Best Practice in Adult Nursing: Injection Technique

Introduction

Nursing is one of the most important areas in the management of patients. This field of healthcare is based on the cumulative evidence on the best care for patients with different conditions. Many procedures that entail nursing care include injections that form the bulk of this profession. Therefore, the most basic qualification in nursing care is how to make an injection. Despite this task being simple and a common procedure, the available evidence shows that some nursing staff members still have a problem with the procedure.

Several researchers have written on the available evidence on injection procedures. Their efforts have led to the formulation of the best practice in injection. From the available evidence, different injection techniques have been formulated. Different institutions, individuals, and organisations have different standards of nursing care. Hence, it is common that different techniques of injection exist (Diggle 35). This essay looks at the different practices and techniques in injection and the available evidence to support them. Besides, it makes appropriate conclusions on the best practices.

PICO Formulation

The essay looks at the population of patients who require the use of injection as one of the major procedures in their nursing care management. The study looks at patients of all genders, age, and settings. The common characteristic is the requirement for injections in the course of patient management.

The intervention on focus is injections during patient care, which forms the focus of the study. The comparison that is provided in the essay is that of the evidence-based practice in injection against procedures that are practiced in different institutions by different individuals (Craig and Smyth 19; Ellis 9). The outcome in this study is a change of injection practice in different institutions.

Different Types and Reasons for Injections

Hospital visits are synonymous with injections. Most patients, especially children, are weary of hospital visits because of the injections that they have to be given in every visit. Before the use of penicillin in treatment in the 1940s, doctors were the main health staff people who were required to give injections (Garner 17).

However, this practice has been handed over to nurses who practice it on a daily basis as they administer different therapies in patient care. The need for injecting drugs into the body arose due to the different encouraging results that had been previously achieved, including bypassing the digestive system and promoting a faster effect on the target organs (Garner 17).

Other reasons for giving drugs using the injection method include the finding that some of the patients are not allowed to take anything through the oral route. These patients include those who are in a state of coma, those with intestinal obstruction, or those who have other types of gut pathology. Some medications are not available in oral form as they are digested by the gastrointestinal system. These drugs include insulin and other hormones that are commonly used in treatment.

When a rapid onset of drug action is required in some patients, the use of injection is preferred to some of the other methods of drug delivery because the drug delivery is faster.

The injection of the drug is preferred to some other routes when the drug delivery needs to be fast, but not as fast as through the intravenous route. Many of the patients who require injections are hospitalised since this procedure usually requires a close supervision. Regular administration of some drugs is done through injections. The most important factors to consider in injection include the route to be used, the technique to be applied, the equipment, and the site where the procedure is to be carried out as discussed in this section.

The most familiar paths of vaccination include, “the intradermal, the subcutaneous, and the intramuscular route” (Bautista, and Zakari 30). Each of these routes is preferred to the others for specific reasons. The intradermal route is preferred where the effects of the substance being injected need to act on a local as opposed to systemic area. In this injection route, the target is the dermis. According to Walsh and Brophy, this route is useful for allergen testing and administration of local anaesthetics (1037). The areas of injection are similar to the subcutaneous injection sites.

The subcutaneous injection route is often applied where the desire is to have a relatively reduced rate of absorption for the administered products (Bautista, and Zakari 30). The most commonly subcutaneously administered drug is insulin. Most substances that require repeated administration are administered via subcutaneous injections. The other advantage is that this route is relatively less painful compared to other injection routes (Avşar, and Kaşikçi 404).

Initially, the practice of subcutaneous administration of substances involved aspiration before the administration of the substance. However, current evidence demonstrates that there is no need for aspiration before injection as the risk of injecting into a vessel through this route is small (Walsh, and Brophy 1035). In fact, some researchers have observed an increase in hematoma formation after aspirating before subcutaneous injection.

Intradermal injections are among the most common procedures in health institutions. This route of drug administration provides benefit over other routes since the highly perfused muscles allow faster and better drug absorption (Garner 19). Some of the factors that determine the site for intramuscular injection include the age of the patient, their general state, the amount, and availability of other routes. Drugs that are administered via this route of injection may have adverse effects on tissues. Hence, it is necessary to monitor the injection site to avoid complications on the skin.

