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1、皮下與皮內(nèi)注射,石秀霞,皮下注射法,皮下注射法,hypodermic injection ,H,將少量藥液或生物制劑注入皮下組織的方法【目的】不宜口服給藥、需在一定時間內(nèi)發(fā)生藥效 預(yù)防接種 局部麻醉用藥,,,皮下注射部位: 三角肌下緣、 上臂外側(cè)、 腹部、

2、 后 背、大腿外側(cè)方,皮下注射部位,,,,,皮下注射法【操作前準(zhǔn)備】,,,-評估患者并解釋 -患者準(zhǔn)備 -護士自身準(zhǔn)備 -用物準(zhǔn)備 -環(huán)境準(zhǔn)備,皮下注射法【操作步驟】,-核對-吸取藥液 -核對 -選擇注射部位 -消毒-二次核對, -排氣-穿刺(抽回血)-推藥 -拔針、按壓 -操作后處理,皮下注射法動作分解,,(1)消毒

3、:常規(guī)消毒(2)進針:左手 右手 角度 深度(3)拔針:干棉簽輕壓針刺處,左手、右手(方法),,,,,角度、深度(方法),,,皮下注射法注意事項,嚴(yán)格執(zhí)行查對制度和無菌操作原則 對皮膚有刺激的藥物一般不作皮下注射注射前詳細詢問用藥史 過于消瘦者可捏起局部組織,適當(dāng)減小穿刺角度,進針角度不宜超過45度,以免刺入肌層,皮下注射法健康教育,長期注射者,讓患者了解建立輪流交替注射部位的計劃,經(jīng)常更換注射部位,以促進

4、藥物的充分吸收,核對 → 選部位 → 皮膚消毒(洗必泰碘) → 待干 → 吸藥 →排氣 → 左手繃緊皮膚 → 右手持注射器→ 食指固定針?biāo)ǎㄓ沂郑?→ 針頭斜面向上,與皮膚呈30~40°角進針 → 深度為針梗的1/2或2/3到皮下 → 松開左手 → 右手固定注射器 → 左手抽吸無回血后 → 緩緩?fù)谱⑺幰?→ 完畢,干棉球按壓針孔處皮膚,迅速拔針 → 安置好病人 → 清理用物 。,皮下注射實施小結(jié),,,,,《 2011版中國糖尿

5、病藥物注射技術(shù)指南》介紹,,注射技術(shù)是糖尿病注射治療的三大關(guān)鍵因素之一,,注射技術(shù):注射部位的選擇注射部位的輪換注射部位的檢查和消毒選擇是否捏皮選擇進針角度針頭留置時間注射器材的廢棄針頭重復(fù)使用的危害,,,腹部以肚臍為中心,半徑2.5cm外的距離。越靠近腰部兩側(cè)(即使是肥胖患者),皮下組織的厚度也會變薄,因此容易導(dǎo)致肌肉注射。,根據(jù)可操作性/神經(jīng)血管距離/皮下組織狀況:適合注射的部位,,上臂上臂側(cè)面或者后側(cè)部位;皮下

6、組織較厚,導(dǎo)致肌肉注射的概率較低。,,臀部臀部上端外側(cè)部位;即使是少兒患者還是身材偏瘦的患者,該部位的皮下組織仍然豐富,最大限度降低肌肉注射的危險性。,大腿大腿外側(cè);皮下組織較厚,離大腿血管和坐骨神經(jīng)較遠,針頭導(dǎo)致外傷的概率較低。,推薦的注射部位,,,,,注射部位還應(yīng)考慮胰島素在不同部位的吸收差異,不同注射部位胰島素吸收不同(分鐘): —研究顯示,50%胰島素吸收所需要的時間腹部最快,手臂中等,大腿和臀部較慢1,1.Th

7、e American Journal of Nursing, Vol. 98, No.7, pp. 55+57,,不同注射部位吸收胰島素速度快慢不一,125I標(biāo)記清除占初始劑量的百分比(%),時間(分鐘),時間(分鐘),*p<0.05 ,大腿 vs 上臂**p<0.05 ,上臂 vs. 腹部***p<0.005,腹部vs. 大腿,注射胰島素后餐后血糖水平(mg/dl),吸收速度:腹部>上臂>大腿,Mud

