COURSE MODULE

N106a- PHARMACOLOGY SKILLS

RLE

Course : N106a
Course Title : Pharmacology
Course Credit : 3 units/51 hours
Contact Hours/Week : 9 hours /week
Pre requisites : Mathematic, Anatomy and Physiology,
Microbiology, NCM100, NCM101, NCM 102
NCM 103, NCM 104
Module IV
Introduction
This module discusses about Parenteral Drug Administration mainly Intramuscular
Injection, Subcutaneous Injection, and Intradermal Injection. Its indications and
contraindications. Acceptable and recommended sites or route, proper syringes and needles to
use for injections following acceptable standards and techniques in drug administration.

Week 4 – Parenteral Drug Administration

Topic: Safe preparation & disposal of parenteral medications & supplies
1. Preventing infection during parenteral drug administration
2. Equipment used in parenteral drug administration
3. Safe Medication Administration
4. Promoting safety and comfort of patient during medication injection
5. Preventing needle stick injuries

Intended learning Objectives

At the end of the module, learner will be able to:
1. Identify principles of sterile technique when preparing injections;
2. Identify needed equipment in parenteral drug administration;
3. Demonstrate safe and acceptable standards in medication administration;
4. Employ safe and comfort of patient during injection; and
5. Demonstrate proper disposal of equipment used.

Activate prior knowledge

Pre- test

Acquire new knowledge

Ppt discussion/lecture (interactive), Demonstration through:
Zoom, video conferencing, telegrams
Video clips
Readings
Return Demonstration tools

Juliet V. Avena, MAN,RN

 Discussion:
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Preventing Infection during an Injection

According to Seigel et al, (2007), research has shown that unsafe injection practices have resulted
in patient exposure to infections leading to outbreaks of infectious diseases. These unnecessary
exposures were the result of deficient health care practices. Injectable medications must be given
in a safe manner to maintain sterility of equipment and prevent the transmission of infectious
diseases between patients and health care workers. Table 7.1 summarizes how to prevent an
infection during an injection.

Safety consideration:

Always follow the principles of sterile technique when preparing injections.

Principle  Additional Information

Always perform hand hygiene before administration and after removing gloves

and dry thoroughly or do alcohol hand hygiene.

Perform hand hygiene.

Prevent needle/syringe Keep sterile parts of the needle and syringe sterile. Avoid letting the needle touch
contamination. unsterile surfaces such as the outer edges of the ampule or vial, surface of the
needle cap, or counter. Always keep the needle covered with a cap when not in
use, and use the scoop-cap method to avoid needle-stick injuries. Avoid touching
the length of the plunger. Keep the tip of the syringe sterile by covering with a cap
or needle.

Juliet V. Avena, MAN,RN

 Parts of a syringe and needle

Wash the patient’s skin with soap and water when it is soiled. Follow agency
policy for skin preparation. When using an alcohol swab, use a circular motion to
rub the area for 15 seconds, and then let the area dry for 30 seconds. If cleaning a
site, move from the center of the site outward in a 5 cm (2 in.) radius

Prepare patient’s skin.

Use single-dose vials/ampules whenever possible. Do not keep multi-dose vials in

patient treatment area. Discard if sterility is compromised or questionable. Do not
Prevent contamination
combine and administer medications from single-dose vials or ampules for later
of solution.
use. Ampules should not sit open and should be used immediately, then discarded
appropriately.

Single use syringe and needle must be used with each patient. Always inspect
Use new, sterile sterile
packaging for intactness; inspect for dryness, rips, torn corners and expiry date. If
equipment with each
single use equipment is not available, use syringes and needles designed for steam
injection.
sterilization.

Universal precautions Wear personal protective gears/equipment whenever necessary

Data source: CDC, 2015; Hutin et al., 2003; Perry et al., 2014; Provincial Infectious Disease Advisory

Juliet V. Avena, MAN,RN

 Committee, 2014; Siegel et al., 2007.

Safe Medication Administration

Medication errors have a substantial impact on health care in Canada (Butt, 2010). When preparing and
administering medication, and assessing patients after receiving medication, always follow agency policy
to ensure safe practice.

Safety consideration:

Agency policy on medication administration and on the medication administration record (MAR)
may vary. Always receive the required training on the use of each agency’s medication system to avoid
preventable errors.

Principle  Additional Information

Avoid distractions. Some agencies have a no-interruption zone (NIZ),

Be vigilant when preparing
where health care providers can prepare medications without
medications.
interruptions.

Always ask patient about allergies, types of reactions, and severity of

Check for allergies.
reactions.