Each of the vaccination paths has its favoured place. For example, the intramuscular injection route is commonly done on areas that have muscles with a rich blood supply. These areas include the deltoid muscle at the upper outer part of the arm where vaccines such as hepatitis B are administered (McWilliam, Botwinski, and LaCourse 105).

This site is also the location where the tetanus toxoid is administered to offer protection against the disease. However, the most common site where intramuscular injections are given is the gluteal region, which is the outer part of the buttocks (Garner 19). This site has muscles with a rich blood supply, including the gluteus minimus, medius, and maximus.

Injection sites that are used in intramuscular injection are associated with some risks of injury to the underlying structures, including the sciatic nerve that is commonly injured while injecting the gluteal area. Arteries that supply the muscles to be injected may also be injured during the exercise, thus resulting in complications of the injection. Some of the vaccination victims are overweight. Hence, injections into these different sites often end up into the fat tissues.

The lateral side of the femur or thigh is also a common injection site, especially in children less than seven months. The femoral nerve may be injured in the process of making this injection. There is a higher risk of muscular atrophy with repeated injections (Carter-Templeton, and McCoy 238).

The ventrogluteal location of intramuscular vaccination is a frequent immunisation spot. According to Diggle, when used, this site has a number of advantages compared to other sites (35). Most researchers suggest that the ventrogluteal site offers safety to the sciatic nerve that is commonly injured while giving the dorsogluteal injection (Carter-Templeton, and McCoy 238). There is also no reported complication of immunisation when a health profession targets the ventrogluteal location. Consistent evidence shows that the thickness of fat tissues in this area is consistently smaller in relation to the dorsgluteal region (Carter-Templeton, and McCoy 238).

Injection Techniques

The techniques to be used during injection depend on the individuals performing the procedures, the patients being injected, and the health institution among other factors. Aside from the different techniques in use during injection, some techniques are founded on the best evidence-based methods (Carter-Templeton, and McCoy 238).

The aims of the different techniques include pain reduction, reduction of complications, and better access and drug retention. Pain reduction during injections is one of the factors that determine the degree of success (Ağaç, and Güneş 565). Patients usually resist painful injections. The success of injections depends on how well the patients are able to cooperate.

The angle of entry into the injection site in relation to the degree of pain has been the subject of most studies, especially for intramuscular injections (Small 294). Some of the researchers who studied the relationship between the angle of entry and pain include Small (294). The researcher stated that nursing staff members do not usually use the 900 entry angle while giving injections, and hence a common cause of pain for their patients.

Therefore, the recommendation while giving intramuscular injections is that the individual giving these injections should aim at achieving a right angle between the needle and the skin. The other aspect of the technique is that the hands that give the injection need to be positioned near the injection site (Small 294). Researchers found that there is a reduced incidence of inaccuracies and accidents while giving the injections using this technique (Small 294).

The conventionally used method during immunisation is where the giver elongates the body membrane at the place where the vaccination is to be made (Small 293). The reasoning behind this technique is that the stretching of the skin reduces the sensitivity of nerve ending at the site, and hence the reduced pain during injection (Cocoman, and Murray 426).

According to Small (293), nurses in the UK have different techniques depending on the degree of knowledge. However, there is limited research into these different techniques. The technique whose practice has been associated with reduced discomfort for patients and less complications is the ‘Z track’ technique (Small 293; Jolley 6).

The effect of pulling the skin is that the coetaneous and subcutaneous tissues are moved away from the intramuscular injection site. The removal of the injection needle and the release of the skin cause an overlap of tissues over the intramuscular injection site, hence covering the site and preventing any leakage (Small 292). A common practice is to exercise the injected limb that to ensure increased perfusion and drug absorption.

Literature Review

Different researchers have demonstrated the existing levels of evidence in the injection practices and techniques. In one of the studies that investigated the injection tactics, Cocoman and Murray investigated the differences in subcutaneous tissue thickness and the association with success on the procedure (426).

In this study, the researchers investigated the injections in 213 adults who had them done in the dorsogluteal areas (Cocoman, and Murray 426). The areas were localised using Ct scans, with the results showing that only 5% of women and 15% of men had the ideal injections while the rest of the patients had subcutaneous tissue injections (Cocoman, and Murray 426).

