The sites chosen for venipuncture varies with the client’s age, the condition of vein, and the purposes of injection. For adult, veins in the hand, arm, leg and foot are commonly used; for infants veins in the scalp and dorsal foot vein are often used. Veins in the scalp are common used for children because of their rich distribution, accessibility, rare movement, easy securing the needle and relative ease of preventing dislocation of the needle. Large veins include temporal superficial vein, frontal vein, occipital vein, and posterior ear vein. Sometimes larger veins are preferred for getting desirable effect rapidly. The median cubital, basilic, and cephalic veins in the antecubital space are commonly used for drawing blood, bolus injections of medication. In addition, the saphena magna vein, saphena parva vein in leg and veins in dorsal foot are common sites of injection too, but they are not the best site, because of the danger of thrombosis caused by the vein valve. Veins in dorsal foot are commonly used for children, but are avoided in adults because of the danger of thrombophlebitis. Clinical guidelines for vein selection are as follow: (a) Use vein from distal limb to proximal limbs gradually; (b) Use the client’s nondominant arm as far as possible; (c) Select a vein that is easily palpated and feels soft, naturally splinted by bone, large enough to accommodate the needle to be used; (d) Avoid usage of veins that are in areas of flex, highly moving, damaged by previous use, phlebitis, infiltration, or sclerosis; (e) Keep the vein away from joint and vein valve.
Equipment and procedure
Arterial Injection and blood sampling
Arterial injection and blood sampling is the nursing skill to inject medications into artery and collect arterial blood as specimen.
The sites of injection commonly used are radial artery, brachial artery, and femoral artery. When administering the medication for chemotherapy, select common carotid artery for the illness in head and face, subclavian artery or brachial artery for illness in superior limb and chest, and femoral artery for illness in inferior limb and abdomen.
Section 4 Inhalation Administration
Inhalation is the process that medications administered with inhalers are dispersed through an aerosol spray, mist, or powder that penetrates lung airways. The alveolarcapillary(肺泡毛细血管) network absorbs medications rapidly. The purposes of inhalation are to decrease resistance of airflow by using bronchodilators（支气管扩张剂）, expectorants（祛痰剂） and decongestants （解除充血剂）to enlarge the passageway, to treat and prevent infection of respiratory system, to increase humidity of airway and to treat lung cancer. This route of medication administration is used for clients who have chronic respiratory diseases such as chronic asthma (哮喘)， emphysema (肺气肿), or bronchitis (支气管炎). Medications given by inhalation relieve of airway obstruction caused by spasm (痉挛) of airway, and because these clients depend on medications for disease control, they must learn the method of administering them safely. Inhalation is often administered by using of nebulizers (喷雾器). There are three types of nebulizations (雾化) in accordance with different nebulizers. Common types are handheld nebulization, oxygen nebulization and ultrasonic nebulization. A handheld nebulizer (HHN) is a metered–dose inhalers (MDIs) that can be used by clients to self-administer measured doses of an aerosol(气雾) medication. It is usually designed to produce local effects. However, some medications can create serious systemic side effects. Oxygen nebulization is accomplished by using the force of an oxygen stream or compressed air passed through the fluid in a nebulizer or an atomizer (喷雾器). This method is valuable for clients who require inhalation of a medication several times a day. The oxygen stream is also useful in the production of vapors when high humidity is needed continuously for long periods. Ultrasonic nebulization creates aerosol spray or mist of medication through high frequency vibration of ultrasonic production film. Aerosol spray or mist can reach terminal bronchiole（细支气管） and alveolus (肺泡). This equipment also can regulate the amount of spray and warm the medication solution.
Section 5 Medication Anaphylaxis Test
Some clients get anaphylactic reactions when taking some medications, which may lead to discomfort, allergic shock and even death. To prevent anaphylactic reactions, nurses should inquire the patient’s allergic history, read the medications instruction, know the chemical structure of the medication and even do the allergic test of some special medications. The nurses should be able to handle the dispensing of allergic reagent of some special medications, the testing method, the determination of testing result and emergency treatment of the allergy.
Skin test of medication is a common clinical method to monitor whether the patients get immediate or delayed anaphylactic reaction after the small dosage medication came into the body through some approaches.
Immediate anaphylactic test is usually used to detect human reaction to foreign antigen such as medication, heterogenous protein (异体蛋白) etc. in order to determine whether the medication can be used and prevent severe anaphylactic reaction. Intradermal test is usually used. The test result is checked after 15 to 20 minutes and the nurse should determine whether the patient is allergic to the medication according to criteria, but sometimes the result is false negative because of insufficient dosage or anti-allergic medication taken before the test. There are still other methods such as conjunctiva method (眼结膜试验法), skin scarification method（皮肤划痕试验法）, and intravenous injection method.
