1
Q
Mandatory IM site for infants?
A
Vastus lateralis (lateral aspect of anterior thigh)
2
Q
IM’s used frequently in children?
A
No, insufficient muscle mass + painful
- But used in emerg
3
Q
Site IM in older children?
A
Deltoid acceptable or ventrogluteal (like adults)
4
Q
Why is gluteal site very hazardous in children under 1?
A
Muscle does not develop until able to walk, so poses great risk of permanent damage to sciatic nerve.
5
Q
Ventrogluteal landmarking?
A
Place heel of hand on greater trochanter and index finger angled toward anterosuperior iliac crestm speading middle finger along the crest posteriorly. Angle between index and middle finger = site.
6
Q
Should you administer an injection to a sleeping child/baby?
How to approach explaining procedure to a child?
A
No, always wake, play with or provide explanation.
Be honest about pain, describe that it won’t be much and will only last for a little bit (so knows has limitations)
7
Q
Approach to giving injection in children?
A
- Give topical anesthetic if wanted (30 mins prior)
- Explain procedure: be brief, don’t give time for anticipation to worsen pain
- If necessary, ask for help in restraining
- Can say “ouch” as distraction technique
- Always comfort + hold child after painful procedure (or have parent do it)
- Record med & site of injection so can ensure rotation
8
Q
Site for infusion pumps in children?
Common drugs given this way?
A
Abdomen (protects pump and allows it to be out of sight)
- Insulin, heparin, deferoxamine
9
Q
Important consideration for children who are not yet toilet trained regarding infusion pumps?
A
Should not be used because risk contamination with urine + feces.
10
Q
How often do infusion pump sites need to be changed?
A
At least every 1-2 days to prevent infection.
11
Q
How early can children use their own autoinjection syringes?
A
age 5-6
12
Q
Typical use of ID injections?
A
Skin testing: TB + allergy testing
13
Q
Why are ID meds administered this way?
A
Potent medications so inject where blood supply is reduced (slow absorption occurs) → can experience anaphylactic rxn if entry bloodstream too quickly
14
Q
Ensure skin is ______ prior to administering ID
A
free of lesions, injuries + relatively hairless
15
Q
Typical ID sites?
A
Inner forearm 3-4 fingers below antecubital space, one hand above wrist)
+ upper back
16
Q
ID:
- What needle length?
- Gauge?
- Degree of insertion?
- Max fluid amounts?
A
- TB or small needle, 3/8 to 5/8in
- 25-27 gauge (fine)
- 5-15 degree angle
- 0.01-0.1mL (only administer up to 0.1 for children)
17
Q
How do you know if you have potentially entered subQ tissue when giving an ID?
A
- Doesn’t form bleb
- Site bleeds when needle withdrawn
18
Q
Should pt experience any discomfort at site after ID injection?
A
No
19
Q
What should you see appear when giving an ID injection?
A
Small, light bleb approx 6mm, 1/4in will form
20
Q
Technique for ID injection?
A
- Stretch skin over site with nondominant hand
- With needle almost against skin, insert slowly at 5-15 angle until resistance felt. Advance into epidermis approx 3mm (1/8in) → will see bulge of needle tip
- Inject med slowly, normally will feel resistance (if not too deep, remove and try again)
- See bleb form
- Remove needle
- Apply alcohol swab gentle over site
21
Q
Results for TB testing:
- When to evaluate?
- What are you looking for in what populations?
A
- Evaluated at 48-72 hours
- Look for induration (hard, dense, raised area) around site of:
- ->15mm or more in pt with no known risk factors for TB
- ->10mm or more from pt who are recent immigrants, IV drug users, residents and employees of high risk settings, pt with certain chronic diseases, children less than 4 yrs, and infants, children, and adolescents exposed to high risk adults
- -> 5mm or more in pt with HIV, have fibrotic changes or prior chest X-ray indicating previous TB infection, organ transplants, or immunosuppressed
22
Q
What is the parental route of choice for chronic pain?
A
SubQ butterfly
23
Q
Indications for SUBQ butterfly?
A
- Circumstances that preclude or compromise oral admin
- Pain or symptom crisis requiring rapid and reliable med admin and absorption
- Poor or variable compliance (dementia, delirium, restless, agitated)
24
Q
Benefits of SubQ butterfly?