Some other researchers suggested the use of the ‘double cross’ technique during injection (Rodger, and King 538). These researchers stated that there was significant reduction in complications while using the technique that involved dividing the buttocks into four quadrants and further dividing the outer upper quadrant into four smaller quadrants (Cocoman, and Murray 426).

Injections were made into the outermost quadrant of the buttocks. This site is associated with the best results. The researchers also suggested that this site would result in minimal risk of nerve or arterial injury during injection (Garner 19).

Some researchers such as Garner investigated the different techniques of carrying out intramuscular investigations, including the Z-track technique (19). Most evidence available supports the use of this technique in effective intramuscular injections, hence this technique is popularised in many places and learning institutions.

The different researchers supporting the technique cite the safety associated with it, the success in reducing infections and the reduced reflux of the administered drug (Garner 19). According to Garner, Z-track technique results in the best outcome during injection (19). It should be the standard technique for use by nursing staff members.

The other available research is on the preparation for injection, especially the injection site. Research shows that infection may be reduced if the injection site is cleaned prior to the injection since this procedure results in fewer abscesses and systemic infection (Garner 19). In most cases where injections were given without cleaning the injection site, there was increased incidence of infection and a return to the health institution for management of the resulting infection. There is little available research on the best disinfectant to use while cleaning the injection area. The most commonly used fluid is the spirit wipe (Garner 19).

Nursing institutions that use spirit wipes or any other disinfection methods have better results with infection control in terms of the number of sterile abscesses that form on the injection site. The duration of injection is also a subject matter in the best practice during injection. Researchers propose that the person giving injections needs to wait for about ten seconds before the withdrawal of the needle to ensure that the area gets the drug saturated within the tissues (Chan 885). If the withdrawal of the needle is done at a rapid rate, the drug being given can be lost and hence the reduced benefit to the patient.

The other common practice during injection is to have the patient exercise the limb after injection. Most patients who exercise the limb that receives an injection often have significantly better and faster drug absorption compared to the patients whose limbs are stagnant after injection (Cocoman, and Murray 426).

According to Chan, the increased limb activity after injection is associated with better absorption since there is increased blood supply to the limb with a resultant improvement in absorption (885). Therefore, nurses should ensure that the limb that is receiving injection gets active and better exercise after injection to increase the absorption of the drug.

Aside from the increased activity of the limb getting injections, researchers such as Chung, Ng, and Wong also investigated the effect of rubbing the injection site after injection (559). The available evidence suggests that the practice of rubbing the injection site after the procedure results in increased infections (Chung, Ng, and Wong 559; Greenhalgh 15).

Therefore, the suggested standard is that nurses and other health workers should not rub the injection site. The needle should be sharp and dry for less painful injection and the injection site should be dry if previously wiped with a disinfectant (Chan 885).

Quality of the Research Articles

The above literature review focuses on the available literature and evidence on the best practice in giving injections. This study uses many articles that have evaluated different aspects of injections, with different researchers evaluating these different practices. The quality of the many research articles is adequate to reach the conclusions provided in this essay and/or provide a basis for influencing the practice. The search for the literature that is used in the study has been followed by a systematic review of the resulting literature.

The hierarchy of evidence is crucial during this search. There is enough evidence to influence the practice of injection, especially for nursing care professionals who constantly face the daily challenge of carrying out this procedure of injections (Garner 19).

Issues of Implementation

Despite the available evidence on the best practices during injection, people on the ground often find it hard to apply this evidence (Garner 19). According to Garner, there are different reasons for the differences between theory and practice in giving intramuscular and other forms of injections. The most common of these reasons for disparity in practice is the attitude of the different professionals who are required to carry out these procedures (Diggle 35). Attitude is a key determinant of practice in healthcare, especially where the nursing staff member is involved in direct patient management.

The other reason for the practices that nurses have in injecting drugs to patients is the difference in training that they get. The nursing staff people are trained in different institutions. Although these institutions have nearly similar practices, some institutions have adopted standards that are different from the internationally practiced standards to suit their area of care (Carter-Templeton, and McCoy 238).

The results of such disparities in patient care include differences in practice, with one of the affected procedures being injection. For example, some institutions may teach their students on the latest injection techniques while their tutors still practice the traditional techniques. Hence, nursing students end up learning these traditional techniques.

