INJECTION TECHNIQUE

The term injection describes the giving of the medicine by means of a needle and syringe.

Injections are invasive, and strict aseptic technique is required during preparation and administration to
minimize the risk of infection.
Learning objectives
At the end of the session the student should be able to:

 Know the indications ,contraindications of the procedure

 Know the principles of drug administration in terms of right person ,right dose, right drug,right time,
right route and right documentation
 Check the safety of medication before administration
 Choose the appropriate size needle and syringe depending on the amount of the drug, age and built
of the person.
 Identify the different sites for giving an intramuscular,subcutaneous and intravenous
injection/venipuncture
 Know the complications that might be expected during the procedure and the immediate measures
that have to be taken for the same.
Indications for giving medication by injection

 Rapid action required

 Drug altered by intestinal secretions
 Drug not absorbed by alimentary tract
 Patient cannot take oral drug
 Drug unavailable in oral form
Key Checks before and after injecting
Prior to administering a drug by SC or IM route, there are common steps to observe.
Check prescription including allergies- Check for any allergies/history of anaphylaxis
Prepare medication as per prescription- Check expiry dates and record lot numbers
Ensure you have the right patient, right time, and right dose.
Obtain consent.
Ensure the patient is comfortable- Avoid over exposure of patient
Select site.
Following injection, observe site for at least 15 minutes, checking for swelling, discomfort or pain.

Involves “SIX (6) Rights” –PDDTRD

 Right patient
 Right drug
 Right dosage
 Right time
 Right route
 Right documentation
 The injectable medicine is available in 2 forms:

1. Ampoule
2. Vial

Needles & Syringes

Subcutaneous
 Only 1-2ml is injected via the subcutaneous route, so using a 5ml
syringe is usual. Needle choice is an orange (25 gauge). This is short,
and unlikely to penetrate the muscle layer. For insulin administration
, a special low dose, 1ml syringe is used for accurate drug
measurement.

Intramuscular
 Needles should be long enough to penetrate the muscle but still
allow a quarter of the needle to remain external to the skin. In an
adult, needle choice is usually a green (21 gauge) or blue (23
gauge). For children a blue is the obvious choice.

 The correct needle is the key to delivering the drug to the correct
area for the maximum effect with the least amount of discomfort.

 The colour at the top of the needle reflects its size

 The higher the number the smaller the lumen (bore)

 Orange needles = 25 gauge = 10mm long (3/8 inch)or 16mm

long(5/8 inch) or 25mm long (1 inch)

 Blue needles = 23 gauge = 25mm long 9 (1 inch)

 Green needles = 21 gauge = 38mm long (1.5 inches)

The Subcutaneous route

A subcutaneous injection is given in the fatty layer of tissue just under the skin.
These injections are given because there is little blood flow to fatty tissue, and the injected medication is
generally absorbed more slowly, sometimes over 24 hours. Some medications that can be injected
subcutaneously are growth hormone, insulin, epinephrine, anticoagulants and other substances. All these
medicines require a slow release.
The technique is relatively pain free, and sites are often suitable for frequent injections.
Suitable injection sites

Sites recommended for sub-cutaneous injection are the lateral

aspects of upper arm and thighs and the peri umbilical region of
the abdomen.
Upper arms are a favorable choice, and least likely to cause
discomfort to the patient.
Avoid areas of bruising, tenderness, hardness, infection or
inflammation.
The amount of subcutaneous tissue may vary at sites. In view of
this, care should be taken to ensure the muscular layer is not
penetrated, particularly when administering Insulin, as
inadvertent I/M injection can cause rapid absorption and
hypoglycemia.