A
- Avoids multiple injections
- Avoids turning + repositioning client
- Allows better rest during the night
- Absorbs effectively
- Simple and inexpensive method of delivery which may be used in the hospital or home care setting
- If client is at home, can teach family members to give by this route
25
Possible complications of subQ butterfly?
- Skin irritation
- Infection
- Pain at the site
- Bleeding, bruising, or swelling
26
When should a subQ butterfly be changed?
- at least once a week + at first sign of inflammation, erythema, leakage, bruising or swelling.
(Palliative pts often kept in longer)
27
If breakthrough pain results fro poor absorption in subQ butterfly, what to do?
Often remedied by changing site
28
If the concentration of a med to be administered by subQ butterfly is changed, what must be done?
New site must be established
29
What additional med must be drawn in subQ butterfly to prime the IV connector?
Is this added each time med is given?
- ONE LINK: add 0.28mL
-
- No, ONLY with initial dose
30
Max volume for subQ butterfly in adults and adolescents?
Adult: 2mL
Adolescent: 1.5-2mL
31
Can more than one med be administered through the same catheter with subQ butterflies?
No, must use separate catheter because is already primed with one med.
32
What problem can occur when more than 1mL of med is administered via subQ butterfly frequently?
Can make site "boggy", causing poor absorption and necessitating more frequent site changes
33
Preferred sites for subcut butterfly injections?
- Abdomen (below costal margin, above iliac crests, away from waistline)
- Posterior flank
- Subclavicular
- Anterior aspects of thigh
- Upper arm
34
Preferred site for subcut butterfly in children and elderly?
Subclavicular
- b/c is less painful + less restricting of movement
- insufficient subQ at other sites in elderly
35
How do you choose a site for subcut butterfly?
- Condition of skin (ability to grasp skin fold, no previous radiation to area, comfort, intact skin, free of infection, bruising + scar tissue)
- Away from bony prominences + large underlying muscles + nerves
36
According to VIHA, how many times should a subcut site be cleansed with alcohol swabs prior to injection?
3 times (5cm, circular motion moving outward)
37
Bevel points ___ when injecting subcut butterfly?
Up
38
Injection angle for subcut butterfly?
30 degrees
39
How big of a skin roll should you make for subcut?
1.25-2.5cm.
40
WHat info to include on label of dressing over subcut butterfly?
- Date
- Drug + drug [ ] used to prime
- Initials
41
Angle to inject IM?
90 degrees
42
What factors influence needle size selection for IM?
Viscosity of med
Injection site
Patient's weight
Amount of adipose tissue
43
How to determine needle gauge for IM?
Based on viscosity of med
44
Gauge (IM) to be used for:
1) Immunizations and meds in aqueous solutions:
2) Viscous/oil based med
3) Children
1) 20-25
2) 18-21
3) 22-25
45
IM Needle Length for:
1) Thin person
2) Average weight/BMI
3) Pt over 70kg
4) Pt over 90kg
o Thin person = 5/8 to 1 inch
o Average = 1 inch
o Pt over 70kg = 1-1 ½ inch
o Pt over 90kg = 1 ½ inch
46
IM NEEDLE length based on site?
1) Ventrogluteal
2) Vastus Lateralis
3) Deltoid
Ventrogluteal = 1 ½ inch
Vastus Lateralis = 5/8 to 1in
Deltoid 1- 1 ½ inch
47
IM Needle length based on child's age:
1) Infants
2) Toddlers
3) Older children
4) preterm or small infants
5) obese
1) Infants: 1inch
2) Toddlers: 1 – 1 ¼
3) Older children: 1 ½ to 2in
4) preterm or small infants: smaller needle
5) obese: up to 1.5 inch
48
Recommended IM sites for children?
o Anterolateral thigh for up to 12 months
o Deltoid 18months +
o Ventrogluteal for children of all ages
49
Fluid amounts for IM?
o 2-5mL safe in large muscles….typically never over 3mL in single injection, however, because does not absorb well
o Older adult + thin → 2mL
o Older infants + children → 1mL
- Older children with larger muscles up to 2mL
50
Advantages of Z-track method?
