Alberta Pharmacists Association

Transcription

1 Alberta Pharmacists Association Administering Injection & Immunizations Preparation Course Welcome & Introductions Presenters 1

2 Outline I. Pre-Study Q&A II. Basic Information Overview of Injection Considerations Cold Chain Management Needlestick Injuries III. Preparing Medications for Injection Theory->Demo->Practice IV. Patient Assessment & Safety Issues V. Administering Medications by Injection Theory->Demo->Practice VI. Assessment Phase Assessment of Injection Administration Written Documentation & Wrap Up I. Pre-Study Q and A 2

3 II. Basic Information Cold Chain Management Needlestick Injury Overview Pharmacists should consider the following items prior to giving injections: Why use injections? More rapid absorption than oral Issues with injections Cold Chain Needlestick injuries Infection risk Allergic reaction Fear Pharmacist role: Knowledge of medication Accurate assessment Emphasis on teaching 7 rights (pt., drug, dose, route, time, reason, documentation) 3 checks drug & dose are correct. 2 considerations allergies, pt. rights Aseptic technique 3

4 Cold Chain DEFINITION: Process used to maintain optimal conditions during transport, storage, & handling of vaccines from manufacturer to administration of vaccine Refrigerated vaccines +2 C to +8 C Frozen vaccines -15 C or lower Protection from light needed for some vaccines Adapted from PHAC National Vaccine Storage and Handling Guidelines for Immunization Providers (Accessed December 2015) Cold Chain Storage Vaccines: group by product space b/w trays to allow for air circulation store in middle of fridge <50% volume of fridge filled with vaccine/drug Label types/bins clearly to avoid errors but don t rely on labels! Read actual drug label. 4

5 Cold Chain Record Keeping Temperature log recorded twice daily more frequently if open > 9 hrs Vaccine inventory (lot, expiry date, etc.) Checklists for storage Needlestick Injuries Prevention Plan for disposal before beginning procedure Use one-handed recapping technique NEVER recap needle that has been used in a patient Used syringe with engineered safety needle goes directly into leak and puncture proof sharps container Workplace must have policy in place regarding needlestick injuries 5

6 Needlestick Injury Infection Risk Needle introduces contaminated blood in to percutaneous route Risk of developing HIV from a needlestick <1% (CDC 2001) Other blood borne infections = Hepatitis B and C Occupational exposure (needlestick or mucosal exposure to blood) accounts for 1%-2% of cases of hep C (Bowker, Soskolne, Houston, et al., 2004). Pharmacists need protection from Hepatitis B 3 doses of Hepatitis B vaccine anti-hbs antibody level assessed & recorded. additional doses may be needed Needlestick Injury Initial Treatment (Tx) Goal dilute # of organisms to < needed to start infection Do not rub wash gently with soap & water for several minutes skin disinfectant can be applied as first aid measure i.e. 10% iodine solution Allow exposure site to bleed freely Post-exposure prophylaxis (PEP) tx may need to be started within 1-2 hrs of exposure 6

7 Needlestick Injury Treatment (cont d) Dependent on patient s HIV, Hep B & C status May require testing of patient or injured party Hep B protocol Canadian Immunization Guide, Evergreen Edition-Figure 2 (accessed December 2015) Dependent on type of injury Superficial puncture of skin Deep puncture, visible blood on needle, or needle from pt s artery or vein Needlestick Injury Treatment (cont d) ACP (Standard 16) + Occupational Health & Safety Act pharmacists must develop needlestick injury tx & protocol. Protocol vary depending on location within province Contact AHS in your zone on how to handle treatment 7

8 Needlestick Injury New Products Alberta Occupational Health & Safety Code (2009) Mandatory as of July 1, 2010 Safety-engineered needles & sharps must be used to reduce the risk of needlestick injuries e.g. include: Blunt-fill, Safety Glide Safety-Engineered Medical Needle e.g. BD Blunt Fill (pictured-only product) For more information: Draw up medications from vial or ampule Once correct dose is drawn up, pull back on plunger to capture medication from needle 8

