Injection training


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Injection training

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Injection training

  1. 1. Vaccination Training for Health Care Providers Betsy Hubbard, RN, MN Immunization Clinical Practice Supervisor Colleen Woolsey PhD, ARNP, MSN H1N1 Flu Training Coordinator
  2. 2. Agenda--1  Overview & Introductions  Flu Disease & Flu Vaccine  Intramuscular Injection  “Immunization Techniques” Video  Skills practice 1: Drawing up vaccines & using safety syringes  Locating IM injection landmarks  Skills Practice 2: Locating IM injection sites
  3. 3. Agenda--2  Skills Practice 3: FluMist administration  Giving Vaccines in a Medication Center  Adverse Reactions  Skills Practice 4: Positioning & comforting restraint  Skills Practice 5: Locating IM injection sites on adult and child arm and leg  Skills Practice 6: Use of Triage Algorithm  Q&A and Evaluation
  4. 4. What is the flu?  Highly infectious viral illness  Characterized by abrupt onset of fever, dry cough, muscle aches and malaise  Cough and malaise may persist up to two weeks  Transmitted by respiratory droplets  Seasonal flu season typically occurs late fall through spring
  5. 5. Flu can complicate underlying medical conditions, causing….  Bacterial infections  Pneumonia  Sinus and ear infections in children  Increased risk of stroke, MI, and heart failure  Increased blood sugar in diabetics  Death
  6. 6. How is influenza transmitted?  Large-particle respiratory droplets (infected person coughs or sneezes near a susceptible person)  Requires close contact (<6 feet)  Novel A H1N1 probably spread in ways similar to other flu viruses
  7. 7. Transmission of Influenza  Other possible sources of transmission:  Contact with contaminated surfaces  Via droplet nuclei--also called “airborne” transmission (particles stay suspended in the air)  All respiratory secretions and bodily fluids (diarrheal stool) of novel influenza A (H1N1) cases should be considered potentially infectious
  8. 8. Distribution by Age Group of Cases Hospitalized with Pandemic H1N1 July 2009 0 5 10 15 20 25 30 35 40 45 50 < 6 mo 6mo-4 yrs 5-9 yrs 10-17 yrs 18-29 yrs 30-49 yrs 50-64 yrs 65+ yrs Age group Percent Seasonal 2007-08 Pandemic 2009* *April 12–June 30
  9. 9. ED Visits for ILI by Age Group King County, WA, 2009 0 50 100 150 200 250 300 03-Jan-09 10-Jan-09 17-Jan-09 24-Jan-09 31-Jan-09 07-Feb-09 14-Feb-09 21-Feb-09 28-Feb-09 07-Mar-09 14-Mar-09 21-Mar-09 28-Mar-09 04-Apr-09 11-Apr-09 18-Apr-09 25-Apr-09 02-May-09 09-May-09 16-May-09 23-May-09 30-May-09 06-Jun-09 13-Jun-09 20-Jun-09 27-Jun-09 04-Jul-09 11-Jul-09 18-Jul-09 25-Jul-09 Week ending NumberofEDvisitsforILI under 2 2 to 4 5 to 17 18 to 44 45 to 64 65 and over
  10. 10. Health Care Workers: Protect Yourself, Protect Your Clients  Individuals are contagious for 1 to 4 days before the onset of symptoms and about 5 days after the first symptom  About 50% of infected people do not have any symptoms but are still contagious  Health care workers are frequently the source of influenza transmission in health care settings
  11. 11. Influenza Vaccine
  12. 12. Why immunize?  Flu is a serious illness, the cause of 36,000 deaths each year in the U.S.  Immunizations are first line of defense: 70-90% effective in <65 yrs; 30-40% in frail elderly  Immunizations prevent serious illness, hospitalization and death
  13. 13. Groups at Increased Risk for Seasonal Flu Complications  Children less than 5 years old  Persons aged 65 years or older  People age <18 years who are on long-term aspirin therapy (risk of Reye syndrome)  Pregnant women  Adults and children with chronic medical conditions  Adults and children who have immunosuppression (caused by medications or by HIV)  Residents of nursing homes and other chronic-care facilities
  14. 14. H1N1 vaccine— Target groups for vaccination  All pregnant women  People who live with or care for children age < 6 months  Healthcare and emergency services personnel  All people ages 6 months through 24 years  Persons ages 25 through 64 years with chronic medical conditions
  15. 15. Who Should Not Be Immunized?  Anyone with:  Severe (anaphylactic) allergy to eggs, gentamycin or a previous dose of influenza vaccine.  Moderate to severe illness, with or without fever  History of *GBS within 6 weeks after a previous flu shot.
