Injection Techniques for the Primary Care Optometrist Michelle Welch, O.D. NSU Oklahoma College of...

Injection Techniques for the Primary Injection Techniques for the Primary Care OptometristCare Optometrist

Michelle Welch, O.D.Michelle Welch, O.D.

NSU Oklahoma College NSU Oklahoma College

of Optometryof Optometry

NeedlesNeedles

• hubhub• shaftshaft• bevel -needle tends to dive away from bevel -needle tends to dive away from thethe

bevel bevel • lumen (18 to 30 gauge)lumen (18 to 30 gauge)• size (1/2 to 2 inches)size (1/2 to 2 inches)

USE THE RIGHT SIZE/LENGTH NEEDLE FOR USE THE RIGHT SIZE/LENGTH NEEDLE FOR THE JOB!!!!!THE JOB!!!!!

NeedlesNeedles

Loading the SyringeLoading the Syringe

• From an ampuleFrom an ampule

Loading the SyringeLoading the Syringe

• From a vialFrom a vial

General ConsiderationsGeneral Considerations

• Check patient allergiesCheck patient allergies

• Complete full patient exam before Complete full patient exam before injectinginjecting

• Check blood pressure and pulseCheck blood pressure and pulse

• Check supplies and have readyCheck supplies and have ready

• Wash hands and put on glovesWash hands and put on gloves

• Patient education regarding procedurePatient education regarding procedure

Intramuscular InjectionsIntramuscular Injections

• AdvantagesAdvantages– Quick absorption (10 – 30 min)Quick absorption (10 – 30 min)– Not a lot of irritation from drug because not Not a lot of irritation from drug because not

many sensory fibersmany sensory fibers

Intramuscular InjectionsIntramuscular Injections

• Intramuscular injections are indicated Intramuscular injections are indicated – when a patient must have medications and when a patient must have medications and

they cannot take the medication orallythey cannot take the medication orally– the medication is not effective orallythe medication is not effective orally– the medication does not come in an oral the medication does not come in an oral

preparation preparation

Intramuscular InjectionsIntramuscular Injections

• Select injection siteSelect injection site– ShoulderShoulder– ButtocksButtocks– ThighThigh

• Select needle sizeSelect needle size– 19 to 23 gauge19 to 23 gauge– 1 to 1 ½ inch length1 to 1 ½ inch length

Intramuscular InjectionsIntramuscular Injections

• Recheck volume of medicationRecheck volume of medication

• Ask patient to relax arm, the more they Ask patient to relax arm, the more they tense the muscle the more sore it will tense the muscle the more sore it will bebe

• Swab the area with an alcohol wipeSwab the area with an alcohol wipe

• Stretch the skin around the injection site Stretch the skin around the injection site or pinch the skin and muscle upor pinch the skin and muscle up

Intramuscular InjectionsIntramuscular Injections

• Insert needle at Insert needle at 90° angle quickly 90° angle quickly – insert needle as if insert needle as if

throwing a dartthrowing a dart– hurts worse if you hurts worse if you

gently insertgently insert– patient should patient should

hang arm at side hang arm at side relaxedrelaxed

• Stick needle Stick needle approximately 2" approximately 2" below topbelow top

Intramuscular InjectionsIntramuscular Injections

• Pull syringe plunger back to check for penetration Pull syringe plunger back to check for penetration of blood vesselof blood vessel

• Inject medication at moderate rate while holding Inject medication at moderate rate while holding needle steadyneedle steady