Medications prone to provoke anaphylaxis include antibiotics, such as penicillin, streptomycin, cephalothin; biological products, such as TAT, narcotics, such as procaine, contrast medium, such as Iodide.
Characteristics of Anaphylactic Reaction to Medications
Medications anaphylactic reaction is also called allergy, which is kind of antigen-antibody reaction when human body contacts the same reagent that came into the body before as antigen. This pathological reaction may cause tissue damage or physiological disturbance. It has common characteristics as follows:
●Anaphylaxis does not usually happen to patients who take the medication for the first time，unless the patient might take it before but there is no record or the patient himself has no idea whether he has used the similar kind of medication or medication with crossing anaphylactic reaction. There is a sensitized course before anaphylactic response occurs, meanwhile, this means there is a latent period in the reaction after the patient was exposed to the medication as the antigen.
●Anaphylaxis only happens to a few persons with allergic habitus, with no relation to dosage. But the dosage influences the serious degree of the allergic reaction.
●The different medications with similar chemical structure may lead to full or part cross reactions.
Penicillin Anaphylactic Test
Penicillin is widely used in clinic settings, which has few side effects. But penicillin is easy to cause anaphylactic reaction with the incidence of 5% to 6%. The reaction is not affected by the patient’s age, sex, medication dosage, and the way it is administered. Therefore, anaphylactic test must be done before the patient takes every form of penicillin. The medication can be administered only if the result of the anaphylactic test is negative.
Anaphylactic is a kind of tissue damage and physical disturbance when antibody-antigen reaction happens in anaphylactic cells. Penicillin G and its compounds of high molecular polymer, such as 6-aminopenicilalkyl acid, degradation products of penicillin such as penicillin-thiazole, and some moulds act as haptens. After entering the human body, they combine protein and polypeptide to form antigen which causes the body to produce specific IgE. The IgE with affinity to tissue cells fixed on the surface of mast cells and white blood cells leads to an anaphylactic condition. When the patient contacts the same antigen again, antigen combines the specific IgE and anaphylaxis occurs. The anaphylaxis leads to cell rupture and then the releasing of histamine, bradykinin, 5-HT, etc. These vasoactive substances act on target organs and cause smooth muscle constriction, capillary dilation and increased capillary permeability, increased secretions of mucous. Different patients have different clinical manifestation due to individual difference.
It often occurs several seconds or minutes, sometimes half an hour after intradermal skin test or medication administration. Only a few patients have anaphylactic shocks during continual medication administration.
Respiratory failure symptoms
Symptoms due to hypoxia (缺氧) and asphyxia(窒息)，the patient feels chest tightness, obstruction in the throat, even dying. Nurses can find that patient has shortness of breath, cyanosis(紫绀) and foam at the mouth.
Cardiovascular failure symptoms
Facial paleness, cold sweat, rapid and weak pulse, and decreased blood pressure are always presented.
Central nervous system symptoms
Due to cerebral anoxia(缺氧症)，dysphoria(烦躁不安), feeling of dizziness, quadriplegia(四肢瘫痪)，loss of consciousness, tic(痉挛), and excrement(大便) and urine incontinence would be presented.
Cutaneous allergic symptoms
There are pruritus(搔痒), urticaria（风疹，寻麻疹）, and other skin eruption.
Serum sickness reaction
It usually happens within 7 to 12 days after exposure. The clinical manifestations are similar to serum sickness such as fever, edema and pain in arthrosis (关节)，pruritus, urticaria, swelling of lymph nodes, and abdomen pain.
Anaphylaxis of organ and tissue
Skin eruption (urticaria) often occurs in severe cases, and exfoliative dermatitis(剥脱性皮炎) may occur.
It may cause asthma or trigger original asthma(哮喘).
Digestive system anaphylaxis
It may lead to anaphylactic purpura (紫癜) with symptoms of abdominal pain and hematochezia (便血).
Symptoms as above may occur alone or simultaneously, or many symptoms and signs may occur at the same time. Respiratory symptoms and pruritus may occur first. Nurses should pay attention to the patient’s complaint.
The treatment of penicillin allergic shock
Emergency treatment on site
Stop medication immediately. Let the patient lie on the back, keep warm, and give puncture on the philtrum (人中).
Inject 0.1% epinephrine 1ml subcutaneously right away. If the patient is a child , the dosage should be reduced. If the symptoms are not relieved, inject 0.5ml every half an hour repeatedly until the patient gets out of the crisis. Epinephrine is the first choice for allergic shock. It can constrict blood vessels, increase peripheral resistance, excite myocardium(心肌), increase cardiac output and relax bronchial smooth muscle.