9 Recapping Blunt-fill Needle (one-handed recapping technique) Place needle cap on flat surface With one hand, slide needle into needle cap Lift up syringe with needle cap on. With other hand, grasp end of needle cap & push cap firmly onto needle. Safety-Engineered Medical Needles e.g. BD SafetyGlide Needle (pictured) BD Eclipse Needle BD Integra Retracting Syringes Securegard Single-Use, Retractable Safety Syringes 9

10 Overview Re-capping Needle & Attaching Safety-Engineered Needle Twist needle cap (& needle) syringe Attach safety-engineered needle with correct gauge for injecting medication Push syringe plunger up until medication appears at end of needle ( prime the needle) Administer injection Remember to put re-capped needle into sharps container. NOTE: This course teaches that if a needle has gone through a stopper that it should be changed to a new needle prior to giving injection to patient. This allows for a less painful shot. This practice is not necessarily standard practice amongst all injectors. III. Preparing Medications for Injection 10

11 Syringes & Needle Parts Aseptic technique for needle preparation Open products using flaps Do not touch anything that will contact patient or med. Syringe 1 ml, 3 ml, 5 ml, 10 ml most common Appropriate size for amount being drawn up Needle Gauge: smaller # = larger diameter Length: based on site/type of injection Ensure both correct for type of injection and patient Syringe and Needle Parts 11

12 Supplied Medication Demo Session Vials Reconstituting powder Ampules Practice Session You will practice: Aseptic technique Opening and attaching needle & syringe Drawing up/preparing medication from: Vials Reconstituting powder Ampules One-handed recapping technique IV. Patient Assessment & Safety Issues 12

13 Assessment: Patient History Age Weight Need for injection Medical History Diabetes, heart disease, auto-immune & blood disorders, & cancer Current Medications Pregnant Previous experiences with injections - Anxiety? - Fainting? - How managed? Allergies Component of vaccine Previous reaction to a vaccine Latex Hypersensitivity Food allergies: banana, kiwi, pineapple, avocado, chestnuts Hx of multiple latex exposures ie. Surgeries Assessment: Injection Site Site Assessment bruising, rashes, abrasions, inflammation, infection edema, tenderness, hardness tattoo (danger of tracking ink into tissues) amount of muscle or subcutaneous tissue Adverse rxns Local: pain, swelling, site Systemic: fever Anaphylaxis: min post injection (> 2 body systems) Overall, any contraindications to giving injection? 13

14 Assessment: Informed Consent Name of immunization Disease being prevented Benefits & risks Expected rxn Usual & rare side effects Rationale for minutes observation post-injection Contact information for follow-up or emergency: Name & phone number of family physician and patient s next of kin Safety Issues Post-Injection Care Pt to remain in pharmacy area x minutes Observe for any reactions to injection Pt to notify pharmacist of any unusual feelings/symptoms Assess site for localized reaction (rxn) Swelling and urticarial rash at injection site can occur observe for at least 30 mins and if rxn remains localized, disappears or no evidence of progression to other parts of the body-> discharge patient Ice can be put on the injection site for comfort (accessed December 2015) 14

15 Safety Issues Anxiety Assess previous response to injections Anxious clients can benefit from: Not watching prep or insertion of needle Ensuring relaxed status prior to needle Humming a tune Safety Issues Fainting Recognition: loss of blood to brain->temporary loss of consciousness response to fear, hunger, pain, & emotional/physical shock may feel lightheaded, dizzy, nauseous, & may look pale Treatment (tx): If pt sitting, put head between knees x 5 minutes Preferred tx position lying down legs & feet slightly elevated clothing around neck loosened Goal is to prevent patient from falling might hit head or sustain other injuries 15

