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  • Injection and staging systems

    To get the medicine from the ampoule, the syringe is taken into the left hand, the needle is inserted into the hole of the broken ampoule( with the second finger of the left hand supporting the ampoule), the piston is pulled by the right hand, sucking the contents of the ampoule into it. When inserting the needle into the ampoule, it is advisable not to touch the outer walls of the ampoule.

    Bottles with sterile medicines of factory production are closed with a rubber stopper and fixed with a metal cap. Before the injection, after reading the etiquette and making sure the drug is transparent, the vial is opened. Preliminary, the cap of the vial is wiped with a sterile cotton ball impregnated with alcohol. Sterile tweezers remove the circle of the cap and wipe the opened part of the plug with alcohol. In a syringe with a thick needle on it, air is collected in a volume equal to the amount of the prescribed drug solution. Puncture the rubber stopper, insert the needle into the vial. Turning the bottle upside down and retaining the previous position of the needle, gain a drug solution.

    In bottles containing dry medicines, also introduce a sterile solvent, trying not to form a yen. The resulting solution or suspension is shaken several times and is taken up in a syringe. If the vial contains a single dose of solution, the needle can be removed, if several, then the needle is left in the vial so that the next batch of solution is poured through it.

    Injection is made with a different needle, not the one with which the cap was pierced. Do not make two or more injections with the same syringe.

    You can not administer two drugs in turn, but you can through the same needle.

    You can not mix solutions of different medications in one syringe and enter them at the same time, without having a special permission from the doctor.

    It should be remembered that many substances are antagonistic to each other.

    1. Intradermal administration of medicinal substances. Intradermal injections are used for diagnostic purposes, as well as for local anesthesia. The needle should be selected no longer than 2-3 cm in length and with a small lumen. For intradermal administration of drugs, the inner surface of the forearm is usually chosen. The skin at the injection site should be rubbed with alcohol and then with ether. After drying, the needle is introduced into the thickness of the skin to a shallow depth, so that the point enters only under the stratum corneum. It should be ensured that the needle does not get into the subcutaneous fatty tissue, since the expected effect will not be achieved. Directing the needle parallel to the surface of the skin, it is injected to a depth of 0.5 cm and carefully poured 1-2 drops of liquid, resulting in the formation of a whitish tubercle in the form of a lemon crust. Gradually moving the needle and squeezing out a few drops of liquid from the syringe, all the necessary amount is injected under the skin. This method conducts diagnostic allergic tests, as well as determine the sensitivity to medicines. After 24-48 hours, redness and swelling appear on the site of the appropriate allergen( streptococcus, house dust, etc.).In the absence of an allergic reaction, the skin remains unchanged.

    2. Subcutaneous administration of medicinal substances. Due to the fact that the subcutaneous fat layer is richly supplied with blood vessels, subcutaneous injections are used for faster action of the drug substance. Usually, drug solutions are injected, which are quickly absorbed by loose subcutaneous tissue and do not have harmful effects on it.

    When subcutaneous injections should be avoided the proximity of large vessels and nerve trunks. The most convenient areas for injection are the outer surface of the shoulder or the radial margin of the forearm, the sub-flap space, the antero-anterior surface of the thigh, the lateral surface of the abdominal wall and the lower part of the axillary region. In these areas, the skin is easily caught in the fold and there is no danger of damage to the blood vessels, nerves and subcutaneous fat.

    It is not recommended to make injections and infusions in places with edematous subcutaneous fatty tissue or in seals after previous injections. With subcutaneous administration, the absorption of medicinal substances, and consequently the manifestation of the therapeutic effect, is slower than with intramuscular and intravenous, but they are more effective in this case.

    Immediately before injection from the syringe, holding it vertically with a needle upward, displace air. If the air bubbles in the solution are small, it is necessary to pull the piston out so that they merge into one big one, and then move the piston away from it. The surface of the skin, where they intend to do the injection, is twice wiped with sterile cotton balls impregnated with alcohol. First time wipe the site 10 x 10 cm, the second cotton ball - directly puncture site 5x5 cm. With the left hand, the skin at the injection site is seized in a crease, into the base of which the needle is inserted quickly. You can hold a syringe and do a skin puncture in two ways.

    In the first method, the syringe barrel is clamped between I and II-III fingers, IV and V fingers and holds the plunger. The injection is made at the bottom of the skin folding from the bottom up( the patient stands) at an angle of 30 ° to the surface of the shoulder. When puncturing the skin, the lumen of the needle should always face upwards. With subcutaneous, intramuscular and intravenous injections, the needle is injected not entirely, but approximately 2/3 of the length, since its fracture can occur only at the junction with the clutch.

