Standard operating procedures for preparation and administration of intramuscular injections Preparation Overview No Action Rationale 1 Collect and check all equipment 2 Check that the packaging of all equipment is intact To prevent delays and enable full concentration on the procedure To ensure sterility. If the seal is damaged, discard 3 Re-check the patient s prescription chart and ascertain the following: (a) Drug (b) Dose (c) Date (including start and end date) and time of administration (d) Route and method of administration (e) Diluting agent as appropriate (f) Validity of prescription (g) Signature of doctor To ensure that the patient is given the correct drug in the prescribed dose using the appropriate diluting agent and by the correct route (NMC 2008a: NPSA. 4 Check all details with another nurse. Note: This does not apply if the injection is administered under a PGD and for lone working practitioners, where possible checking whilst at base with a nursing colleague prior to community visits would be both pragmatic and best practice 5 Decontaminate hands with alcohol hand rub To minimize any risk of medication error (NMC 2008a). To prevent contamination of medication and equipment (DH 6 7 Prepare needle(s), syringe(s), etc, on a tray or receiver. Including sterile needle with a mechanical safety device. (See Appendix 2) Inspect all equipment To contain all items in a clean area To check that none is damaged; if so, discard or report to Medicines and Health Care Products Regulatory Agency (MHRA) 1
No Action Rationale 8 9 10 Select the drug in the appropriate form (in order to differentiate between decanoate and acetate as errors occur) and volume, dilution or dosage and check the expiry date Risk assess the need for Personal Protective Equipment before proceeding with the preparation of the drug Take the prepared dose to the patient. Check and confirm the patients identity Treatment with medication that is outside the expiry date is dangerous. The expiry date indicates when a particular drug is no longer pharmacologically efficacious To protect practitioner during preparation To prevent error and confirm patient's identity (NPSA 2005) Administration Overview No Action Rationale 11 Evaluate the patient s knowledge of the medication being offered. If this knowledge appears to be limited or incorrect, offer an explanation of the use, action, dose and potential side effects of the drug or drugs involved. Provide written information/medication leaflet if appropriate to support this Ascertain whether the patient has any known allergies (particularly to nuts) A patient has a right to information about treatment (NMC 2008) Some long acting injectable drugs have a nut oil base Patient may have an allergic reaction, and be at risk of Anaphylactic shock. Also NPSA alert for chlorhexidine allergy 12 Close room door or curtains if appropriate and decontaminate hands using alcohol hand rub To ensure the patient s privacy and dignity 13 Administer the drug as prescribed. Staff should note that the NMC 2008a states that clinicians should not administer medication drawn into a syringe or container by another practitioner when not in their presence To ensure patient receives treatment 2
No Action Rationale 14 Dispose of equipment into the appropriate waste stream /sharps bin. Remove any PPE and decontaminate hands 15 Record the administration on appropriate charts To maintain accurate records, provide a point of reference in the event of any queries and prevent any duplication of treatment (NMC 2005; NMC 2008a: NPSA Single-dose ampoule: solution preparation 1 Check that the drug has been stored in accordance with manufacturing requirements. This is particularly important when administering Risperdal Consta which has to be refrigerated and used within 7 days post refrigeration. However it should be allowed to reach room temperature prior to administration 2 Check expiry date and inspect the solution for cloudiness or particulate matter. If this is present, discard and follow hospital guidelines on what action to take, eg return drug to pharmacy To prevent the patient from receiving an unstable or contaminated drug To prevent the patient from receiving an unstable or contaminated drug 3 Tap the neck of the ampoule gently To ensure that all the solution is in the bottom of the ampoule (NPSA 4 Cover the neck of the ampoule with a ampoule snapper or sterile gauze swab and snap it open. If there is any difficulty a file may be required 5 Inspect the solution for glass fragments; if present, discard To minimize the risk of contamination. To prevent aerosol formation or contact with the drug this could lead to a sensitivity reaction. To reduce the risk of injury to the nurse To minimize the risk of injection of foreign matter into the patient 3
