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Thursday, September 16, 2010
» the nurses desk: tips and tricks » Where (exactly) to stick a needle into your patients bum.
Where (exactly) to stick a needle into your patients bum.
By impactEDnurse • Aug 15th, 2010 • Category: the nurses desk:, tips and tricksToday a new-graduate nurse taught me how to give an intramuscular injection.
No, really….After studiously watching one of our senior staff give an intramuscular (IM) injection, the new-grad informed us that, in fact, she was not taught to give injections into the upper-outer quadrant.
This is were I have been sticking my needles for many years now, and I have given thousands (if not millions) of injections this way.
We were about to re-orient her….but as this student is no dummy, the senior staff member and I thought we had better get our facts straight before engaging our mouths.
We quickly slipped away under the pretext of ‘going to check for leaks in the pan room’ to find out what exactly is best practice for selecting a site for an adult IM injection in the buttocks.
Turns out she was right.OUT: The Dorsogluteal IM injection site.
This site been used by nurses for years as the target of choice for IM injections.
It is found in the area of the superior lateral aspect of the gluteal muscles, commonly known as the ‘upper outer quadrant’.
It is located by dividing the buttock into four equal quadrants. This is usually done by drawing an imaginary cross (bisecting it vertically and horizontally).Problems that have been identified with using this site include:
- Presence of major nerves and blood vessels in this area, including the sciatic nerve and superior gluteal artery.
It has been taught that you will probably avoid this by further dividing the upper outer quadrant into another quadrant and giving the injection into the upper outer of the upper outer.
Despite this, there have been reports of injuries to the sciatic nerve leading to problems ranging from foot drop to paralysis of the lower limb.- Thickness of fat in this area. A number of studies have found that the depth of muscle in the dorsogluteal region is often greater then the length of a standard needle used for IM injections, resulting in a failure to achieve intramuscular deposition of the medication.
In fact, one study found the success rate of IM injections to be 32% (which fell to 8% in female patients)!
With the increasing incidence of obesity amongst our patients we are probably going to be delivering subcutaneous injections if we choose this location.- Pain receptors are located in the subcutaneous layer, not in muscle tissues and so medication delivered into this area may be more painful.
- Dorsogluteal site has a decreased absorption rate increasing the possibility of a depot effect with drug build up and potential for overdose.
IN: The Ventrogluteal IM injection site.
The ventorgluteal (VG) site has less subcutaneous fat and a thicker muscle mass than the dorsogluteal site with an almost certain probability of penetrating muscle with a standard needle.
The VG site is also sparse of any major innervating nerves or blood vessels whilst remaining well perfused from smaller branches.Locating the VG site.
The ventrogluteal site is located halfway between the hip and the head of the femur. One method to locate the correct site is:
- First, place the heel of your hand (use your L hand if injecting into the patients R VG and vice-versa) over the patients greater trochanter, and feel for the anterior superior iliac spine with your index finger.
- The middle finger then slides across to make a peace-sign pointing up to the iliac crest.
- The injection site is in the middle of this peace-sign.
- Wipe site with alco-wipe in a circular motion and allow to dry.
- Use your peace sign to spread skin taut.
- Insert needle at 90 degree angle. Take care as you are inserting needle in proximity to your fingers.
- There is no evidence for the need to aspirate the plunger when using the VG site.
- Inject medication slowly (around 10 seconds per ml), remove needle quickly, and gently apply pressure to site for 10 seconds.
So, the ventrogluteal site is indeed the best practice location for delivering an adult IM injection.
You live and learn.References:
Intramuscular injections: a review of best practice for mental health nurses:
COCOMAN A. & MURRAY J. (2008) Journal of Psychiatric and Mental Health Nursing 15, 424–434Are techniques used for intramuscular injection based on research evidence? (NursingTimes.net)
I wonder if this is being taught in New Zealand?
Sunday, September 12, 2010
Saturday, September 4, 2010
Thursday, September 2, 2010
Wednesday, September 1, 2010
Wednesday, August 25, 2010
Distractions
Busy work day and an oops. Had a client in the clinic room when I had to leave room for important phone call. I hate giving bad news to people! Got caught up in following through referral and I forgot the first client... Smart woman came out and tracked me down. Very embarrassing.
Tuesday, August 10, 2010
Poop colour chart
I am working on a newborn poop colour chart for all the people who are as colour challenged as I am. I really thought khaki colour was more of an olive rather than a pale colour =P
It seems weird to worry about a chart but I like clarity and consistency in my assessments. That is why I use an informal scale for things like a new mother's tiredness and note the actual estimated daily wet and soiled nappies. "Okay" and "lots" would otherwise be very common responses and quite meaningless.Sunday, May 2, 2010
Premature births still a medical mystery
While recent medical advancements mean most preemies will survive, preventing early birth in the first place is a different story. Doctors have no way of knowing which pregnancies will be preterm, and in about half of all cases, they don't know why a mother delivers early. However, science is beginning to divulge some clues, such as social stress, bacterial infection and hereditary influences, which might be tied to early births.
