and draw the lidocaine into the 10-mL syringe.
Use the skin swabs and antiseptic solution to clean the skin in a circular fashion, starting at the
L3-L4 interspace and moving outward to include at least 1 interspace above and 1 below. Just
before applying the skin swabs, warn the patient that the solution is very cold; application of an
unexpectedly cold solution can be unnerving for the patient.

Place a sterile drape below the patient and a fenestrated drape on the patient. Most spinal trays
contain fenestrated drapes with an adhesive tape that keeps the drape in place.
Use the 10-mL syringe to administer a local anesthetic.
Raise a skin wheal using the 25-gauge needle, then switch to the longer 20-gauge needle to
anesthetize the deeper tissue. Insert the needle all the way to the hub, aspirate to confirm that the
needle is not in a blood vessel, and then inject a small amount as the needle is withdrawn a few
centimeters. Continue this process above, below, and to the sides very slightly (using the same
puncture site).
This process anesthetizes the entire immediate area so that if redirection of the spinal needle is
necessary, the area will still be anesthetized. For this reason, a 10-mL syringe may be more
beneficial than the usual 3-mL syringe supplied with the standard lumbar puncture kit.
The 20-gauge needle can also be used as a guide for the general direction of the spinal needle. In
other words, the best direction in which to aim the spinal needle can be confirmed if the 20-
gauge needle encounters bone in one direction but not in another.
Next, stabilize the 20- or 22-gauge needle with the index fingers, and advance it through the skin
wheal using the thumbs.
Orient the bevel parallel to the longitudinal dural fibers to increase the chances that the needle
will separate the fibers rather than cut them; in the lateral recumbent position, the bevel should
face up, and in the sitting position, it should face to one side or the other.Insert the needle at a
slightly cephalad angle, directing it toward the umbilicus. Advance the needle slowly but
smoothly. Occasionally, a characteristic “pop” is felt when the needle penetrates the dura.
Otherwise, the stylet should be withdrawn after approximately 4-5 cm and observed for fluid
return. If no fluid is returned, replace the stylet, advance or withdraw the needle a few
millimeters, and recheck for fluid return. Continue this process until fluid is successfully
returned.
.