8、allar SR, et al. Diabetes Care 1999; 22: 1501-1506.,關(guān)于注射部位選擇的推薦:,,注射餐時胰島素等短效胰島素,最好選擇腹部[1-7] A1希望胰島素的吸收速度較緩時,可以選擇臀部。臀部注射可以最大限度地降低注射至肌肉層的風(fēng)險[8,9] A1給少兒患者注射中效或者長效胰島素時,最好選擇臀部或者大腿[10] A1,Frid A, Gunnarsson R, Güntner

9、 P, Linde B. Effects of accidental intramuskulær injection on insulin absorption in IDDM. Diabetes Care 1988; 11: 41-45. Frid A & B Linde (1993) Clinically important differences in insulin absorption from the a

10、bdomen in IDDM. Diabetes Research and Clinical Practice: Vol 21. No 2-3. 137-141. Frid A, Lindén B. Intraregional differences in the absorption of unmodified insulin from the abdominal wall. Diabet Med 1992;9:236-9

11、.Annersten M, Willman A. Performing subcutaneous injections: a literature review. Worldviews Evid Based Nurs 2005; 2: 122-30.Zehrer C, Hansen R, Bantle J. Reducing blood glucose variability by use of abdominal insulin

12、injection sites. Diabetes Educ 1985;16:474-7.Henriksen JE, Djurhuus MS, Vaag A, Thye-Ronn P, Knudsen D. Hother-Nielsen O, et al. Impact of injection sites for soluble insulin on glycaemic control in type 1 (insulin-depe

13、ndent) diabetic patients treated with a multiple insulin injection regimen. Diabetologia 1993;36:752-8.Sindelka G, Heinemann L, Berger M. Frenck W, Chantelau E. Effect of insulin concentration, subcutaneous fat thicknes

14、s and skin temperature on subcutaneous insulin absorption in healthy subjects. Diabetologia 1994;37:377-40.Ahern J & ML Mazur (2001) Site rotation. Diabetes Forecast: Vol 54. No 4. 66-68. Wood L, Wilbourne J, Kyne-

15、Grzebalski D, et al. administration of insulin by injection. Practice Diabetes International 2002; 19(Suppl 2-1): S1-S2.Smith CP, Sargent MA, Wilson BP, Price DA. Subcutaneous or intramuscular insulin injections. Arch D

16、is Child 1991;66:879-82.,關(guān)于注射部位輪換的推薦:,,一種已經(jīng)證實有效的注射部位輪換方案:將注射部位分為四個等分區(qū)域(大腿或臀部可等分為兩個等分區(qū)域),每周使用一個等分區(qū)域并始終按順時針方向進行輪換[1,2] A3在任何一個等分區(qū)域內(nèi)注射時,每次的注射點都應(yīng)間隔至少1cm,以避免重復(fù)的組織損傷 A3從注射治療一開始,就應(yīng)教會患者掌握一套簡單易行的注射部位輪換方案[3] A2每次患者就診時,醫(yī)護人

17、員都應(yīng)檢查患者輪換方案的執(zhí)行情況 A3,Diagrams courtesy of Lourdes Saez-de Ibarra and Ruth Gaspar, Diabetes Nurses and Specialist Educators from La Paz Hospital, Madrid, Spain.Lumber T. Tips for site rotation. When it comes to insulin.