    After making a puncture of the skin, shift the syringe to the left hand, II and III with the fingers of the right hand clamp the rim of the cylinder, and I with the finger press on the handle of the piston, injecting the medicine. Then, with your left hand, apply a fresh cotton ball impregnated with alcohol to the injection site and quickly remove the needle. Place the medication slightly massaged with a cotton ball, so that it is better distributed in the cellulose and does not come back. The site of the puncture of the skin is smeared with an alcohol solution of iodine. To avoid burns, a cotton ball moistened with an alcohol solution of iodine can not be kept for a long time at the injection site.

    In the second method, the filled syringe is held with the fingers I and III-IV vertically, with the needle down. Quickly entering the needle, II presses the finger on the handle of the piston and injected the medicine, after which the needle is removed.

    Complications:

    • Violation of aseptic rules and insufficient solution sterilization can lead to local inflammation, up to the development of the septic process. Clinically manifested hyperthermia, hyperemia at the injection site, swelling;

    • mistaken introduction of sodium chloride solution 10% solution( hypertonic solution) instead of any other hypertonic solution can lead to local necrosis. The introduction of too hot a solution( above 40 ° C) can also cause necrosis of the tissues. Incorrect introduction of medicines not prescribed by a doctor, contraindicated to this patient, can lead to death;

    • The most common( more common) complication - infiltrate - reactive tissue multiplication around the site of a mechanical trauma( as a result of an injection with a blunt needle) and chemical irritation with a drug substance, especially with oily solutions and suspensions;as a result of ingestion of a microbial agent. Infiltration is a local compaction and an increase in tissue. With the introduction of poorly soluble drugs, the process of their absorption is slowed down. To speed up the resorption of the formed infiltrates, warming compresses, physiotherapy are used;

    • abscess - organic accumulation of pus in tissues due to their inflammation with melting of tissues and cavity formation. It is characterized by local and general signs of inflammation( pain, hyperemia, hypertension, etc.).It requires either surgical intervention, or( if the patient's condition allows) intensive conservative treatment( antibacterial therapy is mandatory).

    Important point - prevention of infiltrates and abscesses - strict adherence to aseptic rules: use of disposable syringes with unexpired shelf life, reliable sterilization of instruments, treatment of the nurse's hands, patient's skin, drug ampoule with 70% ethyl alcohol and sterile material, preservation of sterility of instruments anddrug solution.

    3. Intramuscular administration of medicinal substances. When intramuscular injection of the drug occurs quickly enough( soluble drugs are absorbed for 10-30 minutes).The volume of the injected substance should not exceed 10-20 ml. Do not inject near neural trunks or fibers. Substances that have an irritant effect can damage nerve fibers. Dangerous can be accidental needle hits in a blood vessel or a nervous trunk.

    Intramuscularly injected drugs that, when administered subcutaneously, give a strong irritation( a solution of acrychin, magnesium sulfate, therapeutic serums) or slowly absorbed( biyohinol, ecmonovicillin, bicillin).

    For intramuscular injections, take a needle 60-80 mm long with a sufficiently wide lumen. Most often they are made into the buttock area. If it is impossible( burns), use the middle third of the anterior non-anterior surface of the thighs. It is very important to introduce the medicine into the muscle, and not into the subcutaneous fat of the gluteal region. Injection is made in the upper-upper quadrant of the buttock, mentally drawing a vertical line through the sciatic tubercle, and horizontal - through a large spine of the femur. The area of ​​the upper quadrant includes the large, medium and small gluteus muscles. They inject into the lower part of the quadrant, trying to get into the gluteus maximus, but they often get into the subcutaneous fat, as in this place it is very well developed. From this area, the drug can spread into the closely located area of ​​the sciatic nerve, causing its damage and a number of other complications. Intramuscular injections can be done in the patient's position both standing and sitting. It is better, when the patient lies on his side with an elongated leg, in this position the muscles are as relaxed as possible. If it is not possible to inject into the gluteal region, drugs are injected into the thigh - its anterior surface, while it is advisable for the patient to lie on its back.

    Preparation of the syringe, treatment of the nurse's hands and the patient's skin is performed according to the general rules of asepsis.

    To do any injections, it is necessary only in sterile gloves [according to order No. 408( for the prevention of the spread of viral hepatitis in the country)].

