PROCEDURE SHAMPOOING

a. General.

A patients hair should be combed daily. In addition, other care is necessary to enhance morale,
stimulate circulation of the scalp, and prevent tangled, matted hair.

b. Daily Care.

Encourage the patient to rub his scalp with fingertips to stimulate circulation. Comb hair in a
becoming style. To assist a patient to comb matted and tangled hair, first comb the ends and
progress toward the scalp. Hold the lock of hair being combed between the scalp and the comb to
avoid pulling. Brush the hair as necessary (figure 1-14).

Figure 1-14. Care of patients hair.

c. Hair Cutting.

Barber service is provided in most service hospitals. The barber makes regular rounds on the
nursing unit or comes by appointment. The patient receiving the service pays the fee directly to
the barber. Occasionally, hairdresser service can be arranged for patients on the unit. Ambulatory
patients go to the barber shop or beauty parlor, if the medical officer approves.

d. Shampoo.

The patient confined to bed will require a cleansing shampoo at least every two weeks. With the
approval of the medical officer, plan the shampoo for a time when the patient feels rested and has
no conflicting treatments or appointments. If the patient can be moved to a stretcher, do so and
take him to a convenient sink. If this is not possible, do the shampoo in bed.

(1) Following is a list of equipment necessary for the procedure.

Large pitcher of warm water.

Bucket.
Newspaper.
Large rubber sheet.
Bath towels (3).
Washcloth.
Shampoo solution.
Clean comb and brush.
(2) Following is the procedure for administering a shampoo to a patient in bed.

Place a newspaper on the chair and the bucket on the newspaper. Place the pitcher of
water, shampoo, comb, brush, and one of the two bath towels on the bedside cabinet.
Move the patient to the near side of the bed. Lower the bed to a level position.
Pull the pillow down under the patients shoulders to assisting extending the neck. Fold
one bath towel around the neck.
Place the narrow side of the rubber sheet under his head and over the edge of the pillow.
Roll the sides of the sheet to improvise a trough, and place the free end in the bucket.
Give the patient a washcloth for his eyes and face.
Check provisions for water drainage before pouring any water.
Wet his hair and apply shampoo. Lather and rinse it.
Reapply shampoo and rinse the hair again repeatedly until his hair is squeaky clean. (A
woman will require more rinse water than a man, but otherwise the procedure is
unchanged.)
Slip a dry towel under the patients bed. Then roll and remove the rubber sheet. Pull the
pillow up into its normal place.
Dry the hair by gently rubbing it with a clean towel.
Remove the equipment and wipe up any water spilled on the floor.

PROCEDURE INJECTION

The World Health Organization estimates that 16 billion injections are given per year. Giving
injections was once the province of doctors, but with the advent of penicillin in the 1940s it
became an extended role activity of the nurse (Beyea and Nicholl 1995). It is now such a routine
nursing activity that nurses can become complacent about it. While evidence-based medicine is
the clinical goal for nurses, several studies over the years have shown that many practices
performed in the clinical setting have been based on ritual, shared knowledge by a peer or
colleague, or on variations in technique found in nursing fundamental texts. Good injection
technique can make the experience for the patient relatively painless; however, mastery of
technique without developing the knowledge base from which to work can still put a patient at
risk of unwanted complications. Today, with increasing demands upon nurses to practice
evidence-based medicine, it is appropriate to reappraise such a fundamental procedure.

There are four main considerations regarding injections: the route, site, techniques and
equipment. The most effective route to administer the medication is dependent on the purpose of
its use, the type of medication to be administered, and the condition of the patient receiving the
drug. The most common injection routes practiced by nurses include intradermal (ID),
subcutaneous (SC), intramuscular (IM), and intravenous infusion (IV).

ROUTE AND SITE

1. The intradermal route injection provides a local, rather than systemic, effect and is used
primarily for diagnostic purposes such as allergy or tuberculin testing, or for local anesthetics.
The sites suitable for ID injection are similar to those for subcutaneous injections (Fig 2) but also
include the inner forearm and shoulder blades (Springhouse Corporation 1993).
2. The subcutaneous route is used for slow, sustained absorption of medication, up to 1-2 ml
being injected into the subcutaneous tissue. It is used for insulin injections which require a slow
and steady release, it is a relatively pain free and suitable for frequent injections.

3. The intramuscular (IM) route injection delivers medication into well perfused muscle,
providing rapid systemic action and absorbing relatively large doses. The choice of the site
should take into account the patients general physical condition and age; and the amount of
medication to be given. The five sites that are used for IM injections are:

The Deltoid muscle of the upper arm which is the preferred site for vaccinations in adults.

