Injections
Giving injections of various types is one of the functions which nurses are expected to be able to perform competently. This article outlines the procedures for three common types of injections: intravenous, intramuscular and subcutaneous.
Article by Peter Ellis
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Purpose
Giving injections of various types is one of the functions which nurses are expected to be able to perform competently (Nursing and Midwifery Council, 2018). Since most injections are associated with the delivery of a medication, this process must reflect the 'rights' of medication administration, including:
- right drug
- right person
- right dose
- right time
- right route
- right formulation
- person’s right to refuse
There are various types of injections which nurses administer, each requires a different set of skills:
- intravenous
- intramuscular
- subcutaneous
Intradermal and intraosseous injections are uncommon, with the latter requiring additional training - these are not covered in this article.
Injection is a surgical procedure, and as such asepsis is paramount.
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Assessment
Prior to administering any injectable medication, the nurse needs a comprehensive understanding of:
- indications for use
- dosing
- routes of administration
- actions on the body
- side effects
- interactions with other medications
- any cautions related to the use of the medication
- required skills
Nurses need to understand the reason for the chosen route of administration and be assured that an injection, rather than, for example oral administration, is the most appropriate route for the patient based on clinical need.
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Equipment
The nurse should check any medication according to local practice and in addition, may need to reference a local formulary, British National Formulary or other formulary (eg Monthly Index of Medical Specialties). The nurse should have access to:
- the prescription chart
- the prescribed medication
- syringe(s)
- drawing up and delivery needles (preferably safety needles)
- skin preparatory wipe (eg a 70% isopropyl alcohol skin wipe, or according to the local policy)
- receiver tray
- sharps box
- gloves – nitrile or latex offer the best protection against inoculation injury (consider latex allergies); refer to local policy and guidance
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Procedure
The nurse must ensure they gain consent for the injection, where possible, ensuring the patient understands the reason for the injection and what the procedure entails. Privacy and dignity must be maintained during the procedure. As with all procedures, the nurse should attend to any issues of infection control, including effective hand hygiene. Prior to initiating the injection, the nurse must ensure that:
- the medication is checked as per local policy (Royal Pharmaceutical Society, 2018)
- the medication is reconstituted as per the manufacturer’s instructions and the prescription chart
- the amount required is withdrawn from the ampoule
- the needle is changed where an intramuscular or subcutaneous injection is being undertaken, so that the needle used for the injection is sharp and sterility is reinforced
- the syringe and needle is placed in the receiver tray
- needles are not re-sheathed
Intravenous
Since local policies, types of intravenous access and
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Risks and complications
Risks to the patient from injections depend on the route being used, and can include:
- bleeding
- bruising
- pain
- erythema
Less common complications include:
- infection
- abscesses
- injury to nerves
- injury to blood vessels
Intravenous cannula sites can become infected and cause superficial thrombophlebitis, which can be uncomfortable for the patient and may require antibiotic treatment in some cases (National Institute for Health and Care Excellence, 2020). Most complications can be avoided by ensuring fundamental hygiene precautions are followed and the injection is not rushed.
As well as the risks to patients, there is the potential risk to the nurse of a needlestick injury. This is most concerning when the needlestick injury occurs after the needle has been used to provide an intramuscular or subcutaneous injection. Safety needles are therefore preferable, and sharps bins should be taken to the patient and used immediately after the injection. Any sharp injury must be managed
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Next steps
Nurses need to be familiar with and competent to perform all the injection methods that are commonly in use in their place of work. Where nurses are not familiar with injection techniques, when techniques change or when nurses change their area of work, they should attend training to ensure that they have the skills and knowledge to perform the procedure. This is necessary both when it comes to meeting the requirements for revalidation and ensuring optimum patient care.
Nurse must ensure they are familiar with the equipment available to them to be able to make informed choices about which needles and syringes they use when administering injections.
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 2: Procedures for the planning, provision and management of person-centred nursing care
9. Use evidence-based, best practice approaches for meeting
needs for care and support with the prevention and
management of infection, accurately assessing the person’s
capacity for independence and self-care and initiating
appropriate interventions
9.3 use effective aseptic, non-touch techniques
11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation
11.7 administer injections using intramuscular, subcutaneous,
intradermal and intravenous routes and manage
injection equipment
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Resources
Ayinde O, Hayward RS, Ross JDC. The effect of intramuscular injection technique on injection associated pain; a systematic review and meta-analysis. PLoS One. 2021;16(5):e0250883. https://doi.org/10.1371/journal.pone.0250883
Barrott L, Foreman E, Harchowal J et al. Medicines optimization: ensuring quality and safety. In: Lister S, Hofland J, Grafton H and Wilson C (eds). The Royal Marsden Manual of clinical nursing procedures. 10th edn. Chichester: Wiley Blackwell; 2021: 803 -935
Greenway K. Rituals in Nursing: intramuscular injections. J Clin Nur. 2014;23(23-24):3583-3588. https://doi.org/10.1111/jocn.12627
National Institute for Health and Care Excellence. Superficial vein thrombosis (superficial thrombophlebitis). 2020. https://cks.nice.org.uk/topics/superficial-vein-thrombosis-superficial-thrombophlebitis/ (accessed 15 November 2023)
Nursing and Midwifery Council. Future nurse: standards of proficiency for registered nurses. 2018. https://www.nmc.org.uk/globalassets/sitedocuments/education-standards/future-nurse-proficiencies.pdf (accessed 15 November 2023)
Royal Pharmaceutical Society. Professional guidance on the administration of medicines in healthcare settings. 2018. https://www.rpharms.com/recognition/setting-professional-standards/safe-and-secure-handling-of-medicines/professional-guidance-on-the-safe-and-secure-handling-of-medicines (accessed 15 November 2023)
Shepherd E. Injection technique 1: administering drugs via the intramuscular route. N Times. 2018a;114(8):23-25
Shepherd E. Injection
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