  16. 16. Flu Vaccine Formulations  Seasonal flu vaccine  Trivalent inactivated influenza vaccine (TIV)  Ten-dose vial  Prefilled syringe 0.25 ml and 0.5 ml  Live attenuated influenza vaccine (LAIV)  Novel H1N1 –monovalent versions of the same formulations  Age range for vaccines and formulations differs by manufacturer
  17. 17. Flu Vaccine Strains  Seasonal flu vaccine components usually change every year  2009-10 vaccine has: A/Brisbane (H1N1), A/Brisbane (H3N2), and B/Brisbane  Novel H1N1 vaccine (A/California) licensed as “change of strain”—would have been in seasonal flu vaccine if outbreak had started earlier in the spring
  18. 18. Flu Vaccine Dosage  TIV and Novel H1N1  0.5 ml--Children 3 years through adult  0.25 ml--Infants/toddlers age 6-35 months  LAIV (seasonal and novel H1N1)  0.2 ml (intranasal)  Two doses of vaccine 4 weeks apart are needed the first year they get it for:  children under age 9 years for seasonal flu  children under age 10 years for novel H1N1
  19. 19. Thimerosal Free Influenza Vaccine--1  Thimerosal is a preservative containing ethyl mercury used in vaccines since 1930’s  No conclusive scientific evidence of harm from exposure to thimerosal  Studies of risk were of methyl mercury  In 1999, USPHS recommended eliminating thimerosal in vaccines for infants, as a precaution and to retain trust in vaccine supply
  20. 20. Thimerosal Free Influenza Vaccine--2  Influenza vaccine in multi-dose vial contains 25mcg/dose  Manufacturers make a limited amount of thimerosal-free (<1mcg /dose) flu vaccine  Benefits of flu vaccine outweigh any theoretical risk from thimerosal  Washington law requires that children <3 years and pregnant women be given thimerosal-free vaccine, as of 7/1/2007
  21. 21. Thimerosal Free Influenza Vaccine--3  Emergency suspension of thimerosal law for H1N1 vaccine only, as of 9/24/09  Can give thimerosal-containing vaccine to children <3 years and pregnant women, BUT must give notice of the suspension to:  Everyone < 18 years  Pregnant and breastfeeding women
  22. 22. 10 minute break Break out Health Educators
  23. 23. Use the correct needle length for IM injections  1” minimum needle recommended  1½” to 2” needle for larger arm  Longer needles:  Hurt less  Cause fewer local reactions1  Assures proper route and a valid dose of vaccine Diggle L, Deeks J. BMJ 2000;321(7266):931-33.
  24. 24. Needle gauge  Determine appropriate needle gauge  IM: 22 - 25 gauge  Lower gauge number = bigger needle  Use for more viscous medications  Usual needle length/gauge for IM vaccines is 25 G 1”
  25. 25. Syringes  Use 3 cc syringes for vaccine  Vanish Point safety syringes have needle attached—various sizes and gauges  Manufacturer-prefilled syringes— need to attach a separate needle
  26. 26. Intramuscular (IM) injection  Insert the needle at a 90º angle to the skin  IM injection sites  Deltoid (arm)  Vastus Lateralis (thigh)
  27. 27. Intramuscular (IM) injection
  28. 28. Vaccine Administration Video Clip from “Immunization Techniques —Safe, Effective, Caring”
  29. 29. Skills Practice—Part 2 Measuring & administering doses  Draw up 0.5 ml dose of sterile water into a 3 cc safety syringe  Show the 0.5 ml dose  Administer 0.5 ml dose into an orange  Activate the syringe’s safety device  Repeat with the Smith syringe
  30. 30. Locating injection landmarks
  31. 31. Landmarks: 2-3 finger widths down from the acromion process; bottom edge is at an imaginary line drawn from the axilla. Deltoid
  32. 32.  The deltoid site may be used on a child that is one year old and walking, depending on the child’s muscle mass  Assess the deltoid muscle of the child to determine if it has sufficient mass for the injection  Bunching of the muscle may be needed with smaller muscle mass Deltoid
  33. 33. Vastus Lateralis Landmarks: Place one hand below the greater trochanter and one hand above the lateral femoral condyle, mid- lateral thigh
  34. 34. The muscle of choice for IM injections in a child less than 12 months of age Vastus Lateralis in Infants
  35. 35. Injection Site Assessment Do not use a site with any of the following:  Muscle atrophy  Inflammation  Edema  Scarring, tattoo, mole, or lesion  IV port/ access  Surgery in the limb/lymph node problems
  36. 36. Skills Practice—Part 3 Locating Injection Sites Locate the appropriate site for a deltoid injection on your partner.