- prevents leakage of med into subQ
- seals med in muscle
- minimizes irritation
- proven to be less painful
51
Technique for Z-track method
o Pull overlying skin and subQ tissue approx 2.5cm to 3.5cm (1-1/2inch) laterally to side with ulnar side of nondominant hand
o Hold position while putting in med, release after withdrawing
o Keep inserted into skin for 10 sec to let med absorb
52
Important to rotate IM sites?
Yes, to prevent hypertrophy
53
Why to avoid emancipated or atrophied muscle for IM?
does not absorb well
54
Do you aspirate with IM injections?
Yes, required for all but vaccines
55
How to pick IM site?
free of pain, infection, necrosis, bruising, and abrasions; consider underlying bones, nerves, blood vessels, and volume of med
56
Advantages of ventrogluteal site?
- Deep + situated away from major nerves + blood vessels
- Easily identified by bony landmarks
- Preferred site for larger vol, more viscous, irritating
- Recom for pediatric IM site for children of all ages
57
Which site is preferred site for larger vol, more viscous, irritating meds?
Ventrogluteal?
58
Vastus lateralis is preferred site for?
```
o biotics (immunizations) to infants, toddlers + children
& recommended for pediatrim IM site for infants up to 12 months
```
59
Landmarking for vastus lateralis?
Extends on adult from handbreadth above knee to same before greater trochanter of femur - use middle third of muscle for injection
60
Advantages of vastus lateralis?
o Absence of major blood vessels + nerves
| o Rapid drub absorption
61
How to have pt relax muscle to use vastus lateralis for IM?
have knee slightly flexed, foot externally rotated; or have sit
62
Special considerations for deltoid site for IM?
- Not well developed in many adults – can damage underlying nerves
- Use only for SMALL AMOUNTS (2mL or less)
63
How to landmark ventrogluteal site?
- Have pt lie on supine or lateral position
- Place heel of hand on greater trochanter, wrist almost perpendicular to femur
- Use right hand for left hip or vice versa
- Point thumb toward pt groin
- Point index finger to anterior superior iliac spine
- Extend middle finger back along iliac crest toward buttock
- Sit is middle of v-shaped triangle formed by of index finger, middle finger + iliac crest.
64
When deltoid is used for IM?
- Routine for immunizations in toddlers, older children, and adults (but vastis lateralis preffered site for immunizations for infants, toddlers + children)
- or if other sites inaccessible
65
Landmarking for deltoid?
o Inject 3-5cm (3 finger widths) below acromion process
66
Before choosing IM site, should palpate for?
tenderness + hardness
67
Speed to inject IM meds?
10 sec/mL
68
What to do immediately before and after injecting IM med?
Before: aspirate
After: wait 10 secounds
69
Should you massage an IM site after admin?
No - just apply gentle pressure (massage can damage underlying tissue)
70
When mixing meds from ampule + vial, which to draw from first?
Vial (then use filter needle to take from ampule)
71
When preparing insulins, what to do with the med first?
Roll vial in hands to suspend med.
72
Can you mix insulins?
| Which to pull up first?
Yes, if compatible
| - always prepare short or rapid-acting first to prevent contaminating it with long-acting
73
Procedure for mixing meds from 2 vials?
- Wipe tops of vials with alcohol swab
1) Inject air into vial A
2) Inject air into vial B
3) Withdraw med from B
4) Withdraw med from A
74
Procedure for mixing short and intermediate/long acting insulins?
- Aspirate air into intermediate/long acting first
- Then into short acting
- Draw up short acting
- Draw up long acting
75
How should a child be positioned during vaccination?
```
NOT SUPINE (as results in more pain)
- sit upright or in arms of parent
```
76
How to ease pain in infants under 12 months receiving vaccines?
- have breastfeed if breastfeeding
| - Otherwise administer sweet tasting solution
77
Is the aspiration, slow injection technique used for children?
No, no aspiration + rapid injection technique used for children
78
When administering multiple vaccinations to a child, should the most painful be administered first or last?
Last
79
Technique for minimizing pain for children 4 and up during injection?
Offer to rub or stroke the skin near injection site with moderate intensity before + during vaccination
80
Children ____ years and older can engage in slow, deep breathing or blowing during vaccination
3
Nursing 242
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