16 Safety Issues Anaphylaxis-Recognition Body s overwhelming response to allergen in food, medication, blood product, insect bite or a chemical Involves at least 2 body systems: Skin Itchy, urticarial rash Painless swelling of face & mouth preceded by itchiness, tearing, nasal congestion or facial flushing Respiratory Sneezing, coughing, wheezing, laboured breathing, hoarseness, difficulty swallowing Circulatory hypotension (develops later in rxn) Changes develop over several minutes Safety Issues Anaphylaxis-Treatment Hives or swelling accompanied by other signs and symptoms, even mild: epinephrine SHOULD be initiated Little risk using epinephrine unnecessarily, BUT anaphylaxis is very serious if not treated 16

17 Safety Issues Anaphylaxis-Treatment Immediate Action Adapted from CIG-Evergreen Ed. (Accessed December 2015 ) Steps 1, 2, 3 should be done promptly and simultaneously 1. Assess circulation, airway, breathing, mental status, skin, and body weight. Secure oral airway if necessary. Direct someone to call Position patient on their back or a position of comfort if there is respiratory distress; elevate lower extremities. Place vaccinee on their side if vomiting or unconscious. 3. Inject epinephrine I.M. in mid-anterolateral aspect of thigh: 0.01 mg/kg body weight of 1:1000 (1 mg/ml) solution ADOLESCENT or ADULT: maximum mg CHILD: maximum mg Record the time of the dose. Repeat every 5 to 15 minutes as needed, for a maximum of three doses. Safety Issues Anaphylaxis-Treatment Immediate Action Adapted from CIG-Evergreen Ed. (Accessed December 2015 ) 4. Stabilize vaccinee; perform CPR if necessary, give oxygen and establish intravenous access if available and give adjunctive treatment (i.e. diphenhydramine hydrochloride or Benadryl ) if indicated. 5. Monitor vaccinee s blood pressure, cardiac rate and function, and respiratory status. 6. Transfer to hospital for observation. 17

18 V. Administration of Injections Theory & Demonstration Intradermal Injection Overview common uses: allergy & TB testing volume: 0.01 ml to 0.1 ml needle gauge: 25-27G needle length: 3/8-5/8 syringe type: tuberculin 18

19 Intradermal Injection Procedure Assess injection site clear, free of lesions, & relatively hairless inner forearm 3-4 finger widths below elbow bend & hand width above wrist upper back Cleanse skin Apply non-sterile gloves Gently pull skin taut Insert needle at 5-15 degree angle about 1/8 with bevel facing up. Inject and watch for wheal or bleb to appear Withdraw, pat lightly DO NOT massage SMITH, SANDRA F.; DUELL, DONNA J.; MARTIN, BARBARA C., CLINICAL NURSING SKILLS, 8th Ed., 2012, Reprinted by permission of Pearson Education, Inc., New York, New York. Subcutaneous Injection Overview common uses insulin, heparin, some vaccines absorption rate- slower than IM volume: up to 1.0 ml needle gauge- 25 to 27 needle length- 3/8 to 5/8 syringe size 1 to 3 ml 19

20 Subcutaneous Injection Sites Posterior of upper arms Subscapular areas (upper back) Abdomen: below costal margins to level of iliac crests (avoid umbilicus) Upper ventral or dorsal gluteal Anterior aspects of thighs SMITH, SANDRA F.; DUELL, DONNA J.; MARTIN, BARBARA C., CLINICAL NURSING SKILLS, 8th Ed., 2012, Reprinted by permission of Pearson Education, Inc., New York, New York. Subcutaneous Injection Procedure Assess site: no lesions, underlying bony prominences, or large muscles or nerves. grasp skinfold with thumb & forefinger. measure skinfold from top to bottom to ensure that needle length is ~1/2 this distance. If not, use 45º angle for insertion. Cleanse area Apply non-sterile gloves Grasp skinfold keep bunched for entire injection Use darting motion 90 or 45º angle depending on assessment Inject fluid rapidly Remove syringe/needle quickly Release skinfold DO NOT massage area SMITH, SANDRA F.; DUELL, DONNA J.; MARTIN, BARBARA C., CLINICAL NURSING SKILLS, 8th Ed., 2012, Reprinted by permission of Pearson Education, Inc., New York, New York. 20