Use two patient identifiers at all

Use at least two patient identifiers before administration AND compare
times. Always follow agency
against the medication administration record (MAR).
policy for patient identification.

All medications require an assessment (review of lab values, pain,

Assessment comes before respiratory or cardiac assessment, etc.) prior to medication
medication administration. administration to ensure the patient is receiving the correct medication
for the correct reason.

Be diligent in all medication Errors in medication calculations have contributed to dosage errors,
calculations. especially when adjusting or titrating dosages.

Slips in memory are caused by lack of attention, fatigue, and

Avoid reliance on memory; use distractions. Mistakes are often referred to as attentional behaviors, and
checklists and memory aids. they account for most errors in health care. If possible, follow a standard
list of steps for every patient.

Juliet V. Avena, MAN,RN


Communicate with your patient
before and after administration.
Avoid workarounds.
Ensure medication has not
expired.
Always clarify an order or
procedure that is unclear.
Use available technology to
administer medications.
Report all near misses, errors, and
adverse reactions.
Be alert to error-prone situations
and high-alert medications.
If a patient questions or expresses
concern regarding a
medication, stop and do not
administer it.
Data source: Agency for Healthcare Research and Quality, 2014; Canadian Patient Safety Institute,
2012; Debono et al., 2013; Institute for Healthcare Improvement, 2015; National Patient Safety Agency,
Juliet V. Avena, MAN,RN
Provide information to patient about the medication before
administering it. Answer questions regarding usage, dose, and special
considerations. Give the patient the opportunity to ask questions.
Include family members if appropriate.
A workaround is a process that bypasses a procedure, policy, or problem
in a system. For example, nurses may “borrow” a medication from
another patient while waiting for an order to be filled by the pharmacy.
These workarounds fail to follow agency policies that ensure safe
medication practices.
Medication may be inactive if expired.
Always ask for help whenever you are uncertain or unclear about an
order. Consult with the pharmacist, charge nurse, or other health care
providers and be sure to resolve all questions before proceeding with
medication administration.
Bar-code scanning (eMAR) has decreased errors in administration by
51%, and computerized physician orders have decreased errors by 81%.
Technology has the potential to help decrease errors. Use technology
when administering medications, but be aware of technology-induced
errors.
Reporting allows for analysis and identification of potential errors,
which can lead to improvements and sharing of information for safer
patient care.
High-alert medications are those that are most likely to cause significant
harm, even when used as intended. The most common high-alert
medications are anticoagulants, narcotics and opiates, insulins, and
sedatives. The types of harm most commonly associated with these
medications include hypotension, respiratory depression, delirium,
bleeding, hypoglycemia, bradycardia, and lethargy.
If a patient questions a medication, stop and explore the patient’s
concerns, review the physician’s order, and, if necessary, notify the
practitioner in charge of the patient.
 2009; National Priority Partnership, 2010; Prakash, et al., 2014

Promoting Safety and Comfort of a Patient during an Injection

Injections can be given safely and effectively, and harm can be prevented if proper injection technique is
used. Most complications related to injections are associated with intramuscular injections, but may occur
with any route. Complications can occur when an incorrect site is used, or with an inappropriate depth or
rate of injection (Malkin, 2008).
Principle  Additional Information

For injections, use a sharp, beveled needle and place bevel side up. Change the
needle if liquid coats the shaft of the needle. Correct needle length allows for correct
delivery of medication into the correct site and can reduce complications such as
abscesses, pain, and bruising. Needle selection should be based on size of patient,
Correct needle gender, injection site, and amount of medication injected. Women tend to have more
adipose tissue around the buttocks and deltoid fat pad, which means more than half
the injections given do not reach the proper IM depths in women. Large bore needles
have been found to reduce pain, swelling, and redness after an injection, as less
pressure is required to depress the plunger.

Inserting the needle at the proper angle (depending on the type of injection) and
entering the skin smoothly and quickly can reduce pain during injection. Hold the
syringe steady once the needle is in the tissue to prevent tissue damage. Withdraw
Proper angle of the needle at the same angle used for insertion. The angle for an IM injection is 90
insertion and removal degrees. With all injections, the needle should be inserted all the way up to the hub.
Holding the syringe like a dart prevents the medication from being injected during
insertion of needle. Removing residue (medication on the tip of the needle) has been
shown to reduce pain and discomfort. To remove residue from the needle, change
needles after preparation and before administration.