Procedure
• Lift up a roll of skin.
• Insert needle at 90 ̊angle. Leave some of the shaft exposed. If you have very little fat on
your body, you may need to learn a different method at a 45-degree angle.
• Inject the medication with a slow steady pressure.
• Withdraw needle quickly whilst placing a gauze square over the site.
• Dispose of sharps immediately.
• Document procedure.
Complications of Subcutaneous Injection
-As with any injection procedure, infection at the site of injection is a possibility. Proper sterile technique
and rotating the site of injection around the body can help prevent bruising, irritation, and skin changes.
-If a patient has poor circulation, absorption from a subcutaneous injection can be slow.
Checklist for injection
 ‘Bunch up’ skin for SC injection
 Stretch skin for IM injection
 Angle needle at 90 ̊. Leave 1/3rd shaft exposed.
 For deep IM injection aspirate. If blood appears, withdraw needle, replace, and start
again.
 Do not aspirate if giving a pre-loaded vaccine IM. Check protocol for drug.
 Do not aspirate for SC injection.
 Depress plunger slowly for IM (1ml/10 seconds).
 Withdraw needle and use gauze to apply gentle pressure.
 Dispose of sharps in appropriate container.
 Document procedure
INTRAMUSCULAR INJECTION
It is one of the routes for drug administration, in which the medication is injected directly into a muscle. The
medication via this route is directly absorbed into the blood vessel supplying the muscle and distributed to
other parts of the body.
Contraindications

 Patients with impaired coagulation mechanisms, occlusive peripheral vascular disease.

 After thrombolytic therapy.
 During acute myocardial infarction and shock.
 Patients with known allergy.
 Infection and scar at the site of injection .
Involves “SIX (6) Rights” –PDDTRD

 Right patient
 Right drug
 Right dosage
 Right time
 Right route
 Right documentation
Right patient should be identified first before injecting the drug by verifying the patient’s full name and age
and examining the drug chart or prescription.
Right Drug by verifying the label of the ampoule or vial and noting the composition of each ml/cc of
medicine present .Expiry date of the medicine should be duly checked .Instructions for the routes of drug
administration on the sticker should be read and ensure that there are no sediments, crystals, or lumps or
any change in color of the solution in the vial or ampoule.
Right Dosage: Correct loading of the medicine in right amount
Right Route and Right site

The choice of site should take in to account the following factors:

 General physical condition of the patient,
 Age of the patient
 The amount of drug being delivered.
 Nature of medication ( certain drugs are very painful on injection)

In an IM injection the needle passes through various structures like the skin and the muscle and may
encounter some intervening structures like nerves and blood vessels and finally the bone .Care should
be taken to select a site where the encounter with these intervening structures is avoided.
The chosen site should be inspected for contraindications of inflammation, infection, or swelling. If the
patient is elderly frail with reduced muscle mass, ensure you ‘bunch up’ the muscle to ensure adequate
bulk before injecting.
Sites
There are 4 possible areas on each side of the body
 Upper arm -Deltoid muscle site
 Lateral thigh –Vastus Lateralis site
 Hip –Ventrogluteal site
 Hip –Dorsolateral site
The Intramuscular route – Deltoid site
The deltoid muscle- Used for vaccines such as tetanus toxoid and hepatitis B. The densest part of the muscle
can be found by identifying the acromial process and the point on the lateral arm in line with the axilla.

Deltoid site procedure

 Expose the entire
shoulder and arm
area.
 Ask the patient to Injection
relax, elbow site
flexed.
 Palpate the lower
edge of the
acromial process.
 Site the needle at 2.5cm below the acromial process.
 Stretch the skin at the site.
 Insert needle at 90 angle.
 Aspirate for a few seconds to ensure the needle is not sited
 in a blood vessel.

The Intramuscular route – The Dorsogluteal site

Using the gluteus maximus muscle, this has been a popular
and traditionally used site. It is still often seen used in wards,
but should be dropped in favor of ventrogluteal site, because
of complications associated with it, namely possible damage
to the sciatic nerve or the superior gluteal artery. If, for any
reason, you cannot use the ventrogluteal site, a good term to
remember for siting is to use the ‘upper outer quadrant of the
outer upper quadrant’ of the gluteus maximus.

The Dorsogluteal site procedure

 Draw an imaginary line between the superior iliac spine and
greater trochanter.
 Inject in the area above the imaginary line.
 Stretch the skin at the site.
 Insert needle at 90 ̊angle.
 Aspirate for a few seconds to ensure the needle is not sited in a blood vessel.
 Inject the medication with a slow steady pressure (1ml over 10 seconds).
 Withdraw needle quickly whilst placing a gauze square over the site
 Dispose of sharps immediately.