    After typing a medicinal substance into the syringe, the patient's skin is treated with 70% ethyl alcohol. The palm of the hand with the maximally withdrawn thumb is applied to the thigh so that the end of the thumb reaches the anterior iliac axis, and its base touches the upper edge of the large trochanter( motion in the hip joint helps to identify the large spit).The index finger should be on the line of the trochanter. The best place for intramuscular injection is in the middle of the line( parallel to the longitudinal axis of the body) that connects the upper edge of the ilium and the large spit. Intramuscular injections around this point can be done within a radius of 2-2.5 cm. One should beware of injections near the trochanter for fear of getting into the vascular surrounding periarticular region.

    Holding the syringe with the needle perpendicular to the skin above the injection site, inject and through the subcutaneous fat enter the muscle. During injection, the left hand is pressed against the skin around the puncture site. There are several techniques for the administration of medicinal substances:

    • the skin above the puncture site is stretched with the index finger and the thumb of the left hand, and the syringe is inserted with the right hand;

    • the syringe should be held as follows: II finger holds the piston, V finger - the needle clutch, and the remaining fingers hold the cylinder;

    • the position of the syringe should be perpendicular to the patient's body surface;

    • When the patient is severely astenished, the injection into the gluteal region is made, as in the thigh: the syringe is held, like a pen, at an angle, so as not to damage the periosteum.

    After inserting the needle into the muscle, pull the plunger towards yourself, make sure that the needle is not in the blood vessel( no blood appears in the syringe), only then press the piston, gradually pushing the solution out to the end. Remove the needle with a quick movement, pressing a cotton swab dipped in alcohol to the skin.

    Fracture of the needle with intramuscular injection occurs for the same reasons as with subcutaneous, but more often because of sudden contraction of muscles during the rough introduction of a blunt defective needle.

    Damage to nerve trunks( sciatic nerve and other nerve branches) can be mechanical( injection needle with wrong choice of injection site), chemical( due to the irritating effect of the drug, the depot of which is located near the nerve), vascular( due to obstruction of vessels,feeding nerve).Damage to the nerve leads to neuritis, impaired sensitivity and movement in the limbs( paralysis, paresis).Medical embolism with intramuscular injections is more common than with subcutaneous injections, as the vascular network in the muscles is more developed. Most often among all types of complications there are infectious( purulent) complications. Infiltration, abscess - the brightest examples of insufficient sterilization of syringes and needles, insufficient cleaning of the ampoule surface before its opening, insufficiently careful processing of the hands of the nurse and the patient's skin. There is no clear division of the existing complications into mechanical, chemical and infectious complications, for there is always a moment when from the mechanical damage an infectious one can develop - for example, bruising, formed from a coarse damage by a blunt needle, contributing to the development of suppuration.

    All complications resulting from intramuscular injections can be divided into three groups:

    • mechanical;

    • chemical;

    • infectious.

    In all kinds of interventions( subcutaneous, intramuscular, intravenous manipulations) without observing aseptic rules, there is a risk of transmission of such infectious diseases as viral hepatitis, AIDS and others transmitted with blood.

    It should be remembered the possibility of allergic reactions to the introduction of a number of medications, including the development of anaphylactic shock. Some medications should be administered only by the method Bezredko( fractional).The greatest danger is represented by foreign proteins( serums, immunoglobulin, albumin, plasma of blood) and chemotherapeutic agents( antibiotics).If it is necessary to administer this or that medicinal substance to persons having a certain allergic mood, desensitisation with antihistamine drugs is carried out.

    4. Intravenous administration of medicinal substances. With this route of administration, the drug enters directly into the bloodstream and has an immediate effect.

    The introduction of drugs into the vein provides a more accurate dosage of drugs, and also allows the introduction of those drugs that are not absorbed from the gastrointestinal tract or irritate its mucosa. The time of blood flow from the veins of the upper limbs to the tongue is 13 ± 3 s. For most drugs, the administration time, equal to 4-5 cycles, is sufficient for uniform dissolution of the drug in the blood.

    Intravenous administration is by venipuncture and venesection. Venipuncture - the introduction of a needle into a vein through the skin to take blood or infuse medicinal solutions, blood, blood substitutes.

    Intravenous infusion is usually performed in the ulnar vein vein. Place the intended injection should be carefully treated with alcohol. Above the ulnar fold on the middle third of the shoulder, a tourniquet is applied to induce swelling of the veins, while it is important not to squeeze the arteries. Apply the tourniquet so that it can be easily dissolve. To increase venous stasis, the patient is offered to squeeze and unclench the fist several times or lower the arm before applying the tourniquet. During the procedure, he should sit or lie, and his hand - lie on the table or bed in the position of maximum extension in the elbow joint;to do this, put a flat pillow or roller, covered with a sterile napkin or a clean towel.

