External use of medical substances

Infriction (rubbing-in) – the insertion of liquid medicine or ointments through skin (cutaneously). Infriction is done on the following cutaneous parts of the body: flexor (flexion) surface of the forearm, back surface of the thigh, flank surfaces of the chest, stomach, i.e. that parts of skin where it is thin and not covered with hair. If necessary the hair is shaven off. At the place of infriction the skin must be clean. If necessary it must be washed with soap. The necessary amount of ointment or liquid is placed on the skin and rubbed in in circles until the skin is dry again.

ž Coating (smearing) as a method of putting onto the patient of different types of medicine is widely spread mostly for skin diseases. Cotton wool orgauze tampon is dipped into a particular solution and then this solution is put on the skin of the patient with easy linear strokes. If that part of skin is covered with hair the solution is smeared along the direction of hair growth. In cases of pyodermatitis the skin is smeared around the lesions from the periphery towards the center.

ž Plaster – is a thick sticky ointment basis covered with impermeable gauze. The ointment basis contains active medical substances.Contra-indications for the use of plaster are: eczema, allergic dermatitis. Before we can use a plaster the skin must be thoroughly degreased with medical spirits and the hair is shaven off. Then using scissors we cut the necessary shape of the plaster and put it on the skin.

ž Dusting or powdering with pulverized medical substances (talcum powder or rice powder) is used to dry the skin in cases of intertrigo or sweating (hyperhidrosis). Clean cotton wool tampon is covered with the powder which is spread over the treated areas.

ž Aerosol inhalation (the inhaling of sprays) is prescribed for patients to improvethe bronchial patency; liquify sputum; fight infection; protect the mucous coat of respiratory tracts from the harmful influence of the irritant agents.

The advantages of using the medicine in the form of inhalations are:

1) The medicine is active directly in the location of pathological process in lungs;

2) The medicine gets into the lesion not passing through liver which increases the concentration of the medical substance.

The drawbacks of this method are:

1) There is no way to set the exact dose;

2) In cases of sharp decrease of the bronchial patency the penetration of the aerosol directly into the pathological lesion is not enough (poor).

3) The possibility of irritation of the mucous coat of bronchi by the aerosol.

ž Enteral way of taking a medicine

Taking of a medicine orally is the most frequent way, because it is simple and convenient for different forms of medicine (pills, capsules, powders, etc.). The disadvantages of this way of taking medicine are: incomplete absorption of the medicine in thedigestive tract, partial or full destruction of the activeinitial part of the medical substance by the digestive ferments, inactivation in liver, the impossibility to foresee the concentration of the medicine in blood. In cases of diseases of the gastric-intestine tract and liver it is especially difficult to find the necessary doses of medicines.

ž The insertion of the medicine through the rectum is used for patients who have vomiting, impassabilityof the esophagus (gullet), deglutition (act of swallowing) dysfunction and psychiatric patients who refuse to take the medicines and are in the excited state. Using the anastomosis betweenthe hemorrhoidal and iliac veins the inserted medicine (i.e., not using portal vein and liver) gets directly into blood which means that it is not being destroyed inside the liver. Due to the absence of ferments in the rectum the inserted medicines are not subjected to splitting (lysis). The medical solution is inserted into the rectum after the cleansing enema.

ž Parenteral insertion of the medicine

Among the advantages of the parenteral insertion are quickness and precision of the dosing. Using this method the medicines get into blood not through the digestive tract which means they are not subjected to the destruction by the digestive ferments. It shortens the time when they start to take effect and increases the precision of the dosing.

ž Absolute contra-indications to the injections: increased tendency for bleeding (hemophilia, etc.); relative contra-indications: psychic or nervous excitement of the patient, fear of the injections, convulsions.

ž Parenteral insertion of the medicine is done by means of injection intracutaneously, subcutaneously, intramuscularly, intravenously, intra-arterially into the pleural or abdominal cavity, heart, joint cavity, bone marrow, cerebro-spinal canal.

ž Organizing the distribution of medicines in the department

The distribution of medicines is done by the medical nurse strictly according to the doctor’s prescriptions. The medical nurse is not allowed to change or cancel the prescribed medicine. Before the distribution of medicines the medical nurse places on her trolley a carafe with water, graduates, droppers (separate for each vial), prescription list. Passing from patient to patient according to the prescription list she distributes the medicines which the patients should take in her presence.

