Reconstitution, mixing, and general injection guidelines

Reconstituting powdered medication

As previously mentioned, vials can contain powdered medication. A powdered medication needs to be mixed with a diluent . Typically, sterile normal saline or sterile water is used as a diluent, although other medications may also be used (according to the provider’s order and the manufacturer’s directions). The most common powdered medications in primary care are live-virus vaccines. These need to be reconstituted.

If the vial is a multidose vial, it is important to write the expiration date on the label. The expiration dates for reconstituted medications will vary. See the manufacturer’s insert for the length of time that the medication will remain stable after reconstitution. Besides the expiration date, include your initials and the fluid that was used to reconstitute the medication. These three pieces of information need to be on the multidose label.

There are four major steps in reconstituting powdered medication and withdrawing a dose of the medication:

• Step 1: Remove air from the powdered medication vial and put air into the diluent vial.
• Step 2: Withdraw liquid from the diluent vial and add it to the powdered medication vial.
• Step 3: Mix the liquid with the powdered medication.
• Step 4: Add in air and withdraw the dose needed.

Mixing insulins

Patients with diabetes may use insulin to help manage their disease. Taking insulin requires about four injections a day. Some patients may need two different insulins at the same time. Many premixed insulins are available for patients. However, for some individuals, the premixed insulins are not an option, and they must mix the two insulins in one syringe. During this combination process, it is important that the vials do not become contaminated with another type of insulin. If by chance contamination occurs, it is better for the rapid-acting or short-acting insulin (Regular insulin) to be mixed in the intermediate-acting insulin vial (e.g., NPH insulin). This means that Regular insulin must be drawn up in the syringe first, and then NPH is added.

Depending on state laws and facility policies, administering insulin may be within the medical assistant’s scope of practice. Understanding how to mix two insulins in the same syringe is important. Not all insulins can be mixed. Use drug reference information to ensure that the two insulins ordered can be mixed.

As discussed earlier, insulin is measured in units. Special insulin syringes are available to measure small or large insulin dosages. Insulin is typically stored in the refrigerator and should be warmed to room temperature prior to administration. Cloudy insulins (e.g., NPH) are suspensions and need to be mixed before drawing up the insulin. Mix cloudy insulins by gently rolling the vial between your hands. Clear insulin (e.g., Regular insulin) does not need to be mixed or rolled in your hand.

Patients receiving insulin must rotate their injection sites. This prevents tissue damage and absorption issues with the insulin. It might be helpful for patients to mark the site of the last injection with a spot bandage or a piece of tape. The easiest way to rotate sites is to give subsequent injections in a circular pattern around the first injection site in a specific location. The goal is to avoid using the same location again for another month.

Giving parenteral medications

Some medications can be given by several routes. Other medications can only be given by injection. Parenteral medication administration has several advantages:

• It is useful when the patient has gastrointestinal distress or is unconscious.
• It offers good absorption compared with other routes, such as the oral route.
• The onset (time medication starts working) is more rapid than with other routes.
• Some types of parenteral medications have a longer duration time (time the medication works in the body).

Pain with the injection and a risk of infection due to the injection are disadvantages of parenteral medications. Another disadvantage is an unpredictable absorption rate for those with poor circulation (e.g., patients with peripheral artery disease, diabetes, obesity, or Raynaud disease).

When it comes to giving injections, you will gain confidence, and it will become easy over time. Always do the following:

• Follow the nine rights of medication administration.

• Check the medication’s label against the order three times.

• Know about the medication you are giving. (What is it, why is it being ordered, how is it given, and what are the common side effects?)

• Label all syringes with the name of the medication they contain.

• Follow medical asepsis and the Bloodborne Pathogens Standard established by the Occupational Safety and Health Administration (OSHA).

  Ensure that the needle is not directed at your hand holding the patient when giving an injection. Slight movement may cause a needlestick.

Following these guidelines will help you perform injections safely and protect your patient from medication errors.

Guidelines for parenteral medications

Prepare and store medications in a separate area, away from the exam rooms. Medications can be prepared without the use of gloves. Ensure that all needles are tightly covered and placed on a tray when carrying them to the exam room. Never transport medication in your pockets. Bring only one patient’s medication at a time to avoid confusion and error.

Follow these guidelines when selecting an injection site:

• Never give an injection near bones or blood vessels.
• Avoid scar tissue, a change in skin pigmentation or texture, or abnormal growth (e.g., mole or wart).
• Avoid abrasions, lesions, wounds, bruises, and edematous areas.
• Select a site that is large enough to hold the amount of medication injected.
• Avoid sites recently used (within the last month).

According to the Immunization Action Coalition (www.immunize.org), it is safe to give SUBQ and IM vaccines into a tattoo. However, it is not a good idea to inject into a newly tattooed area. If you must inject into a tattooed area, attempt to use a lighter pigmented area. All injections pose the risk of a reaction or an infection at the injection site. Dark pigments may mask a reaction or an infection.

Reducing pain and anxiety

To minimize pain with injections, insert SUBQ and IM needles swiftly. Inject the medication at the rate of 10 seconds per 1 mL to avoid unnecessary discomfort. Remove the needle quickly, using the same angle as for entry.

Various techniques can be used to reduce a patient’s pain and anxiety about injections:

• Give a sugar-coated pacifier or sugar water (must be ordered by the provider), which helps soothe children under the age of 1 after injections.
• Apply a topical anesthetic skin refrigerant (e.g., Pain Ease), which works immediately.
• Apply a topical anesthetic (e.g., EMLA cream) at the injection site, which works in about 30 to 40 minutes.
• Talk with the patient to distract them from the procedure.
• Have patients move their toes or fingers on the extremity receiving the IM injection. (Have a patient “play the piano” with their fingers when giving a deltoid injection.)
• Administer the most painful injection last.
• Use products that provide cold and vibration sensations (e.g., Buzzy), which overwhelm the nerves affected by the injection.

Special situations

Even if the procedure was done correctly, sometimes things can go wrong. It is important for the medical assistant to know what to do in those situations.

If a needle breaks during an injection or separates from the syringe, pull out the needle if it is visible. Discard the needle in the biohazardous sharps container. If the needle breaks off and is not visible, mark the spot with a pen and yell for help. If the injection was given in the arm, place a tourniquet above the spot to prevent the needle from moving in the body. Notify the provider immediately.

With intramuscular injections, sometimes the bone can be hit during the procedure. If this occurs, pull the needle out about one-quarter inch and give the medication.

With any medication, a patient can experience an anaphylactic reaction. Anaphylaxis is a severe allergic reaction that can be life-threatening. Having the patient wait 15 minutes after an injection allows you to monitor for unusual symptoms. Symptoms include the following:

• Warm feeling, flushing, throat tightening, difficulty swallowing, cough
• Shortness of breath, dyspnea (difficulty breathing), wheezing
• Anxiety, loss of consciousness, shock
• Pain or cramping, vomiting, diarrhea, palpitations, dizziness

If the patient is experiencing any unusual symptoms, it is important to tell the provider immediately. The first-line medication for anaphylaxis is epinephrine.