    Intravenous administration is carried out by either a doctor or a specially trained nurse. For intravenous infusions, you need to have a syringe with a capacity of 10-20 ml. It is necessary to comply with all the rules of asepsis. To inject the medicine intravenously and take blood for research is necessary only in rubber gloves.

    Sterile clear solutions are used for intravenous infusions. Dosage with this method of administration is slightly different from the dosage with subcutaneous injection, and the administration of potent agents is always slow. There are means that can be administered only intravenously, such as hypertensive solutions( 40% glucose solution, 10% calcium chloride solution, etc.).High concentrations of medicinal substances and hypertensive solutions are quickly diluted with blood and do not have harmful effects when administered intravenously to the vascular wall and adjacent tissues. Because of the danger of necrosis, they should not be administered subcutaneously or intravenously.

    Before entering the solution into the syringe, the nurse must check whether the solution is taken, the date of its manufacture and dosage, the presence or absence of contraindications for this patient, as well as allergic predisposition, in order to avoid mistakes. The solution in the syringe is collected directly from the ampoules through a large diameter needle. It is necessary to remove all air bubbles that may appear in the syringe. Holding the syringe vertically with a needle up, pulling the piston collect small bubbles into larger ones and remove through the needle with internal infusions. Be careful not to get into the blood even a small amount of air because of the danger of air embolism. With intravenous administration, you should be very careful: before you enter the drug, you need to make sure that the needle is in the vein;the ingestion of a drug substance into the peri-venous space can be accompanied by strong irritation, up to the development of tissue necrosis.

    Some drugs, such as cardiac glycosides, are injected very slowly, because a rapid increase in their concentration in the blood can be dangerous for the patient's life. For a slow infusion of a low-density liquid( saline solutions or glucose), thin needles are used, with the introduction of viscous liquids( blood, polyglucin, protein hydrolysates) - needles with a large diameter( for example, a Dufau needle).

    A one-time method of venepuncture requires a lot of skill: the skin is pierced above the vein, while the acute angle between the needle and the skin decreases during the puncture process. Advancement to the vein after hitting is performed with the needle position almost parallel to the skin. For beginners it is better to use a two-stage method: holding the needle with your right hand, cut in parallel upward along the planned vein and at an acute angle to the skin, make a puncture - the needle lies next to the vein and parallel to it, then the side is pierced with a vein. It creates a sense of failure in the void, if the needle is in the vein, blood will go. If there is no blood, then, without removing the needle from the skin, it is advanced by several millimeters into the vein, fixing in this position.

    Puncture begins as far as possible distally on the forearm and, if necessary, repeated injection continues in the direction of the elbow, so that in case of vascular damage( thrombophlebitis) do not block the entire distal vein. Before the administration of the solution, the tourniquet is carefully removed, after which, slightly pulling the piston, the needle position is checked again. The introduction of the solution begins only after this. The introduction is slow, within 1-2 min. So that even a minimal amount of irritant medicine does not get under the skin during the extraction of the needle, it is necessary, by pulling the piston, to suck up the remnants of the medicine from the needle into the syringe. To move the plunger, when injecting the medicine, it is necessary with the 1st finger of the left hand. It is possible to shift the syringe into the left hand, right to clamp the rim of the cylinder between the II and III fingers, pressing I on the piston handle.

    It is very cautious to transfer the syringe from one hand to the other, at that moment the needle can exit the vein - a swelling appears at the injection site, and the patient complains of burning sensation. In this case, it is necessary, without removing the needle, to try to suck the vein injected solution with a syringe. Then, disconnect the syringe with the medicine, quickly fill with a 0.25-0.5% solution of novocaine or an isotonic sodium chloride solution with another syringe, connect it to the needle and inject several milliliters of the solution to lower the concentration of the injected substance.

    Drip infusions allow the injection of large amounts of fluid without overloading the cardiovascular system. The liquid to be injected should have a composition that does not change the osmotic pressure of the blood, and do not contain any potent agents, be carefully sterilized and heated to 37 ° C.

    For intravenous administrations use disposable systems made of pyrogen-free, non-toxic plastics sterilized by the manufacturer and manufactured in a sterile package indicating the series and date of sterilization. They are designed for a single infusion of vials closed with a rubber stopper. The system consists of a short tube with a needle for entering the air bottle and a long tube with a dropper. At one end of the short tube there is a needle, on the other there is a filter for dust retention. On the cone of the long tube there is a needle for piercing the rubber plug of the vial, at the other end there is a needle inserted into the vein. Needles are in special caps. Before applying the system, check the tightness of the packaging bag and the integrity of the cap on the needles. Open the system by ripping the packaging bag and take it out, without removing the caps from the needles. After mixing the contents of the vial, treat it with alcohol or iodine, releasing the needle from the protective cap, insert it into the vial of the bottle as deeply as possible. The discharge tube of the needle is fixed parallel to the wall of the vial. After releasing the needle, close to the dropper, it is also injected through the stopper into the vial, squeezing the system above the dropper with the plate clamp in the bag. The bottle is turned upside down, strengthened on a tripod and the usual way is to fill the system. From the filter and the dropper, the air is forced out, raising the system so that the nylon filter is at the top and the tube is at the bottom. The injected solution is filled up to half a dropper, then lowered and expelled air from the lower part of the tube until the solution comes from the needle by the stream. A clamp is placed on the tube in front of the needle.