The Intramuscular route - Ventrogluteal site

This is a safer option which accesses the gluteus medius muscle. It avoids all major nerves and blood
vessels. The area also has the benefit of having a relatively consistent thickness of adipose tissue (3.75cm)
compared with 1-9cm on the dorsogluteal site. The patient can be prone, semi-prone or supine for using
this injection site.
 Ventrogluteal site procedure.

 Place palm of your right hand over the greater trochanter of the
patients left hip (or vice versa).
 Extend index finger to touch anterior superior iliac crest.
 Stretch middle finger to form a V. Thumb points towards the front of
leg.
 Needle should enter the V at 90 ̊. Leave 1/3rd of the shaft exposed.
 Aspirate for a few seconds to ensure the needle is not sited in a blood
vessel.
 Inject the medication with a slow steady pressure (1ml over 10 sec).
 Withdraw needle quickly whilst placing a gauze square over the site.
 Dispose of sharps immediately.
 Document procedure

The Intramuscular route-Vastus Lateralis site

This is a large muscle that is situated laterally to the femur.
The drug absorption rate is faster here than from the gluteus
maximus, but slower than the deltoid.
The site has traditionally been used for children, but research
indicates the ventrogluteal site to be a safer option. Risks
associated with incorrect siting are accidental damage to the
femoral nerve or muscle atrophy through overuse. Injection
site

Vastus Lateralis site procedure

• In adults measure a hands breadth laterally down from the
greater trochanter, and a hands breadth up from the knee.
• Identify the middle third of the quadriceps muscle as the injection site.
• Stretch the skin at the site.
• Inject the needle at 90 angle. Leave 1/3rd of the shaft exposed.
• Aspirate for a few seconds to ensure the needle is not sited in a blood vessel.
• Inject the medication with a slow steady pressure (1ml over 10 sec).
• Withdraw needle quickly whilst placing a gauze square over the site.
• Dispose the sharps immediately.
• Document procedure.
• For deep IM injections especially in sites other than the deltoid region, we would recommend aspiration
to ensure the needle tip is not placed in a blood vessel
Checklist for IM injection
• Wash hands, apply gloves for preparation of drug.
• Consult drug chart- right patient, right drug, right dose, right
date/time, right route.
• Check for allergies.
• Select appropriate syringe and needles.
• Prepare medication to correct dose.
• Explain procedure to patient and obtain consent.
• Assist patient to comfortable position.
• Select appropriate site-give rationale
• Clean site with 70% isopropyl alcohol swab if appropriate
Recommended medication volumes per muscle site

 Ventrogluteal Up to 4ml in a well-developed muscle

Up to 2ml in less developed muscle
 Vastus lateralis Up to 4ml in a well-developed muscle
Up to 2ml in less developed muscle
 Deltoid Up to 1ml in a well-developed muscle
Up to 0.5ml in less developed muscle

Factors that can cause pain are

• The needle
• The technique
• The speed of the injection
• The solution and composition of the drug
• The volume of the drug
• The approach and attitude of person administering the injection

COMPLICATIONS
 Infection
 Incorrect location of injectate
 Pain
 Anaphylaxis

Potential Complications
 Long and short term nerve damage
 Intramuscular hemorrhage
 Hitting a blood vessel
 Sterile abscess
 Lipodystrophy
IV cannulation
Learning outcomes
At the end of the session the student should be able to

• Select the appropriate site for venipuncture aka phlebotomy, venesection.

• Perform a Venipuncture procedure /IV line
• Indications, contraindications, and complications of the procedure.
Definition
Venipuncture is the medical procedure in which the vein is pierced to get access to the vein to either
-withdraw a blood sample
-give and intravenous injection/administer IV fluids
-Blood Transfusion

The superficial veins are just below the dermis of the skin

Indications

• To provide parenteral nutrition

• To provide avenue for dialysis/apheresis
• To transfuse blood products
• To provide avenue for hemodynamic monitoring
• To provide avenue for diagnostic testing
• To administer fluids and medications with the ability to rapidly/accurately change blood
concentration levels by either continuous, intermittent or IV push method

Contraindications
 Infection
 Phlebitis
 Sclerosed veins
 Previous repeated intravenous infiltration
 Burns, areas of scarring and wounds
 Traumatic injury proximal to insertion site
 Arteriovenous fistula in the extremity