Posted via web from nzmidwife
Monday, March 29, 2010
Lifestyle: Shaken babies: Alternatives to anger
Inconsolable crying is the most frequently reported reason by caregivers for losing control with a child, Green said.
And it only takes a few seconds for the damage to occur.
“Because of a baby’s relatively heavy head and weak neck muscles, shaking makes their fragile brains bounce back and forth inside the skull and causes bruising, swelling and bleeding,” she explained.
Symptoms can vary from mild to severe and include loss of consciousness, lethargy, extreme irritability, decreased alertness, pale or bluish skin, vomiting, convulsions and no breathing.
Hope Galantino, clinical educator for labor and delivery at Washington County Hospital, said shaking an infant usually comes about out of frustration at not being able to soothe a fussy baby.
“When a baby starts to cry, many parents think their child is crying for a reason,” Galantino said. “But many infants cry for no reason.”
This is identified as PURPLE crying by the National Center on Shaken Baby Syndrome.
The term PURPLE, Galantino said, is an acronym intended to help caregivers recognize when this type of crying is occurring. (See box at left.)
Green said inconsolable crying is most common in babies up to five months.
As the parent becomes frustrated in trying to soothe the baby, she said, he or she reaches a breaking point and that breaking point triggers violence.
“We want parents to know that it’s normal for babies to cry,” she said. “But when the pressure gets to you, find someone else to give you a break. If there is no support system, it’s important to know that it’s OK to put the baby safely in the crib and take a few minutes to collect yourself.”
Galantino said there is no socioeconomic, age, racial or cultural group more likely than another to shake their babies.
Parents who are unable to stop their children’s crying have one thing in common: feeling inadequate.
Giving parents the tools
In an effort to educate parents, Galantino said members of three local chapters of the Exchange Club worked together about one year ago to secure more than 1,000 DVDs called “Did You Know Your Baby Would Cry Like This.” The videos were obtained from the National Center on Shaken Baby Syndrome and given to the Washington County Hospital’s Family Birthing Center to pass on to new parents.
The hospital purchased an additional 1,100 copies of the DVD so they would be able to give a copy to every new parent over the next year, Galantino said.
Green said the video emphasizes steps parents can take to comfort their crying babies. The most important step, she said, is easy to remember: Never shake or hurt a baby.
It’s also important, she said, to always check with your doctor to see if there is something wrong that is causing the crying.
Parents are encouraged to watch the video before leaving the hospital, Green said. The staff is then available to answer any questions parents or caregivers might have before they take their babies home. They also are urged to show the DVD to anyone who will help take care of the baby.
“Hopefully, the DVD will make a difference,” Galantino said. “We can talk to people about not shaking their baby. We teach it. But there is no impact like watching the DVD. It’s a more effective way of reaching parents.”
Green said staff members have taken the DVD out into the community to further raise awareness about abusive head trauma. She also noted that pediatricians are aware of the DVD and have the ability to go online to purchase it.
“It’s our hope that these DVDs will save innocent lives,” she said.
Ways to comfort a baby:
• Meet the baby’s basic needs. Check to see if he is sleepy, hungry, needs burping, needs changing or is too hot or cold.
• Rock, walk, sing or dance with the baby.
• Give the baby a warm bath.
• Take the baby for a walk in a stroller or for a ride in the car.
• Hold the baby close to you with skin-to-skin contact. Breathe slowly and calmly. The baby may feel your calmness and become quiet.
• Lower any surrounding noise and lights.
These ideas won’t work every time, but they may be able to reduce crying by about 50 percent. Remember: You should always check with your doctor to see if there is something wrong that is causing prolonged crying.
— Provided by the National Center on Shaken Baby Syndrome
For more information on PURPLE crying, visit the National Center for Shaken Baby Syndrome Web site at www.dontshake.org.
PURPLE:
P: peak of crying
U: unexpected
R: resists soothing
P: pain-like face
L: long-lasting
E: evening, which is when this type of crying more commonly occurs.
— National Center on Shaken Baby Syndrome
Posted via web from nzmidwife
Monday, March 22, 2010
Review
My midwifery review yesterday was much more affirming than my previous one. I welcome the awesome future I get to create one step at a time.