    Before puncture, the skin is treated with alcohol. If there is confidence in properly performing a vein puncture( blood flow through the needle), the system is connected to the needle and proceeds to inject the solution into the vein. For several minutes, it is observed whether the liquid enters the skin under the skin( swelling may appear), then the needle is fixed with a sticky patch in the direction of the vein, and the puncture area is covered with a sterile tissue.

    During the injection of the solution, the entire system should be monitored: the dressing does not get wet, if the infiltration or swelling in the infusion area is formed due to fluid intake past the vein, whether the fluid flow has stopped due to systemic tube folding or vein blockage. If the fluid flow stops, if it is caused by vein thrombosis, you can not raise the pressure in the system and try to clean the cannula. It is necessary to change the infusion site, producing a new vein puncture in another place. When the liquid stops flowing into the dropper, the drip infusion is stopped.

    A nurse during the procedure should monitor the appearance of the patient, the pulse, the frequency of breathing, pay attention to his complaints. At the slightest deterioration of the condition, she urgently calls the doctor.

    Solution introduction can be:

    • Inkjet;

    • drip.

    To jet injections( not more than 50 ml of liquid), if necessary, quickly recoup the volume of the circulating fluid( with massive blood loss during surgery, shock or collapse).With the drop method, the solution injected slowly, drop by drop into the bloodstream;the number of drops is adjustable.

    The dropper should always be above the lower cannula to prevent air from dropping into the bloodstream. The intravenous drip infusion is carried out for a long time, so the patient should be conveniently placed on the back, the limb fixed with a soft bandage and for puncture choose a vein of a smaller caliber than the ulnar( the vein of the foot or the back surface of the hand).The container with the infusion solution is placed at a height of 1 m above the bed level and the system clamp is set so that the fluid flow rate is 50-60 drops per minute. After the injection of the solution, the needle is removed from the vein and the puncture site is treated with iodine tincture or 70% alcohol.

    Important importance is attached to the compatibility of drugs with infusion solutions. Infusion solutions, as a rule, are used as carriers for other drugs. Thus, a controlled administration of the drug is achieved for a long time, and there is always the possibility of undesirable reactions. Preparations should be added only in really necessary cases, when their effectiveness is guaranteed only with prolonged infusion. In emergency cases, medications are administered during infusion in the place( tube) of the infusion device provided for this purpose. If possible, only one drug should be added, since with the combination of several medicines there is always the danger of incompatibility due to the difficult-to-predict interaction of the drugs.

    A complex of compatible solutions of electrolytes or amino acids, as well as alkaline solutions such as sodium hydrogen carbonate, are less suitable for addition than isotonic solutions of sodium chloride or carbohydrate solutions. Fatty emulsions as carrier solutions are completely unsuitable, since the additive can disrupt the structure of the emulsion. Exceptions are vitamins that dissolve in fat( fat-soluble vitamins).

    All necessary supplements prescribed by the physician should be performed immediately before infusion, in aseptic conditions and be carried out by specially trained middle medical personnel.

    The main complications for venipuncture, intravenous injections and infusions are as follows:

    • hemorrhages at the venous puncture site, painful swelling;

    • pouring a part of the injected drug into the surrounding subcutaneous fatty tissue, as a result of which necrosis may develop;

    • damage to nerve trunks( puncture force or irritant solution);depending on the degree of damage, develops a disorder of the function of the affected nerve( up to paralysis);

    • Air embolism as a result of infringement of intravenous infusion techniques.

    All information on the administration of medications together with isotonic solutions should be recorded on infusion tanks and in the medical history( type, amount, time of onset and speed of infusion).It is recommended to use filters to protect the infusion solution from foreign particles. Particular attention should be paid to the sterility of the infusion device.

    The solution in which the drug has been added needs to be controlled according to its physicochemical characteristics: pay attention to the turbidity of the solution, the appearance of a precipitate or a change in its color. With such changes, the administration of drugs is stopped.