The Dorsogluteal (DG) performed by entering through the gluteus maximus muscle. Care
should be given to avoid damage to the sciatic nerve and vessels surrounding this area.

The Ventrogluteal site is a safer option which accesses the gluteus medius muscle. Research
of IM injections has shown this site to be the primary location for IM use as it avoids all major
nerves and blood vessels; and there have been no reported complications (Beyea and Nicholl
1995).

The Vastus Lateralis is a quadriceps muscle situated on the outer side of the femur and is
used as a primary site for children. It does have risks associated to it due to overuse but has been
suggested safe for children up to seven months old.

The Rectus femoris is the anterior quadriceps muscle which is rarely used by nurses but is
easily accessed for self- administration, or for infants.
There is interesting research which shows that several aspects of the IM injection process varied
among texts. In an article titled Are We On the Same Page? : A comparison of intramuscular
injection explanations in nursing fundamental texts by Heather Carter-Templeton, and Tammie
McCoy, researchers compare instructions for IM techniques from five fundamental nursing
textbooks. Issues related to needle size selection and common procedures associated with IM
injections (z-track, bubble technique, filter needle, site selection) are explored and reported.

For example, in the use of the Deltoid muscle, the literature reviewed for the use of this muscle
was largely in agreement. Discrepancies were related to the method for determining the exact
injection site with the area for this muscle. Some authors recommended using an imaginary
triangle to isolate the injection site (Rodger & King, 2000); while others suggested a site two
finger breadths below the acromion process (Potter & Perry, 2005).

Regarding the Dosogluteal muscle, a query of 36 nurses at local clinical institutions yielded 27
responses to the EBP Information Sheet, a tool designed in an undergraduate baccalaureate
nursing course to collect data from practicing nurses on IM injection techniques. Seventy-five
percent stated that they utilized the DG muscle as the site of choice for administering large-
volume IM injections; 4% of the respondents did not identify a specific site (Avery et al. 2006).
However, Beyea and Nicoll (1995), Nicoll and Hesby (2002), Potter and Perry (2005), and
Rodger and King (2000) did not advocate the utilization of this site for IM injections!
4. Intravenous route injection uses a hypodermic injection into a vein for the purpose of instilling
a single dose of medication, injecting a contrast medium, or beginning an IV infusion of blood,
medication, or a fluid solution, such as saline or dextrose in water.

TECHNIQUES AND EQUIPMENT

Before giving an injection of any kind the health care provider is obliged to undertake the
following when administering an injection:

Inform and educate the patient on the need and effect of the medication being delivered
Ensure the correct identification and verification procedures are followed
Provide privacy for the patient during the procedure
Understand the theory behind selecting appropriate injection sites
Ensure that the proper equipment and dosage is selected
Clean the site with an alcohol swab or other cleansing agent
Demonstrate correct technique when undertaking the procedure
Monitor for complications
Document all relevant information and ensure safe disposal of equipment

The technique will vary depending on the route and site used; however, the angle of the needle
entry is important to understand as it relates to reducing the pain for the patient. For example, IM
injections should be given at a 90 degree angle to ensure the needle reaches the muscle. A study
by Katsma and Smith (1997) revealed that nurses did not always ensure needle entry to the skin
at 90 degrees and they speculated that this would cause more pain for the patient due to the
needle shearing through the tissues. The following is a review of the most common injections
and the proper technique to administer them:

1. To give an ID injection, a 25-gauge needle is inserted at a 10-15 degree angle, bevel up, just
under the epidermis, and up to 0.5 mL is injected until a wheal appears on the skin surface. If it
is being used for an allergen testing, the area should be labeled indicating the antigen so that an
allergic response can be monitored after a specific time lapse.

2. Traditionally, SC injections have been given at a 45 degree angle into a raised skin fold.
However, with the introduction of shorter insulin needles (5, 6, or 8 mm), the recommendation
for insulin injections is now an angle of 90 degrees. The skin should be pinched up to lift the
adipose tissue away from the underlying muscle, especially in thin patients. It is no longer
necessary to aspirate after needle insertion before injecting subcutaneously as studies have
shown that piercing a blood vessel in a SC injection is very rare.