Correct Hypoxia and improving respiratory
Oxygen is administered immediately, mouth-to-mouth artificial respiration is indicated if the patient’s respiration is depressed, and respiratory stimulants such as nikethamide and lobeline are injected. Prepare for incision of trachea or intubation of trachea if laryngeal edema which influences respiration occurs.
Treating allergic shock
Dexamethasone 5 to10mg is administered by intravenous injection, or hydrocortisone 200 to 400mg in500ml 5%~10% glucose solution is given by IV infusion. Administer anti-histamine medications such as异丙嗪、苯海拉明.
Improve cardiovascular function（correct shock）：
Increase peripheral blood capacity by intravenous infusion of 10% glucose solution or balanced solution. If the blood pressure is not up, administer dopamine(多巴胺) or metaraminol（间羟胺）by intravenous infusion. If cardiac arrest occurs, implement cardiac compression.
Observe the patient intensively and record information：
Assess the client’s temperature, pulse, respiration, blood pressure, urine volume, and other clinical manifestation. Make nursing record of the patient’s condition. Do not move the client when he or she is still in critical situation.
The Method of Penicillin Anaphylactic Test
The following patients need skin test to detect whether they are allergic to penicillin. First take medication (首次用药者), stop penicillin three days ago and reuse（停药3天以上再用者）, the batch of the medication is changed (更换批号者).
The anaphylactic test reagent and its dispensing method
Skin test reagent is isotonic saline with 200u to 500u penicillin G per milliliter. Inject 0.1 ml (include penicillin G 20 to 50u) intradermally. There are different standards for injection dosage in different places. The standard in shanghai is 20u while 50u in Beijing and Shandong province. The diluting method is as follows:
(1) Inject 4ml isotonic saline into vial with P 80,0000u, so there is 20,0000u per milliliter.
(2) Dilute the 0.1ml P solution in (1) with isotonic saline to 1ml, that is 2,0000 per milliliter.
(3) Dilute the 0.1ml P solution in (2) to 1ml, that is 2000u per milliliter.
(4) Dilute 0.25ml P solution in (3) to 1ml, that is 500u per milliliter which is the anaphylactic testing reagent. Mix completely when diluting every time.
Method of anaphylactic test Inject 0.1ml reagent containing 50u penicillin intradermally at the patient’s medial forearm, and observe the result after 20minutes.
There is no skin redness, swelling, blush and the patient has no uncomfortable feeling.
Positive result: •The wheal becomes large.
•There is skin redness and swelling.
•The diameter of the wheal is more than 1cm, or there is pseudopodium.
•The patient has pruritus feeling.
•Dizziness, fluster, nausea may occur in severe cases, even anaphylactic shock.
Cautions of penicillin administration •Inquire the patient’s medication history, allergic history and family allergic history before test.
•Normal/isotonic saline is always used as menstruum to dissolve and dilute penicillin.
•Menstruum, injector and pinhead used in dilute penicillin is banned to use in other medications.
•Use fresh allergic test reagent. The dosage and concentration of reagent is accurate.
•Anti－histamine medications is banned in 24h before test in case of false negative .
•Be ready for aids before, keep epinephrine on hand .
•Keep close watch on the patient. The nurse should watch on the patient with first skin test for 20miniutes and then can leave .
•If positive, penicillin should be banned, and the nurse should report to the doctor. Record penicillin positive result on the doctor’s order sheet, medical record，injection card and bedside card, and inform the patient and his family of the result.
•If you doubt false positive，control experiment is made to exclude allergy induced by disinfector.
Streptomycin Anaphylactic Test
Clinical Manifestation of Anaphylactic Reaction
Streptomycin itself has severe toxic effects that include the damage to renal function, deaf, numbness and twitch due to deficient calcium etc.. Furthermore, it will lead to anaphylaxis similar to penicillin approximately.
The treatment of anaphylaxis of streptomycin is similar to that of penicillin by and large. In addition, 10%葡萄糖酸钙、5％氯化钙 can be administered to relieve the toxic effects of streptomycin because the streptomycin can joint with the calcium.
The Reagent of Streptomycin and its Dispensing Method
Skin test reagent is isotonic saline with 2500u streptomycin per milliliter. Inject 0.1 ml (include streptomycin 250u) intradermally. The diluting method is as follows:
(1) Inject 3.5ml isotonic saline into vial with streptomycin 100,0000u, so there is 25,0000u per milliliter.
(2) Dilute the 0.1ml S solution in (1) with isotonic saline to 1ml, that is 2,5000 per milliliter.
(3) Dilute the 0.1ml s solution in (2) to 1ml, that is 2500u per milliliter that is the anaphylactic testing reagent. Mix completely when diluting every time.
Method of anaphylactic test
Inject 0.1ml reagent containing 250u streptomycin intradermally at the patient’s medial forearm, and check the result after 20minutes.