IV complications
Infiltration
Hematoma
Embolism
Thrombosis and endarteritis
 Infiltration: Occurs when fluid is injected outside of the vein into surrounding soft tissue. Will cause swelling
and smooth, pale skin in the affected area. Can be a minor or serious issue depending on the medicine being
administered.
 Hematoma: Occurs when blood leaks from the vein into the surrounding tissue, usually after more than one
vein wall is accidentally punctured. Often accompanied by pain, bruising, and irritation. Will usually resolve
within several weeks light pressure.
 Embolism: Occurs after injecting air into the vein. Often caused by air bubbles in the IV tubing. Children are
especially at risk. In serious cases, causes trouble breathing, chest pain, blue skin, low blood pressure, and
even stroke.
 Thrombosis and endarteritis: Life-threatening conditions that can result from injecting into an artery, rather
than a vein. Can lead to severe pain, compartment syndrome (high pressure on a muscle leading to a very
painful "tight" or "full" feeling) gangrene, motor dysfunction, and even the eventual loss of the limb.

A Good Vein should be

 Large and visible
 Springy ,soft and bouncy
 Refill when depressed
 Straight and well supported ideally (not over a bone )
 Avoid areas where 2 veins are joining (as valves are present there )

To avoid
Thrombosed veins –hard and cord like
Inflamed or bruised area of skin
Too thin veins
Veins that have undergone multiple punctures

CHECKLIST Intravenous injection

I -Introduce oneself to the patient
C- Consent from patient to give IV injection

E-Expose the site for injection

Equipment
• Gloves
• Needle/Cannula 21G
• Cannula dressing
• Tourniquet
• Gauze
• Saline – 10ml
• Syringe – 10ml
• Alcohol swab/povidone
Technique
Greet the patient

1. Wash your hands.

2. Reassure the patient and explain the procedure.
3. Uncover arm adequately s
4. Have the patient relax and support his arm below the vein to be used.
5. Apply tourniquet and look for a suitable vein. Do not apply too tight or leave the tourniquet on for more
than 2 mins. Avoid nipping the patient’s skin
6. Wait for the vein to swell.
7. Disinfect skin.-Apply antiseptic in circular motion beginning from site and moving outwards, and allow it
to dry.
8. Stabilize the vein by pulling the skin taut in the longitudinal direction of the vein. Do this with the hand
you are not going to use for inserting the needle.
9. Insert the needle with bevel facing upwards at an angle of around15-30degrees.
10. Insert the needle swiftly through the skin and into the lumen of the vein until you have a giveaway
feeling , or loss of resistance .At the same time observe the needle hub for a flash back of blood.
11. Hold the syringe and needle steady. If no blood is seen the needle may not be in the lumen so move it
little forward and backwards gently and adjust the angle.
12. Aspirate. If blood appears hold the syringe steady, you are in the vein. If it does not come, try again.
13. Loosen tourniquet with other hand.
Pull the plunger if withdrawing blood, or push the plunger if injecting the medication in the vein
14. Inject (very) slowly. Check for pain, swelling, hematoma; if in doubt whether you are still in the vein
aspirate again!
15. Withdraw needle swiftly. Press sterile gauze onto the opening. Secure with adhesive tape.
16. Check the patient's reactions and give additional reassurance, if necessary.
17. Clean up; dispose of waste safely; wash your hands.

For IV Line
Access to the vein is through plastic cannula to give continuous access for a long time.
Indication
For Parenteral nutrition (IV Fluids)
To transfuse flood
To give multiple doses of medication
To maintain IV access for long
During surgical and emergency procedures

Needle Stick Injury -Although healthcare workers are those most often affected by needle stick injuries, other
occupations can be affected - e.g., refuse collectors, cleaners and tattoo artists. Needle stick injuries may also
affect corers and children picking up used needles.
The major blood-borne pathogens of concern associated with needle stick injury are hepatitis(HBV), hepatitis C
virus (HCV) and HIV. However, other infectious agents also have the potential for transmission through needle
stick injury

Management of Needle stick injury

 Bleed wound under running water
 Wash with soap and water
 Attend Occupational Health dept. – assess risk and take appropriate action
 Identify source of contamination e.g. patient details
 Document and Report incident