18、where you inject is just as important as how much and when. Diabetes Forecast 2004;57:68-70.Thatcher G. Insulin injections. The case against random rotation. Am J Nurs 1985; 85: 690-2.,注射部位的輪換:不同注射部位之間的輪換,午餐前,晚餐前,不同注射部位

19、之間的輪換:“每天同一時間注射同一部位,每天不同時間注射不同部位”,早餐前,午餐前,晚餐前,早餐前,睡前,一天注射三次:,一天注射四次:,注射部位的輪換:左右輪換,注射部位左右輪換:左邊一周,右邊一周,部位對稱輪換左邊一次,右邊一次,部位對稱輪換,注射部位的輪換:同一注射部位內(nèi)的輪換,同一注射部位內(nèi)的輪換:每次注射時離上次注射點之間距離至少間隔1cm,關(guān)于注射部位檢查和消毒的推薦:,,患者應(yīng)于注射前檢查注射部位[1,2] A3

20、一旦發(fā)現(xiàn)注射部位若出現(xiàn)脂肪增生、炎癥或感染,應(yīng)更換注射部位[3-10] A2注射時,應(yīng)保持注射部位的清潔[11] A2當(dāng)注射部位不潔凈,或者患者處于感染已于傳播的環(huán)境(如:醫(yī)院或療養(yǎng)院),注射前應(yīng)消毒注射部位[2,12,16-18] A3,Danish Nurses Organization. Evidence-based Clinical Guidelines for Injection of Insulin for Ad

21、ults with Diabetes Mellitus, 2nd edition, December 2006.Association for Diabetescare Professionals (EADV). Guideline: The Administration of Insulin with the Insulin Pen. September 2008.Johansson U. Amsberg S, Hannerz L

22、, Wredling R, Adamson U, Arnqvist HJ & P Lins (2005) Impaired Absorption of insulin Aspart from Lipohypertrophic Injection Sites. Diabetes Care: Vol 28, No 8, 2025-2027. Ariza-Andraca CR, Altamirano-Bustamante E, Fr

23、ati-Munari AC, Altamirano-Bustamante P, Graef-Sanchez A. Delayed insulin absorption due to subcutaneous edema. Arch Invest Med 1991;22:229-33.Saez-de Ibarra L, Gallego F. Factors related to lipohypertrophy in insulin-tr

24、eated diabetic patients; role of educational intervention. Pract Diabetes Int 1998;15:9-11.Young RJ, Hannan WJ, Frier BM, Steel JM, Duncan LJ. Young RJ, Hannan WJ, Frier BM, Steel JM Diabetic lipohypertrophy delays insu

25、lin absorption. Diabetes Care 1984;7:479-80.Chowdhury TA, Escudier V. Poor glycaemic control caused by insulin induced lipohypertrophy. BMJ 2003;327:383-4.Johansson UB. Impaired absorption of insulin aspart from lipohy

26、pertrophic injection sites. Diabetes Care 2005;28:2025-7.Overland J, Molyneaux L, Tewari S., Fatouros R, Melville P, Foote D, et al. Lipohypertrophy: Does it matter in daily life? A study using a continuous glucose moni

27、toring system. Diabetes Obes Metab2009;11:460-3.Frid A, Linden B. Computed tomography of injection sites in patients with diabetes mellitus. Injection and Absorption of Insulin. Stockholm: Thesis, 1992.Gorman KC. Good

28、hygiene versus alcohol swabs before insulin injections (Letter). Diabetes Care 1993;16:960-1.Schuler G, Pelz K, Kerp L. Is the reuse of needles for insulin injection systems associated with a higher risk of cutaneous co

29、mplications? Diabetes Res Clin Pract 1992;16:209-12.Workman B. Safe injection techniques. Nurs Stand 1999;13:47-53.Bain A, Graham A. How do patients dispose of syringes? Pract Diabetes Int 1998; 15: 19-21.Chantelau E,

30、 Schiffers T, Schutze J, Hansen B. Effect of patient-selected intensive insulin therapy on quality of life. Patient Educ Couns 1997 Feb; 30(2): 167-73.Le Floch JP, Herbreteau C, Lange F, Perlemuter L. Biologic material

31、in needles and cartridges after insulin injection with a pen in diabetic patients. Diabetes Care 1998;21:1502-4.McCarthy JA, Covarrubias B, Sink P. Is the traditional alcohol wipe necessary before an insulin injection?