ž The needle for injections is a thin metal tube, one end of which is cut diagonally and sharpened and the other is firmly attached to the short metal socket. Needles are varied in length (15-90 mm) and diameter (0,4-2 mm). Thus for intracutaneous injection we use a needle 15 mm long and 0,4 mm in diameter, for subcutaneous – 25 mm long and 0,6 mm in diameter, for intravenous – 40 mm long and 0,8 mm in diameter, for intramuscular – 60 mm long and 0,8-1mm in diameter. The grinding (sharpening) of the needles can be done under different angles, e.g. for intravenous infusions it is 45⁰, and for subcutaneous injections the angle is more acute.

ž Some time ago the size of the needles was marked with numbers starting from №10 up to №32. Needle №10 had the largest diameter (1,4 mm), needle №32 – the smallest (0,5 mm). Nowadays there is a numeric way of marking the needles when the first two digits show the diameter and the last 2-3 digits – the length in millimeters. Most frequently used needles: №0640, 0804, 0860, 1060.

ž The procedure for filling the syringe with the medicine

-get ready the necessary vial with the medicine, syringe and two needles;

-uncover the central part of the metal cap with non-sterileforceps;

-to process the rubber cap with spirits using cotton wool;

-penetrate the rubber cap with the needle that is on the syringe and inject inside a solution (for antibiotics – isotonic solution of sodium chloride or 0,5% solution of novocaine, the proportion is 0,5 ml to 100 000 Units of penicillin);

-take the vial together with the needle off the syringe and shake it until full dissolution of the medicine;

-attach the syringe back to the needle and moving the piston towards yourself take the necessary amount of medicine;

-take the needle out of the rubber cap of the vial and then change the needle for another one.

ž Intracutaneous injections

Intracutaneous injections are used as sensitive diagnostical tests, and also for infiltrate skin anesthesia. They are painful and we use 1-2 drops of the solution. For local anesthesia 1-2 ml of the solution can be injected subcutaneously.

ž The syringe is held in such a way so that I,III,IV and Vfingers fixate the cylinder and the piston of the syringe, and II finger – socket of the needle. The bevel of the needle faces upwards. After drying of the skin using the left hand finger the skin is pulled downwards below the place of injection, and the needle is injected almost parallel to the surface of the skin only with the sharp end (1-2 millimeters deep). As soon as the bevel is inside the epidermis very carefully controlling the dosing we inject 0,1-0,2 ml of the substance. If the injection was conducted successfully at the place of the injection there appears a whitish bulge (thickening) which resembles lemon peel.

ž Subcutaneous injections

Subcutaneous injections are done into that body parts where there are most developed subcutaneous fatty tissues, but no main veins or arteries. This includes the outer surface of a shoulder, front-flank surface of a thigh, infrascapular regions and front-flank surface of the belly.

ž After the processing of the skin with two tampons dipped in spirits the syringe is taken into the right hand the same way as for intracutaneous injections. Using I and II fingers of the left hand we make a fold that allows us to pull the skin. With the quick move the needle is injected into the base of that fold at 30⁰angle. The depth of injection must be no less than 1,5-2 cm. We must control the insertion of the needle so that at least 0,5 cm is above the surface of the skin. The temperature of the injected oily solution must be no less than 25-30⁰C. After the insertion of the needle the skin fold is released keeping the cylinder of the syringe fixated with the right hand and the left hand pushes the piston slowly injecting the medical substance.

ž Complications

When conducting subcutaneous injections there can be possible complications that are caused by the violation of the required technique. Infectious complications (abscess, phlegmon) are the result of insufficient sterilization of the syringe, needle, improper processing of the nurse’s hands, the patient’s skin. Formation of poorly biodegradable infiltrates at the place of injection is possible in cases of one-time streaming injection of large amounts of medicines, constant injections of medicine into the same areas. Such kind of infiltrate apart from being extremely painful is fraught with infectious complications due to the violation of blood circulation in that area.

ž Lipodystrophy is one form of complications of insulin therapy. It is manifested by the disappearance or less frequently hypertrophy of subcutaneous fatty tissue at the places of subcutaneous insulin injections. Causes of lipodystrophy are not fully discovered yet. To prevent lipodystrophy constant change of the place of the injection is vitally important as well as the injection of the medicine of room temperature.