Result determination is similar to penicillin.
TAT (tetanus antitoxin) anaphylactic test
The cause of anaphylaxis
Tetanus antitoxin is made from the immune serum of equine, which can neutralize tetanus toxin in the client’s body fluid. It is used to prevent and cure tetanus. It can control the progress of the illness or can be used as passive immune antitoxin. TAT is a kind of heterogenous protein to human body that may cause anaphylaxis. Its clinical manifestations include fever, immediate or delayed serum sickness. Generally, the reaction is not serious, but occasionally, there may be allergic shock or even death in some severe cases. So nurses should perform anaphylactic test before using TAT. The patients who have used TAT more than 1 week before should take the test again if they want to reuse it. Only the patients with negative result can use TAT with injection dosage for one time. Patients with positive result may use desensitized injection of TAT because TAT is a specific antibody to tetanus without replacement. When applying desensitized injection, the nurse should observe the client’s reactions intensively. If finding some abnormal condition, the nurse should give effective first aid immediately.
The anaphylactic test reagent and its dispensing method
Dilute the original TAT fluid (1500u per milliliter) 0.1ml to 1ml, which is 150u per milliliter. This solution is the reagent.
Method of anaphylactic test
Inject 0.1ml reagent solution (TAT 15u) at client’s forearm intradermally, and check the result in 20 minutes.
No local skin redness and swelling. No abnormal systemic reaction.
•The wheal is red and swelling.
•Induration with diameter larger than 1.5cm, and blushing with diameter larger than 4cm.
•Sometimes there is pseudopodium.
•The patient has pruritus feeling.
•The systemic reaction is similar to that of penicillin and serum sickness is the most common.
TAT desensitized injection
Mechanism of desensitized injection
If the test result is positive and there is no substitute, nurses should divide the dosage into several smaller dosages and inject them separately and continuously in a short period time. Several smaller dosages come into the human body consequently, combine the IgE on the mast cells and basophils and release the active substance, such as histamine, gradually. There is enzyme of histamine released from human body, which could decompose histamine with no harm to the body. So the client has no clinical manifestation. After continuous injection with small dosage in a short period of time, most of the IgE on cells will be almost or totally consumed, and no anaphylaxis will occur even exposed to a large amount of TAT. But this kind of desensitization is temporary and IgE will be produced in a period of time and anaphylaxis will happen again. That could explain why the anaphylactic test should be done again if the TAT is reused later.
Desensitized injection method
According to table 12-, the nurse makes an intramuscular injection at the interval of 20 minutes until the total dosage is accomplished and observes the client’s reactions intensively during desensitized injection. The nurse should stop injection immediately and help the physician to start first aid if the client has facial paleness, shortness of breath, cyanosis, urticaria, dizziness, palpitation or even allergic shock. If the anaphylactic reaction is not severe, each dose can be decreased and injection times can be increased base on the client’s condition until desensitized injection is finished under intensive observation.
Table 12- Desensitized injection method of TAT
Dilute to 1ml
Procaine (Novocaine) Anaphylactic Test
Procaine is akind of local anesthetic, which can be used in infiltrationanesthesia, conduction anesthesia, lumbar anesthesia and epidural anesthesia. Anaphylaxis from slight to severe may occur occasionally. Skin anaphylactic test should be done before it is used for the first time if procaine is needed in operation or special exam. Application is permitted if the result is negative.
Procaine anaphylactic test method: inject 0.25% procaine solution 0.1ml intradermally, and check the result in 20 minutes.
Other details can be referred to the penicillin anaphylactic test.
Cytochrome C anaphylactic test
Cytochrome C is an activator of cell respiration that is a kind of assisted medication used in tissue hypoxia. Anaphylaxis may occur occasionally. Anaphylactic test should be done before using. There are 3 general methods for anaphylactic test:
Dilute 0.1ml of Cytochrome C solution (15mg per 2ml) to 1ml, which is 0.75mg per milliliter solution. This is the test reagent. Administer 0.1ml (containing cytochrome C 0.075mg) by intradermal injection, and check the result in 20minutes. The result is positive if there is local redness and swelling，with the diameter of wheal larger than 1cm，and papular appears.
Skin scarification test
Choose the medial side of forearm, and sterilize the local site with 70% alcohol solution. Put one drip of original Cytochrome C solution on the forearm, and make two scarifications with the length of 0.5cm and depth of little bleeding. Check the result in 20minutes. The result determination can be referred to intradermal test.
The eye drop method has also been reported, which is to put one drip of original Cytochrome C on the conjunctiva, and check the result after 20 minutes. If there are congestion, edema, or itch in conjunctiva, the result is positive.
Cephalosporin anaphylactic test