32、Dogma disputed (Letter). Diabetes Care 1993;16:402.Swahn A. Erfarenheter av 94000 osterilt givna insulininjektioner (Experiences from 94000 insulin injections given without skin swab). Sv Lakaresallskapets Handlingar Hy

33、giea 1982;92:160(3O).,關(guān)于捏皮的推薦:,,所有患者在起始胰島素治療時就應(yīng)掌握捏皮的正確方法 A3捏皮時力度不得過大導(dǎo)致皮膚發(fā)白或疼痛 A3不能用整只手來提捏皮膚,以避免將肌肉及皮下組織一同捏起最佳的注射步驟為:捏起皮膚形成皮褶 和皮褶表面呈90°角進針后,緩慢推注胰島素 當(dāng)活塞完全推壓到底后,針頭在皮膚內(nèi)停留10秒鐘(采用胰島素筆注射) 拔出針頭 松開皮褶 A3,Clauson PG

34、, Linde B. Absorption of rapid-acting insulin in obese and nonobese NIDDM patients. Diabetes Care 1995;18:986-91.Jamal R, Ross SA, Parkes JL, Pardo S, Ginsberg BH. Role of injection technique in use of insulin pens: pro

35、spective evaluation of a 31-gauge, 8mm insulin pen needle. Endocr Pract 1999;5:245-50.Birkebaek N, Solvig J, Hansen B, Jorgensen C, Smedegaard J, Christiansen J. A 4mm needle reduces the risk of intramuscular injections

36、 without increasing backflow to skin surface in lean diabetic children and adults. Diabetes Care. 2008 Sep;22(9): e65. Gibney MA, Arce CH, Byron KJ, Hirsch LJ. Skin and subcutaneous adipose layer thickness in adults wit

37、h diabetes at sites used for insulin injections: Implications for needle length recommendations. Curr MedRes Opin 2010;26:1519-30.Hirsch L, Klaff L, Bailey T, Gibney M, Albanese J, Qu S, et al. Comparative glycemic cont

38、rol, safety and patient ratings for a new 4 mm\32G insulin pen needle in adults with diabetes. Curr Med Res Opin 2010;26:1531-41.Kreugel G, Keers JC, Jongbloed A, Verweij-Gjaltema AH, Wolffenbuttel BHR. The influence of

39、 needle length on glycemic control and patient preference in obese diabetic patients. Diabetes 2009;58:A117.Kreugel G, Beijer HJM, Kerstens MN, ter Maaten JC, Sluiter WJ, Boot BS. Influence of needle size for SC insulin

40、 administration on metabolic control and patient acceptance. Europ Diab Nursing 2007;4:1-5.Van Doorn LG, Alberda A, Lytzen L. Insulin leakage and pain perception with NovoFine 6 mm and NovoFine 12 mm needle lengths in p

41、atients with type 1 or type 2 diabetes. Diabet Med 1998;1:S50.Solvig J, Christiansen JS, Hansen B, Lytzen L. Localisation of potential insulin deposition in normal weight and obese patients with diabetes using Novofine

42、6 mm and Novofine 12 mm needles. Meeting Federation European Nurses in Diabetes, Jerusalem, Israel, 2000 (Abstract).Schwartz S, Hassman D, Shelmet J, Sievers R, Weinstein R, Liang J, Lyness W. A multicenter, open-label

43、, randomized, two-period crossover trial comparing glycemic control, satisfaction, and preference achieved with a 31 gauge x 6mm needle versus a 29 gauge x 12.7mm needle in obese patients with diabetes mellitus. Clin The

44、r 2004;26:1663-78.Frid A, Lindén B. Where do lean diabetics inject their insulin? A study using computed tomography. BMJ 1986; 292:1638.,關(guān)于進針角度的推薦:,,使用較短(4mm或5mm)的針頭時,大部分患者無需捏起皮膚,并可90°進針[1-9] A1使用較長(≥8mm)的針頭

45、時,需要捏皮或45°角以降低肌肉注射風(fēng)險[10,11] A1,針頭留置時間,藥液的流速還與注射筆針頭的內(nèi)徑有關(guān),注射筆針頭的內(nèi)徑越大,其藥液流速更快。目前,臨床上有采用 “薄壁”設(shè)計的針頭,在同等外徑的情況下內(nèi)徑更大,在降低注射引起不適感的同時保證胰島素的流速,更利于機體對胰島素的吸收,* Frid A. New injection recommendations for patients with diabetes.D