There are other reasons for the differences between training and actual practice in injecting drugs. The unavailability of resources in some areas means that nursing staff members and other healthcare providers are unable to offer these services to their patients (Carter-Templeton, and McCoy 238). For example, in the third-world countries where resources are scanty, the available resources do not allow the practice of some techniques. Some of the nursing staff officials have resulted in improvising materials to cater for the unavailable resources. This move has led to poor practice in the institutions.

Other reasons that have been cited for the poor practice of safe and clean injections include the patient factor. Some patients often have particular demands that nursing care finds difficult to address. These demands include provision of injections that are less painful and involving. Patients are often uneasy. They make the injections more painful by moving while being injected (Diggle 35). Trauma and increased infections are some of the effects of poor injections. They result from patient issues. Patients should be aware of the procedure before it is done to avoid such results.

Despite the large number of nurses who do not use the right procedures during injections, the evidence-based injection techniques are widely practiced in different areas. These areas have seen reduced infection and complications at the injection site (Diggle 36). The significant success in some of these areas may be attributed to the positive attitude of nursing staff people. Their support allows continuous education and availability of resources among others (Diggle 37).

The adoption of evidence-based injection techniques should result in improved care for patients through reduced complications at the injection site (Barker 12).

Conclusion

In conclusion, one of the most vital roles of nurses in patient care is the provision of drugs. Most of these drugs are administered through injections. This review of literature has provided information that is important in shaping the existing practice of injecting drugs into patients. The review has established that the best techniques involve adequate preparation, skin cleaning and disinfection, and Z-track and a 900 angle of entry into the injection area. Some of the reasons why some nurses do not practice the evidence-based injection procedure include ignorance, negative attitude, and unavailability of resources.

Works Cited

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Avşar, Gülçin, and Mağfiret Kaşikçi. “Assessment Of Four Different Methods In Subcutaneous Heparin Applications With Regard To Causing Bruise And Pain.” International Journal Of Nursing Practice 19.4(2013): 402-408. Print.

Barker, Janet. Evidence-Based Practice for Nurses. Los Angeles, LA: Sage, 2010. Print.

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Carter-Templeton, Heather, and Tammie McCoy. “Are We On The Same Page?: A Comparison Of Intramuscular Injection Explanations In Nursing Fundamental Texts.” MEDSURG Nursing 17.4(2008): 237-240. Print.

Chan, Harriet. “Effects Of Injection Duration On Site-Pain Intensity And Bruising Associated With Subcutaneous Heparin.” Journal Of Advanced Nursing 35.6(2001): 882-892. Print.

Chung, Joanne, Winnie Ng, and Thomas Wong. “An Experimental Study On The Use Of Manual Pressure To Reduce Pain In Intramuscular Injections.” Journal Of Clinical Nursing 11.4 (2002): 457-461. Print.

Cocoman, Andrew, and John Murray. “Intramuscular Injections: A Review Of Best Practice For Mental Health Nurses.” Journal Of Psychiatric & Mental Health Nursing 15.5 (2008): 424-434. Print.

Craig, Jean, and Rosalind Smyth. The Evidence-based Practice Manual for Nurses. Edinburgh: Churchill Livingstone, 2007. Print.

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Greenhalgh, Trisha. How to Read a Paper. The basics of Evidence Based Medicine. London: BMJ Books, 2010. Print.

Jolley, Jeremy. Introducing Research and Evidence-Based Practice for Nurses. England: Pearson, 2010. Print.

McWilliam, Paula, Carol Botwinski, and John LaCourse. “Deltoid Intramuscular Injections And Obesity.” MEDSURG Nursing 23.1 (2014): 4-7. Print.

Rodger, Michael, and Lindy King. “Drawing Up And Administering Intramuscular Injections: A Review Of The Literature.” Journal Of Advanced Nursing 31.3 (2000): 574-582. Print.

Small, Sandra. “Preventing Sciatic Nerve Injury From Intramuscular Injections: Literature Review.” Journal Of Advanced Nursing 47.3 (2004): 287-296. Print.

Walsh, Lorna, and Kathleen Brophy. “Staff Nurses’ Sites Of Choice For Administering Intramuscular Injections To Adult Patients In The Acute Care Setting.” Journal Of Advanced Nursing 67.5 (2011): 1034-1040. Print.