• Withdraw needle quickly Withdraw needle quickly • Cover puncture with antiseptic swab and massage Cover puncture with antiseptic swab and massage

area area • Place Band-aid over areaPlace Band-aid over area• Dispose of needle, syringe, and other supplies Dispose of needle, syringe, and other supplies

appropriately (NO RECAPPING)appropriately (NO RECAPPING)• Observe patient for adverse effects for up to 30 Observe patient for adverse effects for up to 30

minutesminutes

VenipunctureVenipuncture

• AdvantagesAdvantages– drug goes directly into bloodstream and drug goes directly into bloodstream and

therefore reaches eye quicklytherefore reaches eye quickly

• DisadvantagesDisadvantages– drug goes directly into bloodstream and drug goes directly into bloodstream and

therefore reaches everything quicklytherefore reaches everything quickly– highest risk to patienthighest risk to patient– impossible to reverse the effects of the drug impossible to reverse the effects of the drug

once deliveredonce delivered

VenipunctureVenipuncture

• Patient education regarding the procedure Patient education regarding the procedure • Wash hands carefully and have all equipment Wash hands carefully and have all equipment

and supplies ready and supplies ready • Wear latex gloves to protect from blood Wear latex gloves to protect from blood

exposure exposure • Open a new vial of fluorescein and withdraw Open a new vial of fluorescein and withdraw

into the syringe, eliminate the air bubble, and into the syringe, eliminate the air bubble, and attach to the IV tubing attached to the needleattach to the IV tubing attached to the needle

• Place the tourniquet on the upper arm and Place the tourniquet on the upper arm and select the best injection site, then release to select the best injection site, then release to clean area clean area

VenipunctureVenipuncture

• Select a suitable veinSelect a suitable vein– non-dominant arm non-dominant arm – choose distal vein firstchoose distal vein first– straight and lies on a flat surfacestraight and lies on a flat surface– well-fixed, does not rollwell-fixed, does not roll– should feel springy when palpatedshould feel springy when palpated– back of hand or antecubital fossaback of hand or antecubital fossa

VenipunctureVenipuncture• Avoid:Avoid:

– veins that are crooked, hardened, scarred, veins that are crooked, hardened, scarred, inflamed, tenderinflamed, tender

– veins in an edematous armveins in an edematous arm– affected arm of mastectomy patientaffected arm of mastectomy patient– performing venipuncture distal to a previously performing venipuncture distal to a previously

used or injured veinused or injured vein– IVs in areas that require immobilizing a jointIVs in areas that require immobilizing a joint– areas where an arterial pulse is palpable close areas where an arterial pulse is palpable close

to the vein to the vein – veins of the lower extremitiesveins of the lower extremities

VenipunctureVenipuncture• Apply tourniquet Apply tourniquet

– 2-6" above site2-6" above site– slip knotslip knot– check to make sure a pulse is still present check to make sure a pulse is still present

after the band is in placeafter the band is in place• Prepare the venipuncture sitePrepare the venipuncture site

– scrub the selected area with Betadine or scrub the selected area with Betadine or alcohol swabalcohol swab

– wipe the area in widening circles around wipe the area in widening circles around the site, leaving a wide marginthe site, leaving a wide margin

VenipunctureVenipuncture

• Dilate the veinDilate the vein– have patient lower arm and handhave patient lower arm and hand– digital pressuredigital pressure– have patient open and close fist 4-6 times have patient open and close fist 4-6 times

and keep it closedand keep it closed– tap vein lightlytap vein lightly

• Stabilize veinStabilize vein– apply pressure on it below the point of entryapply pressure on it below the point of entry

VenipunctureVenipuncture

• Remove needle guard and position needleRemove needle guard and position needle– grasp wings firmlygrasp wings firmly– point in direction of blood flowpoint in direction of blood flow– bevel upbevel up

• Enter the veinEnter the vein– tell patient to inhale slowlytell patient to inhale slowly– insert needle at approximately a 45 insert needle at approximately a 45

degree angledegree angle

VenipunctureVenipuncture

• Observe for backflowObserve for backflow– When you have entered the vein, blood When you have entered the vein, blood

will return through the needlewill return through the needle– If you mistakenly entered an artery, the If you mistakenly entered an artery, the

blood will be bright red, will have a greater blood will be bright red, will have a greater force and may pulsateforce and may pulsate

VenipunctureVenipuncture• TroubleshootingTroubleshooting

– No backflowNo backflow– Very little backflowVery little backflow– Very little backflow and then noneVery little backflow and then none