6 If you have access to a filter needle, apply and withdraw the required amount of solution, tilting the ampoule if necessary. If not use standard needle, withdraw 7 Attach a new needle (and discard used needle into appropriate sharps container) Staff must not re-sheath the needle depending on the product used a designated needle may be provided for this purpose. To avoid drawing in any air To reduce the risk of infection. To avoid tracking medications through superficial tissues. To ensure that the correct size of needle is used for the injection. To reduce the risk of injury to the clinician Single-dose ampoule: powder preparation 1 Tap the neck of the ampoule gently To ensure that any powder lodged here falls to the bottom of the ampoule 2 Depending on the type of ampoule used refer to manufacturer s instruction for opening. To minimize the risk of contamination. To prevent contact with the drug this could cause a sensitivity reaction. To prevent injury to the nurse 3 4 Inject the correct diluting agent slowly into the powder within the ampoule Agitate the ampoule as per manufactures instructions as some preparations require tapping on the hand To ensure that the powder is thoroughly wet before agitation and is not released into the atmosphere To dissolve the drug 5 Inspect the contents. To detect any glass fragments or any other particulate matter. If present, continue agitation or discard as appropriate (NPSA 4
6 When the solution is clear withdraw the prescribed amount, tilting the ampoule if necessary To ensure the powder is dissolved and has formed a solution with the diluting agent. To avoid drawing in air 7 Tap the syringe to dislodge any air bubbles. Expel air To prevent aerosol formation. To ensure that the correct amount of drug is in the syringe (NPSA 8 Attach a new needle (and discard used needle into appropriate sharps container) or attach a sterile plastic end cap. Staff must not re-sheath the needle To reduce the risk of infection. To avoid tracking medications though superficial tissues. To ensure that the correct size of needle is used for the injection. To reduce the risk of injury to the nurse (NPSA Multi-dose vial: powder preparation 1 Remove the tamper evident seal and clean the rubber septum with the chosen antiseptic and let it air dry for at least 30 seconds. To prevent bacterial contamination of the drug, as the plastic lid prevents damage and does not ensure sterility Use either of these methods for reconstitution (2-6): 2 Insert a 21 G needle into the cap to vent the bottle To prevent pressure differentials, which can cause separation of needle and syringe 5
3 Inject the correct diluting agent slowly into the powder within the ampoule To ensure that the powder is thoroughly wet before it is shaken and is not released into the atmosphere 4 Remove the needle and the syringe To enable adequate mixing of the solution 5 Place a sterile topical swab over the venting needle and shake to dissolve the powder. Note: the nurse may encounter other presentations of drugs for injection, eg vials with a transfer needle, and should follow the manufacturer's instructions in these instances 6 Inspect the solution for cloudiness or particulate matter. If this is present, discard. Follow hospital guidelines on what action to take, e.g. return drug to pharmacy To prevent contamination of the drug or the atmosphere. To mix the diluting agent with the powder and dissolve the drug (NPSA To prevent patient from receiving an unstable or contaminated drug Reconstitution method (b): 7 13 7 8 9 10 Draw into the syringe a volume of air equivalent to the required volume of solution to be drawn up Remove the needle cover and insert the needle into the vial through the rubber septum Invert the vial. Keep the needle in the solution and slowly depress the plunger to push the air into the vial Release the plunger so that the solution flows back into the syringe (if a large volume of solution is to be withdrawn use a push pull technique) To prevent bacterial contamination of the drug (NPSA To gain access to the vial To create an equilibrium in the vial To create an equilibrium in the vial 6
11 12 13 Inject the diluting agent into the vial. Keeping the tip of the needle above the level of the solution in the vial, release the plunger. The syringe will fill with the air that has been displaced by the solution With the needle and syringe in place, gently swirl the vial to dissolve all the powder Inspect the solution for cloudiness or particulate matter. If this is present, discard. Follow Trust guidelines on what action to take, eg Discuss with pharmacist Continue from 14 below This equilibrium method helps to minimize the build-up of pressure in the vial To mix the diluting agent with the powder and dissolve the drug To prevent patient from receiving an unstable or contaminated drug Withdrawal of medication from vial (14-16) 14 15 16 Withdraw the prescribed amount of solution, and inspect for pieces of rubber that may have cored out of the cap: Note, coring can be minimized by inserting the needle into the cap, bevel up, at an angle of 45 to 60. Before complete insertion of the needle tip, lift the