21 Intramuscular Injections Overview Common uses: vaccinations, analgesics, anti-emetics, antibiotics Absorption rate: faster than SC Volume: up to 3 ml (adult) - site dependant Needle gauge: 22 25G aqueous solutions 18 21G oil-based or more viscous Needle length: depends on site, age & weight adults 1 ventrogluteal site in children ->adolescents Lateral aspect upper arm. top = 3 fingerbreadths below acromion process Bottom = opposite axilla Needle length: 5/8 <132 lbs (60kg) 1 >132 lbs (60kg) These are general guidelines, each patient needs to be assessed individually Intramuscular Sites Deltoid up to 1 ml volume MAX. SMITH, SANDRA F.; DUELL, DONNA J.; MARTIN, BARBARA C., CLINICAL NURSING SKILLS, 8th Ed., 2012, Reprinted by permission of Pearson Education, Inc., New York, New York. 21

22 Intramuscular Sites Vastus Lateralis Middle 1/3 & lateral aspect of thigh Muscle extends from middle of thigh to middle of lateral side of thigh Top = greater trochanter of femur Bottom = lateral femoral condyle of knee needle, up to 3 ml MAXIMUM SMITH, SANDRA F.; DUELL, DONNA J.; MARTIN, BARBARA C., CLINICAL NURSING SKILLS, 8th Ed., 2012, Reprinted by permission of Pearson Education, Inc., New York, New York. Intramuscular Sites Ventrogluteal pt lying on side your thumb pointing to front of pt, heel of hand over greater trochanter with hand in line with femur feel for greater trochanter as pt lifts leg point index finger towards anterior superior iliac spine & swing middle finger along iliac crest towards buttock. V formed b/w fingers is correct site. 1.5 length (adult), up to 3 ml MAX *Dorsogluteal site NOT recommended. SMITH, SANDRA F.; DUELL, DONNA J.; MARTIN, BARBARA C., CLINICAL NURSING SKILLS, 8th Ed., 2012, Reprinted by permission of Pearson Education, Inc., New York, New York. 22

23 Intramuscular Sites Ventrogluteal SMITH, SANDRA F.; DUELL, DONNA J.; MARTIN, BARBARA C., CLINICAL NURSING SKILLS, 8th Ed., 2012, Reprinted by permission of Pearson Education, Inc., New York, New York. Intramuscular Injection Procedure Assess & landmark site Cleanse area Apply non-sterile gloves Use Z track method Pull skin 1 to 1.5 inches laterally away from injection site with edge of non-dominant hand ie. skin is pulled taut at injection site) Keep z track for entire injection Use darting motion quickly inject needle into area (90º angle) Stabilize syringe with hand still in Z track position Inject fluid rapidly without aspiration* Quickly remove needle / syringe Release Z track DO NOT massage site *NOTE: aspiration is no longer recommended in use with immunizations SMITH, SANDRA F.; DUELL, DONNA J.; MARTIN, BARBARA C., CLINICAL NURSING SKILLS, 8th Ed., 2012, Reprinted by permission of Pearson Education, Inc., New York, New York. 23

24 Z-Track Method After displacement released Maintaining displacement SMITH, SANDRA F.; DUELL, DONNA J.; MARTIN, BARBARA C., CLINICAL NURSING SKILLS, 8th Ed., 2012, Reprinted by permission of Pearson Education, Inc., New York, New York. Injection Pain Reduction Strategies Technique Change to Safety Glide needle before administration pain from irritating medications Use as fine a gauge needle as possible Wait until skin prep is dry Encourage pt to relax muscles pt. to take big breath & then blow it out while injection occurs Reduce pain by darting quickly Tightly grasp syringe during entire injection Inject medication rapidly Withdraw needle quickly 24