The patient’s position may affect their perception of pain. Proper position will also
facilitate proper land marking of the site. For IM injections, for example, the
Patient position
ventrogluteal site has the greatest muscle thickness and is free of nerves and blood
vessels, with a small layer of fat.

Position the patient’s limbs in a relaxed, comfortable position to reduce muscle

tension. For example, lying prone may help a patient relax prior to an IM injection.
If giving a deltoid IM injection, have the patient relax the arm by placing the hand in
Relaxation technique
the lap. If a patient is receiving an IM injection in the vastus lateralis or
and distraction
ventrogluteal site, encourage the patient to gently point toes outwards to relax the
methods
muscle. Relaxation skills of the health care provider will help decrease the patient’s
anxiety-heightened pain. If possible, divert the patient’s attention away from the
injection procedure.

Pre-medication, if To decrease pain upon insertion, a pain spray, topical anesthetic, or wrapped ice may

Juliet V. Avena, MAN,RN

 be placed on the insertion site for a minute prior to injection. For IM injections, two
required studies found that applying pressure to the injection site for 10 seconds before the
injection reduced pain. This data supports the gate theory of pain control.

Some research shows that the Z-track technique results in reduced pain and
Z-track method for
complications, and fewer injection lesions. However, other research shows that Z-
IM injections
track injections result in more pain and bleeding at the injection site.

Research has found that administrating medications at 10 seconds per ml is an

effective rate for IM injections. Increasing the rate to 20 seconds per ml did not
Administration rate
show any reduction in pain. Always review drug administration rate as per pharmacy
or manufacturer’s recommendations.

Gentle touch with Gently apply a dry sterile gauze to the site after the injection. Rotate injection sites
insertion sites to prevent the development of indurations and abscesses.

Aspiration with IM Review the latest research regarding the utility of aspirating IM injections. There is
injections lack of strong evidence to support the technique of aspiration with IM injections.

Data source: Ağac & Günes, 2011; Canadian Agency for Drugs and Technologies in Health, 2014; Cocoman
& Murray, 2008; Greenway, 2014; Hunter, 2008; Malkin, 2008; Mitchell & Whitney, 2001; Nisbit, 2006;
Ogston-Tuck, 2014a; Perry et al., 2014; Rodgers & King, 2000; Sisson, 2015; Workman, 1999

Preventing Needle-Stick Injuries

Health care providers can be at risk for needle-stick injuries in any health care setting. The most common
places for needle-stick injuries to occur are in the operating room and patient rooms. Tasks that place the
health care provider at risk include recapping needles and mishandling IV lines. Table 7.4 provides
guidelines to prevent needle-stick injuries.
Principle  Additional Information

Avoid recapping needles. Recapping needles has led to the transmission of infection. If possible,
always use devices with safety features — i.e., safety shield.

Dispose of the needle

immediately after Immediately dispose of used needles in a sharps disposal container
injection. (puncture-proof and leak-proof) to avoid unsafe disposal of a sharp.

Avoid using needles if possible. Use a needle only when performing an SC,
Reduce or eliminate all
ID, or IM injection. Use a needleless system and engineered safety devices
hazards related to needles.
for prevention of needle-stick injuries.

Juliet V. Avena, MAN,RN

 Plan the safe handling and disposal of needles before beginning a procedure
Plan disposal of sharps
that requires a sharp needle. Bring sharps container close to the bedside prior
before injection.
to injection. Sharps containers should be at eye level and within arm’s reach.

Follow all standard

Follow all agency policies regarding infection control, hand hygiene,
policies related to
standard and additional precautions, and blood and body fluid exposure
prevention / treatment of
management.
injury.

Report all needle-stick injuries and sharp-related injuries immediately. Data

collected regarding the nature of injuries help guide needle-stick prevention
strategies for new practices and devices. Review how to manage needle-stick
Report all injuries.
injuries and follow agency policy regarding exposure to blood-borne
pathogens. Policies help decrease the risk of contracting a blood-borne
illness.

Attend training on injury-prevention strategies related to needles and safety

Participate in required
devices as per agency policy. Participate in and evaluate the selection of
training and education.
safety devices, and report known needle-stick hazards to managers.

Data source: American Nurses Association, 2002; Centers for Disease Control, 2012; National Institute for
Occupational Safety and Health, 1999; Perry et al., 2014; Pratt et al., 2007; Wilburn, 2004; Wilburn &
Eijkemans, 2004

Analysis
Case Analysis
Journal sharing
Quiz

Application
Return Demonstration

Assessment
Individual /group activities
Periodical examination

Prepared by:

Juliet V. Avena
Professor

Juliet V. Avena, MAN,RN