ž Intramuscular injections

Are made into the rich vascularized muscle tissue. For intramuscular injections we need to choose places with no large vessels, nerves, and the muscles are fully developed so that there is no danger to get the needle to the bone. To these areas belong upper outer square of the buttock, quadriceps muscle of thigh, triceps muscle of arm, deltoid muscle. The maximum amount of intramuscular injection must not exceed 10 ml otherwise overdistension of the muscle leads to the decrease of medicine absorption and formation of infiltrates.

ž The skin of the patient is twice processed with disinfectant solution. Syringe is taken into the right hand so that I, III, IV fingers fixate the cylinder of the syringe, II – piston, and V holds the socket of the needle. During the injection the patient must be lying. Full relaxation of the muscle is a necessary condition otherwise the stiffening of the muscle may obstruct the insertion of the needle or even break it. Making the injection into the buttock area the skin is extended with the fingers of the left hand, with a quick move the needle with the syringe is inserted into the muscle so that at least 1 cm of needle remains above the surface of the skin. The needle most frequently breaks at the place of connection with the socket. If it happens the remaining part of the needle can be taken out with the forceps. When making the injection into thigh or triceps muscle of arm and in cases with weak-developed buttock muscles it is recommended to make a fold of skin before the injection. This both tightens the skin and prevents the needle from getting into bone.

ž Complications

In cases when the rules of injection techniques were broken there can be a number of complications. Instantaneous injection of large amounts of medicine (more than 10 ml) leads to overdistension of the muscle and weak (poor) resorption of the medicine. Infectious complications arise when we do not follow the rules of aseptics or antiseptics. The injection of diluted medicine into subcutaneous fatty tissue leads to poor resorption of the medicine, formation of infiltrates. Most frequently this type of complication happens in cases of overdeveloped subcutaneous fatty tissue and use of short needles.

ž Intravenous injections

The fastest way when the medicine takes effect is intravenous injection. Most frequently these injections are done into a vein on the bend of elbow. It is advised to choose the bifurcation places where there is better fixation inside the subcutaneous fatty tissue. Drastic medicines are as a rule injected in the form of strong dilutions, because streaming injection of such medicines as strophanthine, procainamide hydrochloride, etc. may lead to complications that endanger the life of the patient.

ž The technique of the intravenous injection

1. The nurse processes her hands; takes the syringe; takes the medicine into the syringe from the ampule and changes the needle.

The patient must take the correct position (under the elbow bend of his extended hand she places an oilskin pillow wrapped in a towel). The extended hand with the palm facing upwards is placed on a special small table or an armrest of a armchair.

Tourniquet (garrot) is placed 5 centimeters above the elbow bend. If the garrot is made of rubber we put a napkin under it. We fix the tourniquet so that it is convenient to untie it with one hand. Instead of the garrot we can use the cuff of a manometer pumped with air. If the tourniquet is used correctly the veins expand and the pulse can still be detected on the radial artery. To increase the expansion of the veins the patient can press his fist tightly several times, massage from the forearm toward the elbow bend, slap slightly the area of cubital fossa.

Double processing of the place of the injection with the sterile tampon with alcohol.

Removal of air from the syringe by letting out some drops of the medicine holding the syringe vertically.

Extend the skin below the place of injection, fixate the vein. The syringe is taken into the right hand so that fingers I,III,IV fixate the cylinder of the syringe, and finger II – the needle. The needle is inserted with the bevel facing upwards.

2. Intravenous infusion

The skin is penetrated with a sharp move, in parallel with the vein, the needle is inserted along the vein for 1,5-2 cm, then the vein wall is penetrated. To control the position of needle inside the vein the piston of the syringe is pulled backwards.

When the blood flows into the syringe the garrot is untied and slowly during 2-3 min the diluted medicine is injected.

Placing a sterile tampon with alcohol on the place of the injection we take the needle out. The tampon should be pressed to the place of the injection for no less than 5 min.

ž transfusion of blood, blood products and blood substitutes.

Nowadays Intravenous drop infusions are done in cases of need for large amounts of fluid, for intravenous drop infusions we use one-time (disposable) sterile systems for blood transfusion. The transfusion of whole blood and blood products is only allowed using disposable systems.

Single-use sterile system for intravenous infusions are kept in plastic bags that are vacuum sealed; the system consists of an air duct with the needle on the end and air filter inside, long tube with the dropper, both ends of the tube have needles – one is for vein puncture, the other is to penetrate the cap of the bottle with the solution. It also has a clamp (clip) to regulate the speed of infusion. The dropper has a special grid filter to prevent large particles from getting into blood. The needles have protective caps.