ALERTDo not compound IV push medications (combining two or more medications) in a single syringe outside the pharmacy.undefined#ref4">4 Show
Insulin is considered a high-alert medication, and it is strongly recommended that insulin doses be verified by two nurses to prevent errors.5 If indicated by the organization’s practice, have the dose of clear insulin verified before mixing. Have the dose verified a second time after the medications are mixed. Administer a mixture of insulin quickly after preparation. Rapid- or short-acting insulin can bind with intermediate- or long-acting insulin, thus reducing the action of the more rapid-acting insulin. Do not use a single-dose vial more than once. Multiple use of single-dose vials increases the risk for blood-borne pathogen infections.7 Use one needle, one syringe, only one time on one patient.7 Take steps to eliminate interruptions and distractions during medication preparation. OVERVIEWSome medications must be mixed from two vials or from a vial and an ampule. Mixing compatible medications avoids the need to give a patient more than one injection. Most nursing units have medication compatibility charts. Compatibility charts are in drug reference guides or are posted within patient care areas. If uncertain about medication compatibilities, consult a pharmacist. When mixing medications, fluid must be correctly aspirated from each type of container. When using multidose vials, the nurse must not contaminate the vial’s contents with medication from another vial or ampule. When mixing medications from a vial and an ampule, the nurse should prepare medications from the vial first and then withdraw medication from the ampule using the same syringe and a filter needle. When mixing medications from two vials, the nurse must not contaminate one medication with another and must ensure that the final dose is accurate. Aseptic technique must be maintained.9 Single-dose vials do not contain antimicrobials; therefore, multiple accesses place the patient at risk for infection.7 The nurse must give special consideration to the proper preparation of insulin. Insulin is the hormone used to treat diabetes mellitus. Insulin is classified by rate of action, including rapid acting, short acting, intermediate acting, and long acting. A patient with diabetes sometimes requires more than one type of insulin. In addition, some patients require several injections in a day that combine two different insulin preparations to duplicate the normal pattern of their insulin production. Insulin is available in vials. If more than one type of insulin is required to manage the patient’s diabetes and the types of insulin are compatible, the nurse may mix them in one syringe. This may result in a patient response to insulin that is different from the response that would occur if the insulins were given separately. When mixing insulin in one syringe, the rapid- or short-acting insulin should be drawn up first. Only insulins from the same manufacturer are recommended for mixing.9 The American Association of Diabetes Care & Education Specialists has a list of recommendations for mixing insulins (Box 1). Insulin syringes are available in sizes that hold 0.3 to 1 ml and are calibrated in units. Most insulin syringes are U-100s, designed to be used with U-100 strength insulin (Figure 1). Each milliliter of U-100 insulin contains 100 units of insulin. Use U-100 insulin syringes with preattached 25- to 31-G needles when giving U-100 insulin and 1-ml tuberculin syringes when giving U-500 insulin. The U-500 insulin is five times more potent than U-100 insulin; however, a specific U-500 insulin syringe does not exist. U-500 insulin contains 500 units of insulin per 1 ml of fluid and should be used only for patients requiring doses above 200 units a day.3 Before use, the nurse must carefully examine the syringe to determine the measurement scale and to ensure use of the correct syringe for preparing the ordered medication.9 To help reduce the impact of pharmaceutical waste on the environment, the Environmental Protection Agency (EPA) released a final rule on the management of hazardous waste pharmaceuticals.2 The rule decreases the cost of disposing of certain nicotine products and streamlines the process of disposing of pharmaceutical waste. The organization’s practice for safe disposal of ampules, vials, syringes, and needles should be followed. If the patient expresses concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified. EDUCATION
ASSESSMENT AND PREPARATIONAssessment
Preparation
PROCEDURE
Mixing Medications From Two Vials
Mixing Insulin
Mixing Medications From a Vial and an Ampule
MONITORING AND CARE
EXPECTED OUTCOMES
UNEXPECTED OUTCOMES
DOCUMENTATION
PEDIATRIC CONSIDERATIONS
OLDER ADULT CONSIDERATIONS
HOME CARE CONSIDERATIONS
REFERENCES
ADDITIONAL READINGSSchutijser, B.C.F. and others. (2019). Interruptions during intravenous medication administration: A multicentre observational study. Journal of Advanced Nursing, 75(3), 555-562. doi:10.1111/jan.13880 *In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice. Adapted from Perry, A.G. and others. (Eds.). (2022). Clinical nursing skills & techniques (10th ed.). St. Louis: Elsevier. Elsevier Skills Levels of Evidence
Which should the nurse use when administering a subcutaneous injection?Nurses administering subcutaneous injections must use safety syringe devices and know how to activate the safety mechanism. If the patient is obese, pinching the tissue and using a needle long enough to insert through the fatty tissue at the base of the skinfold is effective.
What are the factors to consider when administering a subcutaneous injection?Insert the needle quickly at a 45- to 90-degree angle. Inserting quickly causes less pain to the patient. Subcutaneous tissue is abundant in well-nourished, well-hydrated people. For patients with little subcutaneous tissue, it is best to insert the needle at a 45-degree angle.
When preparing a subcutaneous injection the nurse would choose which type of syringe and needle?Subcutaneous (Subcut) injections
Inject at a 45-degree angle into fatty tissue overlying the triceps muscle — a 5/8" needle, 23–25 gauge is recommended.
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