25 Recording On patient & pharmacy medication/immunization record to include: Date and Time of administration Medication name, lot # & expiry date Dose Route & injection site Patient response to injected medication Patient education Revisit vaccination record Due date for future injections (if applicable) Name of pharmacist & signature & pharmacy location Questions & Answers about Injections 25

26 VI. Assessment Phase Assessment of Injection Administration Each participant will prepare two syringes of normal saline: one for a subcutaneous (SC) injection 0.3 ml one for an intramuscular (IM) injection 0.5 ml Working in pairs, each participant will: landmark a SC injection site on arm & give SC injection to partner landmark the deltoid site & give an IM injection to partner document the injections given. Each participant will also landmark ventrogluteal site VI. Assessment Phase Written Documentation (All Sheets Must Be Handed-In) Documentation Sheet Workshop Participant s Name: Date: Injection Assessment Guide x 2 (IM & SC) Your name: Name of Rater: Date: Location: Evaluations Program Evaluation Overall Event Presenters x 2- Pre & Post Workshop Questionnaire (4 pgs total) 26

27 VI. Assessment Phase Wrap Up Participants to continue to practice injection skills many times (using a sponge) so that it will become automatic. Hand-in all necessary paperwork to instructors Rene A. Day, PhD, RN, Professor Emerita, Faculty of Nursing, University of Alberta Heather Scarlett-Ferguson, BSP, MDE, RPh Instructor, Grant MacEwan University Updated 2015 Betty Golightly, BSP, RPh President, Go Travel Health Inc. References Bowker, S., Soskalne, C. Houston, S. et al. Human immunodeficiency virus (HIV) and Hepatitis C virus (HCV) in a northern Alberta population. Canadian Journal of Public Health 2004; 95(3): (Accessed June 2015) Canadian Immunization Guide-Evergreen Edition (Accessed December 2015) (Accessed December 2015) (Accessed December 2015) Centers for Disease Control and Prevention. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for post-exposure prophylaxis. Morbidity and Mortality Weekly Reports 2001, 50,RR-11:1-42. (Accessed June 2015) College & Association of Registered Nurses of Alberta. Change in blood-borne virus infection reporting. Alberta RN 2010; 66(6); (Accessed June 2015) Day RA, Paul P, Williams B, Smeltzer S, Bare B, (Eds.) Brunner & Suddarth s textbook of Canadian medical-surgical nursing. (2 nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins; (Accessed June 2015) Potter PA, Perry AG, Ross-Kerr JC, Wood, MJ. Canadian fundamentals of nursing (4 th edition). Toronto, ON: Elsevier Canada; (Accessed June 2015) Smith AJ, Cameron SO, Bagg J, Kennedy D. Management of needlestick injuries in general dental practice. British Dental Journal 2001;190: (Accessed June 2015) Smith SF, Duell DJ, Martin BC. Clinical nursing skills. Basic to advanced skills. (8 th ed.) Upper Saddle River, NJ: Pearson Prentice Hall; (Accessed June 2015) Public Health Agency of Canada. Canadian Immunization Guide (7th ed.). Author; 2006.; and National Vaccine Storage and Handling Guidelines for Immunization Providers Available online: (Accessed December 2015). 27

28 References for Diagrams SMITH, SANDRA F.; DUELL, DONNA J.; MARTIN, BARBARA C., CLINICAL NURSING SKILLS, 8 th Edition, 2012, Reprinted by permission of Pearson Education, Inc., New York, New York. Slide 37: Intradermal Needle Insertion Angle, p. 609 Slide 39: SC Injection Sites, p. 615 Slide 40: SC Needle Insertion Angle, p. 609 Slide 42: IM (Deltoid) & SC Injection Sites, p. 615 Slide 43: Vastus Lateralis Injection Site, p. 622 Slide 44: Ventrogluteal Injection Site, p. 618 Slide 45: Ventrogluteal Injection, Landmarking, p. 621 Slide 46: IM insertion angle, p. 621 Slide 47: Z-track Method, p. 623 &