  37. 37. Intranasal Vaccine (LAIV)
  38. 38. Skills Practice—Part 4 FluMist Administration  Dispense the first half of the FluMist dose into the air (NOT INTO YOUR NOSE!)  Remove the dose-divider clip  Dispense the second half of the FluMist dose
  39. 39. Getting ready to give vaccines in a Medication Center  Assessment and client education is done by others in Step 1:  Registration/Consent form  Risk vs. benefit of vaccine (Vaccine Information Statement)  Thimerosol Information Sheet  After care instructions  Emergency Situations call 911 and use PH CHS Emergency Response Procedures (see Handouts for Vaso-vagul and Emergency Response)
  40. 40. Getting Ready--2  Identify antigen/formulation to be administered  Patient documentation  Wash/sanitize hands  Draw up/prepare the vaccine  Have bandage and supplies ready
  41. 41. Giving the injection  Ensure client is seated  Gloves are not required, unless there is a break in the skin on the nurse’s hand(s)  Clean the injection site with alcohol and let it dry before injecting  Suggest client take slow deep breath, relax arm muscle during injection  Aspiration not necessary
  42. 42. After the immunization--1  Engage syringe’s safety device  Have the patient hold the cotton on their injection site  No need to massage the injection site  Used needles and syringes go into sharps container  Place empty vials into biohazard bags
  43. 43. After the immunizaton--2  Partial vials and unused manufacturer pre-filled syringes go back into the cooler or refrigerator (35-46° F)  If you attach a needle to a manufacturer pre-filled syringe, you must use it in the same clinic day or discard it
  44. 44. Immediate Adverse Reactions: Be Prepared!  Monitor, if possible, for 15-20 minutes  Anaphylaxis rare but may be life-threatening  Symptoms:  Dyspnea, rapid breathing, wheezing  Flushed face, perspiration, anxiety  Hives, itching, swelling at injection site  Itchy/puffy eyes, swelling of mouth or throat  Hypotension, cold/clammy skin, syncope  Summon help from paramedics!
  45. 45. Additional Considerations  Bloodborne Pathogen Exposure  Vaccine Adverse Event Reporting System (VAERS)
  46. 46. Positioning the Patient  Adults and adolescents should sit down!  Parents should use “comforting restraint” technique  Parent embraces the child and controls all four limbs  Avoids “holding down” or overpowering the child, but helps you steady and control the limb of the injection site
  47. 47. Comforting Restraint for Infants & Toddlers Hold the child on parent’s lap 1. One of child’s arms embraces parent’s back and is held under parent’s arm 2. Other arm controlled by parent’s arm and hand--for infants, parents can control both arms with one hand 3. Both legs anchored with the child’s feet held firmly between parent’s thighs, and controlled by parent’s other arm.
  48. 48. Comforting Restraint for Kindergarten & Older Kids  Hold the child on parent’s lap or have the child stand in front of the seated parent 1. Parent’s arms embrace the child 2. Both legs are firmly between parent’s legs
  49. 49. Skills Practice—Part 5  Positioning an infant and child to receive vaccine
  50. 50. Skills Practice Locating landmarks and giving IM injections  Locate IM injection sites on adult arm  Locate IM injection sites on baby leg  Practice giving IM injections
  51. 51. Triage  Why? ●Assure safe disposition of patients ●Present patient information consistently ● Expansion of skill set for potential public health response
  52. 52. Triage: A piece of the pie  Screening clients assists in: ● determining those who may need vaccination ● prophylaxis or ● urgent medical attention
  53. 53. Triage  How? Using the algorithms ● Pediatric Algorithm ● Adult Algorithm ● Home Care Instructions ● Triage Note
  54. 54. Pediatric Triage Algorithm Patient Presents With Influenza Like Illness (ILI) · Fast breathing or trouble breathing · Bluish skin color · Not drinking enough fluids · Severe or persistent vomiting · Not waking up or not interacting · Infants with no wet diapers for 6 hours and not taking fluids, irritable or screaming with pain · Flu-like symptoms improve, then return with fever and worse cough · Irritability where the child doesn’t want to be held Answers yes to one or more of the indicators of severe illness Elevated Risk Advise to seek medical care immediately Assess for Co-morbid Conditions · Fever: Newborns with fever over 100.4 F 3 months – 2 year with fever > 102 F Any age – fever > 100.5 F x 3 days Any age – fever > 105 F · Fever with rash · Not drinking enough fluids · Asthma, Cystic Fibrosis or Chronic Obstructive Pulmonary Disease · Coronary Vascular Disease or Congestive Heart Failure · Diabetes · Pregnancy* If PHSKC patient, refer triage to provider for treatment · Morbidly obese (BMI >40%) · Organ transplant recipient or immune compromised · AIDS · Renal Dialysis · Sickle cell or other hemolytic anemias · Receiving or completed chemotherapy in the past 30 days · Neurocognitive and/or Neuromuscular Disease · On chronic aspirin therapy · Live with someone 65 years or older Other household contacts with an underlying condition (listed above) who are at risk? Does the patient have one or more co-morbid factors? Low Risk Okay for self-care at home. Repeat self assessment if condition worsens. Any positive answer No positive answers Yes No positive answers Pediatrics < 18 years Sick with a fever >100F, and a cough or sore throat Intermediate Risk Conditions Recommend person contact at their primary care provider or seek care in clinic.