VenipunctureVenipuncture

• Advance until needle well within veinAdvance until needle well within vein– gentle lifting pressure gentle lifting pressure

• Tell patient to release fistTell patient to release fist

• Release the tourniquet and connect the Release the tourniquet and connect the syringe to the adaptersyringe to the adapter

VenipunctureVenipuncture

VenipunctureVenipuncture

• Administer the medicationAdminister the medication– ensure no air in syringeensure no air in syringe– pull back on plungerpull back on plunger– Hold syringe verticallyHold syringe vertically

• After the patient has received small After the patient has received small amount of medication, check for amount of medication, check for anaphylactic reactionsanaphylactic reactions

• Inject at appropriate speedInject at appropriate speed

VenipunctureVenipuncture• Check for infiltrationCheck for infiltration

– if infiltration under skin occurs, stop. if infiltration under skin occurs, stop.

• Monitor the patient (esp. breathing)Monitor the patient (esp. breathing)– do not leave patient alonedo not leave patient alone– recheck blood pressure and pulse before releaserecheck blood pressure and pulse before release

• Remove IVRemove IV– hold sterile gauze above sitehold sterile gauze above site– quickly withdraw needle by pulling straight outquickly withdraw needle by pulling straight out– apply immediate pressure with gauzeapply immediate pressure with gauze– tape down gauze tape down gauze

• Patient instructionsPatient instructions• Discard supplies appropriatelyDiscard supplies appropriately

Subconjunctival InjectionsSubconjunctival Injections• Between anterior conjunctiva and Between anterior conjunctiva and

Tenon’s capsuleTenon’s capsule

Subconjunctival InjectionsSubconjunctival Injections

• DisadvantagesDisadvantages– Injections uncomfortable (more of a fear Injections uncomfortable (more of a fear

reaction in my opinion)reaction in my opinion)– Drug may remain in eye for several days – Drug may remain in eye for several days –

weeksweeks

• Clinical UsesClinical Uses– Local antibiotic injectionLocal antibiotic injection– Local steroid injectionLocal steroid injection– Local antimetabolite injectionLocal antimetabolite injection

Subconjunctival InjectionsSubconjunctival Injections

• ProcedureProcedure– Patient education regarding the procedure Patient education regarding the procedure – Wash hands carefully and have all Wash hands carefully and have all

equipment and supplies ready equipment and supplies ready – Wear latex gloves to protect from blood Wear latex gloves to protect from blood

exposureexposure– Instill topical anestheticInstill topical anesthetic

• Use small short needle (30 g ½ inch)Use small short needle (30 g ½ inch)

• Swab 4% topical xylocaine over Swab 4% topical xylocaine over injection area (optional)injection area (optional)

• Use forceps to create a “tent” of conj to place your injection – Use forceps to create a “tent” of conj to place your injection – watch needle tip at all times – No needle to pull back on plunger watch needle tip at all times – No needle to pull back on plunger if needle tip visualized as in this caseif needle tip visualized as in this case

ComplicationsComplications

• Subconjunctival hemorrhageSubconjunctival hemorrhage

• ChemosisChemosis

• PainPain

• Retained drug depositsRetained drug deposits

• Perforation of globePerforation of globe

Subcutaneous InjectionsSubcutaneous Injections

Subcutaneous InjectionsSubcutaneous Injections

Subcutaneous InjectionsSubcutaneous Injections

VIDEO DEMONSTRATIONSVIDEO DEMONSTRATIONS

• Loading syringe with aseptic techniqueLoading syringe with aseptic technique

• Subcutaneous injectionSubcutaneous injection

• Intramuscular injectionIntramuscular injection

• Subconjunctival injectionSubconjunctival injection

• VenipunctureVenipuncture

• Cleaning area with aseptic techniqueCleaning area with aseptic technique

AND NOW FOR THE HANDS ON AND NOW FOR THE HANDS ON LABORATORY!!!LABORATORY!!!