Sunday, March 14, 2010
Too Many Women Dying in U.S. While Having Babies: http://ow.ly/1iMfH (via @Joyce_Johnson)
Too Many Women Dying in U.S. While Having Babies
Amnesty International may be best known to American audiences for
bringing to light horror stories abroad such as the disappearance of
political activists in Argentina or the abysmal conditions inside South
African prisons under apartheid. But in a new report on pregnancy and
childbirth care in the U.S., Amnesty details the maternal-health care crisis
in this country as part of a systemic violation of women's rights.
The report, titled "Deadly Delivery," notes that the likelihood of a
woman's dying in childbirth in the U.S. is five times as great as in Greece,
four times as great as in Germany and three times as great as in Spain.
Every day in the U.S., more than two women die of pregnancy-related causes,
with the maternal mortality ratio doubling from 6.6 deaths per 100,000
births in 1987 to 13.3 deaths per 100,000 births in 2006. (And as shocking
as these figures are, Amnesty notes that the actual number of maternal
deaths in the U.S. may be a lot higher, since there are no federal
requirements to report these outcomes and since data collection at the state
and local levels needs to be improved.) "In the U.S., we spend more than any
country on health care, yet American women are at greater risk of dying from
pregnancy-related causes than in 40 other countries," says Nan Strauss, the
report's co-author, who spent two years investigating the issue of maternal
mortality worldwide. "We thought that was scandalous."
Full article at: http://ow.ly/1iMfH
Amnesty International report at: http://www.amnesty.org/en/library/info/AMR51/007/2010/en
The WHO Child Growth Standards
The WHO Child Growth Standards (via @LifeWithPooka and @newgreenbaby)
http://www.who.int/childgrowth/standards/en/Documentation
The following documents describe the sample and methods used to construct the standards and present the final charts.
WHO Child Growth Standards: Methods and development: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age WHO Child Growth Standards: Methods and development: Head circumference-for-age, arm circumference-for-age, triceps skinfold-for-age and subscapular skinfold-for-age WHO Child Growth Standards: Methods and development: Growth velocity based on weight, length and head circumference Acta Paediatrica Supplement Chart catalogueIndicators
:: Length/height-for-age:: Weight-for-age
:: Weight-for-length
:: Weight-for-height
:: Body mass index-for-age (BMI-for-age)
:: Head circumference-for-age
:: Arm circumference-for-age
:: Subscapular skinfold-for-age
:: Triceps skinfold-for-age
:: Motor development milestones :: Weight velocity
:: Length velocity
:: Head circumference velocity
Thursday, February 11, 2010
nzmidwife@gmail.com sent you a link to content of interest
http://www.homebirth.net.au/2010/02/new-born-screening-2.html The sender also included this note: Watch Gattaca for the sci-fi version of the end result of testing. DNA from the metabolic screen has been used in NZ for court cases. I usually remember to tell parents they can request the test card back.
Osteopathic care may ease late-pregnancy back pain | Reuters
Osteopathic care may ease late-pregnancy back pain
NEW YORK (Reuters Health) - Gentle manipulation from an osteopathic doctor may relieve late-pregnancy back pain that frequently hinders bending, lifting, or walking, findings from a small study hint.
Doctors in osteopathic medicine (DOs) are medical doctors additionally trained in gentle manipulative techniques to help restore function, range of motion, and lessen pain in bones and adjoining muscles supporting the neck, back, chest, shoulders, and hips.
Osteopathic manipulation may particularly benefit pregnant women seeking medication-free back pain relief, note Dr. John C. Licciardone and colleagues at University of Texas Health Science Center in Fort Worth.
The study, in the American Journal of Obstetrics and Gynecology, included 144 otherwise healthy pregnant women, about 24 years old on average, with moderate levels of back pain and related movement difficulties during late pregnancy.
The women were randomly assigned to one of three groups: usual obstetric care only, usual obstetric care plus weekly 30-minute osteopathic manipulation treatments from the 30th week of pregnancy through delivery, or usual obstetric care plus sham ultrasound skin stimulation sessions.
Over the course of the study, women in the osteopathic group reported improved back pain and related symptoms, Licciardone noted in an email to Reuters Health. The sham ultrasound group reported no pain improvement and those in the standard care group reported increased pain. However, none of these differences were statistically significant.
Late pregnancy back-related movement problems generally worsened until delivery, but did so to a lesser degree in the osteopathic manipulation group.
Overall, these results suggest osteopathic manipulation may compliment conventional obstetric care, Licciardone and colleagues conclude. They call for further, larger investigations to assess the benefits and costs of this form of combined care.
SOURCE: American Journal of Obstetrics and Gynecology, January 2010
Nice to know research is reiterating what we already know and suggest to pregnant women.