  55. 55. Adult Triage Algorithm Patient Presents With Influenza Like Illness (ILI) · Difficulty breathing or shortness of breath · Constant pain or pressure in the chest or abdomen · Less responsive than normal or becoming confused · Severe or persistent vomiting · Unable to keep liquids down · Exhibiting signs of dehydration such as dizziness when standing or absence of urination · Seizures · Flu-like symptoms improve but then return with fever and worse cough Answers yes to one or more of the indicators of severe illness Elevated Risk Advise to seek medical care immediately Assess for Co-morbid Conditions · 65 years or older · Asthma, Cystic Fibrosis or Chronic Obstructive Pulmonary Disease (COPD) · Coronary Vascular Disease (CVD) or Congestive Heart Failure (CHF) · Diabetes · Pregnancy* If PHSKC patient, refer triage to provider for treatment · Morbidly Obese (BMI >40%) · Organ transplant recipient or immune compromised · AIDS · Renal Dialysis · Receiving or completed chemotherapy in the past 30 days · Neurocognitive and /or Neuromuscular Disease · Sickle Cell or other hemolytic anemias · Live with a child less than 19 years old on chronic aspirin therapy Check in with caller to see if there is any other close household contact that is showing possible “flu” like symptoms that may affect patient with above conditions. Other household contacts with an underlying condition who are at risk? Does the patient have one or more co-morbid factors? Low Risk Okay for self-care at home. Repeat self assessment if condition worsens. Any positive answer No positive answers Yes No positive answers Adults >18 years Sick with a fever >100.0 F with a cough or sore throat Intermediate Risk Conditions Recommend person contact at their primary care provider or seek care in clinic.
  56. 56. Home Care  Home Care Recommendations for ILI  Keep away from others as much as possible. This is to keep from making others sick.  Get plenty of rest.  Drink clear fluids (such as water, broth, sports drinks, and electrolyte beverages for infants) to keep from being dehydrated. You will probably be sick for several days with fever, cough and stuffy nose.  Cover your cough and sneezes.  Frequent hand washing.  Don’t share drinking glasses or eating utensils. Dishes can be done in dishwasher or with hot soapy water.  Throw away tissues and other disposable items used by the sick person in the trash. Wash your hands after touching used tissues and similar waste.  Have everyone in the household wash hands often with soap and water, especially after coughing or sneezing. Alcohol-based hand cleansers are also effective.  Avoid touching your eyes, nose and mouth.  Take medications for symptom relief as needed for fever and pain such as acetaminophen (Tylenol®) and ibuprofen (Advil®, Motrin®, Nuprin®) and cough medicine. These medicines do not need to be taken regularly if your symptoms improve.  Stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of fever-reducing medicine.)  Do not give aspirin (acetylsalicylic acid) or products that contain aspirin (e.g. bismuth subsalicylate – Pepto Bismol) to children or teenagers 18 years old or younger.  Children younger than 4 years of age should not be given over-the-counter cold medications without first speaking with a health care provider.  􀂾 If you develop any of the following, seek medical care immediately:  o Difficulty breathing  o Purple or blue discoloration of lips  o vomiting or unable to keep liquids down  o Dizziness, no urination, lack of tears in infants (signs of dehydration)  o Seizures, uncontrolled convulsions  o Confusion, less responsive than normal
  57. 57. Triage Note
  58. 58. Skills Practice- Part 6 Using the tools  Use pediatric and adult algorithms  Demonstrate when to advise home care vs. office visit  Preview triage note and use in conjunction with the home care sheet
  59. 59. Questions?
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