3. To administer an IM injection, prepare the syringe by removing the needle cover, inverting the
syringe, and expelling any excess air. Approximately 0.1-0.2 mL of air should be left in the
syringe which will assist in forcing the entire amount of medication to be delivered. When ready
to inject, spread the skin using the fingers of the non-dominant hand. Holding the syringe with
the thumb and forefinger of the dominant hand, quickly pierce the skin at a 90 degree angle and
enter the muscle. It is no longer necessary to aspirate after needle insertion when administering
an IM injection. If the person administering the injection is at the correct anatomical location and
is educated about where the major vessels lie, there should be no reason to aspirate. Continue to
slowly inject the medication at a constant rate until all medication has been delivered. Withdraw
the needle and syringe quickly to minimize discomfort. Depending on the medication given, the
site may be massaged although it is sometimes not recommended by the manufacturer. Check the
site at least once more a short time after the injection to ensure that no bleeding, swelling, or
other signs of a reaction to the medication are present.

4. Z- Track technique for IM injections was initially introduced for drugs that stained the skin or
were particularly irritant. It is now used more universally for IM injections as it is believed to
reduce pain as well as the incidence of leakage into the subcutaneous tissue or skin. The gluteal
muscle is the recommended site for this technique. Select a long needle (2-3 inches; 5-7.5 cm)
depending on the size of the patient with a 21-or 22-gauge in order to place the medication
deeply within the muscle. To give a Z- track injection, begin using the non-dominant hand to
move and to hold the skin and subcutaneous tissue about 1-1.5 in (2.5-3.75 cm) laterally from the
injection site. Alert the patients when the medication is about to be injected. Ask them to breathe
through their mouth and to try to relax the muscle to avoid muscle resistance. Continue holding
the displaced skin and tissue until after the needle is removed. Dart the syringe rapidly into the
displaced skin at a 90 degree angle. Aspirate on the syringe to be sure that a blood vessel has not
been penetrated. Inject the medication slowly into the muscle. Never inject more than 5ml of
medication at a time when using the Z-track method. If a larger dose is ordered, divide it and
inject it into two separate sites. Be sure that the syringe is completely empty, including air,
before withdrawing it. Upon withdrawal of the syringe, immediately release the skin and
subcutaneous tissue.

5. Air bubble technique arose historically from the use of glass syringes which required an added
air bubble to ensure an accurate dose was given, and was also intended to seal the medication
after injection. Since plastic syringes are calibrated more accurately than glass ones, it is no
longer recommended by manufacturers as a technique to use. There are also issues related to the
accuracy of the dose when using this technique as it may significantly increase the dosage. There
have been studies to compare the Z-track and the air bubble techniques with regards to which
one is more successful at preventing leakage (Quart ermine &Taylor 1995, and MacGabhann
1998) with the former study finding the air bubble more effective, and the later findings were
inconclusive.

6. Intravenous injection technique is considerably more complicated and more dangerous than
other types of injection. That said, proper technique can at least minimize the possible damage.
First, clean the injection site with isopropyl alcohol. Wrap the tourniquet around your arm just
above the injection site. When tying the tourniquet, tuck it in upon itself or use a self-tightening
loop. You want it to be able to slip off. Insert the needle at a 45 degree angle with the vein. You
are injecting WITH the flow of the vein (which flows to the heart). Pull back the plunger slightly
to test for blood. If there is no blood, pull it out as you missed the vein. If the blood is bright red,
foamy, and has considerable pressure behind it, pull it out and apply direct pressure as you hit an
artery. This is unlikely except when you are going for deep veins. If the blood is dark you
connected with the vein. Remove the tourniquet since injecting while a tourniquet is tied will
cause too much pressure to build and may cause the vein to burst. Slowly push the plunger and
administer the medication. Pull out and apply pressure with clean gauze and band aid.
7. Intraosseous injection is a process of injection directly into the marrow of the bone. This
technique is used in emergency situations to provide fluids and medication when an IV line
cannot be used. The needle is injected through the bones hard cortex and into the soft marrow
interior which allows immediate access to the vascular system. Often the antero-medial aspect of
the tibia is used as it lies just under the skin and can be easily palpated and located. The anterior
aspect of the femur, the superior iliac crest and the head of the humerus are other sites that can be
used. Although intravascular access is still the preferred method for medication delivery in the
prehospital area, advances in IO access (such as the F.A.S.T. 1 and the EZ-IO system) have
made IO more common in emergency medical services (EMS) systems around the world.

In conclusion, giving an injection safely is considered to be a fundamental nursing activity, and

yet it requires knowledge of anatomy and physiology, pharmacology, psychology,
communications skills and practical experience. Nurses are encouraged to review the current
research-based practices and incorporate the best ones into their everyday practice.