Wednesday, February 10, 2010
Age of mother affects child's autism risk: study | Reuters
Age of mother affects child's autism risk: study
Being an older mother significantly increases the risk of having a child with autism, but being an older father only increases the risk when the mother is under the age of 30, U.S. researchers said on Monday.CHICAGO (Reuters) -
They found that a 40-year-old woman's risk of having a child later diagnosed with autism was 50 percent greater than that of a woman between 25 and 29.
But being an older father -- 40 or older -- only contributes significantly to autism risk when the mother is under 30.
"The older the mother, the more the risk that the child will develop autism, regardless of whether the father is young or old," said Irva Hertz-Picciotto of the University of California Davis MIND Institute, who worked on the study published in the journal Autism Research.
The findings contradict a 2006 study of children born in Israel that suggested paternal age played a much larger role.
"There has been a debate over whether it is maternal or paternal risk. A lot of people were thinking it's not really mom's age," Hertz-Picciotto said in a telephone interview.
Researchers and policymakers are increasingly looking for causes to explain the growing numbers of children diagnosed with autism, which affects 1 percent of U.S. children.
There is no cure for autism, a spectrum of diseases ranging from severe and profound inability to communicate and mental retardation to relatively mild symptoms such as with Asperger's syndrome.
The current study, which incorporates data on 4.9 million births and 12,159 autism cases in California, helps to clarify the contribution of age from both parents.
"We have such a very large database we were really able to disentangle the mother's age very well," Hertz-Picciotto said. This can be a challenge because older mothers and fathers tend to have children together.
"We found it does vary for the father, but not for the mother," she said.
For example, among babies born to mothers under 25, children whose father was over 40 were twice as likely to develop autism as those whose father was between 25 and 29.
This could be because when both parents are older, the risk conferred by the father is outweighed by the risk from the mother, Hertz-Picciotto said.
OLDER PARENTS
She said the point of the study is not to blame parents, but to gain clues about what is going on in older parents that could increase a child's risk of developing autism.
Older parents, for example, are more likely to have infertility problems and have used fertility treatments; the mothers are more likely to have autoimmune conditions, including gestational diabetes; and both have accumulated more toxins over their lifetimes, so the sperm and egg are more likely to have some changes that could increase risk.
"We see these age findings as clues for where to look next," Hertz-Picciotto said.
Autism researchers are looking at a broad range of potential environmental factors, including household products, medical treatments, diet, food supplements and infections.
And the National Institute of Mental Health, one of the National Institutes of Health, is looking at potential genetic causes of autism and has plans to sequence the entire genomes of hundreds of children and their parents to gain a better understanding of the role genes play.
(Editing by Cynthia Osterman)
Blood pressure, rich blood affect baby's growth | Reuters
Blood pressure, "rich" blood affect baby's growth
Women with high blood pressure and blood over-rich in red blood cells are more likely to give birth to babies who are too small or born too early, researchers in the Netherlands reported on Tuesday.WASHINGTON (Reuters) -
Mothers who smoked or who did not take supplements correctly also were more likely to have babies who were underweight or born too early, the study found -- and these factors seem to affect the fetus during the first three months of pregnancy, before a woman has had much prenatal care.
But early ultrasounds may help identify the babies most at risk, the study, published in the Journal of the American Medical Association, suggests.
Dr. Dennis Mook-Kanamori and colleagues at Erasmus Medical Center in Rotterdam studied 1,631 pregnant women, doing ultrasound scans of their fetuses between 10 and 13 weeks gestation.
Babies that were the smallest during this period of early, rapid growth were also more likely to be born early or to be underweight at birth, Mook-Kanamori's team reported.
But as they grew into toddlers, these babies tended to grow too fast -- a pattern that can cause such children to become obese.
"Higher diastolic blood pressure and higher hematocrit levels were associated with a shorter crown to rump length," the researchers wrote. Hematocrit is a count of red blood cells in the blood.
A low hematocrit means anemia, but levels can be too high if a person is dehydrated, smokes or has some kinds of heart disease. The researchers suggested that if a woman was dehydrated, perhaps not enough blood was getting to the placenta to nourish the fetus.
Smokers and women who did not take folic acid supplements also tended to have small fetuses during the first trimester, the researchers found.
And these children, when born, grew at quicker than optimal rates. "Shorter first-trimester crown to rump length was associated with accelerated growth rates in early childhood," the researchers wrote.
"Complications of late pregnancy may, at least for some women, already be determined in the first 3 months postconception, even before a woman has sought prenatal care," Dr. Gordon Smith of Britain's University of Cambridge wrote in a commentary.
"Combined ultrasonic and biochemical screening in early pregnancy may be able to identify women at high risk of complications in late pregnancy."
(Editing by Eric Walsh)