needle to 90 and proceed Remove air from syringe without spraying into the atmosphere by injecting air back into the vial or replace the sheath on the needle and tap the syringe to dislodge any air bubbles. Expel air Attach a new needle (and discard used needle into appropriate sharps container) or attach a sterile plastic end cap. Staff must not re-sheath the needle To ensure that the correct amount of drug is in the syringe (NPSA. To prevent the injection of foreign matter into the patient To reduce risk of contamination of practitioner. To prevent aerosol formation To reduce the risk of infection. To avoid possible trauma to the patient if the needle has barbed. To avoid tracking medications through superficial tissues. To ensure that the correct size of needle is used for the injection 7
Intramuscular injection administration 1 Explain and discuss the procedure with patient 2 Check the patients consent 3 Re check the patient s prescription chart, and ascertain the following: (a) Drug (b) Dose (c) Date (including start and end date) and time of administration (d) Route and method of administration (e) Muscle / Site as determined by manufacturer s instructions etc (f) Other things stated for prescribing section allergies etc (g) Diluting agent as appropriate (h) Validity of prescription (i) Signature of doctor Note: See Appendix 2 and 3 for descriptions of possible IM routes and Z Track technique 4 Decontaminate hands. Risk assess the need for personal protective equipment. Then assist the patient into the required position 5 Remove the appropriate garment to expose the injection site To allow access to the injection site and to ensure the designated muscle group is flexed and therefore relaxed (Workman 1999) To gain access for injection (Workman 1999). Refer to Appendix 2 for injection site detail, rationale and diagrams 6 Assess the injection site for signs of inflammation, oedema, and infection and skin lesions. Do not use site if any of these signs are present. Discuss with patient any contraindications To promote effectiveness of administration (Workman 1999). To reduce the risk of infection (Workman 1999). To avoid skin lesions and avoid possible trauma to the patient (Workman 1999) 8
7 Although current guidance does not recommend pre-injection skin disinfection for individuals with visibly clean skin, it does recommend skin disinfection with a 2% Chlorhexidine Gluconate in 70% Isopropyl wipe for injections in the following cases: o Injection into the thigh o Older Adults o Patients with compromised immunity o Patients with a known infection eg MRSA For services/teams that care for patients on alcohol detoxification medication, alcohol free wipes can be used eg Astroplast To reduce the number of pathogens introduced into the skin by the needle at the time of insertion, to prevent stinging sensation if alcohol is taken into the tissues upon needle entry (Workman 1999) 16 Intramuscular injection administration continued (8-14) 8 Use Z Tracking technique. (Refer to pictorial guide in appendix 2) 9 Reassure patient to maintain cooperation and prepare them for the actual administration. Holding the needle at an angle of 90 quickly plunge it into the skin See Appendix 2 for rationale, technique description and diagram To ensure that the needle penetrates the muscle (Workman 1999) 10 For Dorsogluteal Injections only: Pull back the plunger If no blood is aspirated, depress the plunger at approximately 1 ml every 10 seconds and inject the drug slowly (except in cases of rapid tranquilisation) If blood appears, withdraw the needle completely and activate the mechanical safety device, replace it and begin again Explain to the patient what has occurred All other injection IM sites have no major blood vessels below them making this unnecessary. To confirm that the needle is in the correct position and not in a vein (Workman 1999). This allows time for the muscle fibres to expand and absorb the solution (Workman 1999). To prevent pain and ensure even distribution of the drug 9
11 Wait 10 seconds before withdrawing the needle (except in cases of rapid tranquilisation when an individual risk assessment may change this time frame exceptions to SOP should be documented in patients clinical record) To allow the medication to diffuse into the tissue (Workman 1999) 12 Withdraw the needle rapidly and activate the mechanical safety device. Using gauze apply pressure to any bleeding point. To prevent haematoma formation (E) 13 Dispose of equipment into the appropriate waste stream/sharps bin at the point of care. Remove any PPE and decontaminate hands with liquid soap and water. If soapy hand wipes are used follow with alcohol hand rub. To ensure safe disposal and to avoid laceration or other injury to staff (MHRA 2004 DH 2005b:) 14 Record the administration on appropriate charts. To maintain accurate records, provide a point of reference in the event of queries and prevent duplication of treatment (NMC 2005 NMC 2008a: NPSA 10