46、iabetes & Metabolism 36 (2010) S3-S18,*,A3,,,關(guān)于疼痛的推薦:,,減輕注射疼痛的方法包括:室溫保存正在使用的胰島素 如果使用酒精對注射部位進行消毒,應(yīng)于酒精徹底揮發(fā)后進行注射 避免在體毛根部注射 選用直徑較小、長度較短的注射筆針頭 每次注射使用新針頭[1-5] A2,Bohannon NJ. Insulin delivery using pen devices. Simpl

47、e-to-use tools may help young and old alike. Postgrad Med 1999;106:57-8.Dejgaard A, Murmann C. Air bubbles in insulin pens. Lancet 1989;334:871.Danish Nurses Organization. Evidence-based Clinical Guidelines for Injecti

48、on of Insulin for Adults with Diabetes Mellitus, 2nd edition, December 2006.Association for Diabetescare Professionals (EADV). Guideline: The Administration of Insulin with the Insulin Pen. September 2008.Chantelau E,

49、Lee DM, Hemmann DM, Zipfel U, Echterhoff S. What makes insulin injections painful? BMJ 1991;303: 26-7.,關(guān)于出血和淤血的推薦:,,應(yīng)使患者放心,注射部位局部出血或淤血并不會給胰島素的吸收或者糖尿病的整體管理帶來不良的臨床后果 A2,有時注射時針頭會觸到血管,導(dǎo)致局部出血或淤血。更換注射筆針頭的長度或者改變其他注射參數(shù),似乎并不能改變出

50、血或淤血的發(fā)生頻率,盡管一項研究提出5mm針頭注射可減少出血或淤血的發(fā)生。,Kahara T Kawara S. Shimizu A, Hisada A, Noto Y, Kida H. Subcutaneous hematoma due to frequent insulin injections in a single site. Intern Med 2004;43:148-9.Kreugel G, Beter HJM, Ker

51、stens MN, Maaten ter JC, Sluiter WJ, Boot BS. Influence of needle size on metabolic control and patient acceptance. Europ Diab Nursing 2007;4:51-5.,關(guān)于胰島素貯存的推薦:,,已開封的瓶裝胰島素或胰島素筆芯可在室溫下保存(保存期為開啟后一個月內(nèi),且不能超過保質(zhì)期) A2未開封的瓶裝胰島素或

52、胰島素筆芯應(yīng)儲藏在2℃~8℃的環(huán)境中,切勿冷凍 A2避免受熱或陽光照射,防止震蕩 有必要培訓(xùn)患者,在抽取胰島素之前,先確認(rèn)是否存在結(jié)晶體、浮游物或者顏色變化等異?,F(xiàn)象,Perriello G, Torlone E, Di Santo S. Fanelli C. De Feo P. Santusanio F. Brunetti P, Bolli GB. Effect of storage temperature on pharmac

53、okinetics and pharmadynamics of insulin mixtures injected subcutaneously in subjects with type 1 (insulin-dependent) diabetes mellitus. Diabetologia 1988;31:811 -815.,關(guān)于胰島素混勻的推薦:,,在使用云霧狀胰島素(如NPH和預(yù)混胰島素)之前,應(yīng)將胰島素水平滾動和上下翻動各1

54、0次,使瓶內(nèi)藥液充分混勻,直至胰島素轉(zhuǎn)變成均勻的云霧狀白色液體[1-5] A2,King L. Subcutaneous insulin injection technique. Nurs Stand. 2003;17:45-52.Jehle PM, Micheler C, Jehle DR, Breitig D, Boehm BO. Inadequate suspension of neutral protamine Hagend

55、orn (NPH) insulin in pens. Lancet 1999;354:1604-7.Brown A, Steel JM, Duncan C, Duncun A, McBain AM. An assessment of the adequacy of suspension of insulin in pen injectors. Diabet Med 2004;21:604-608.Nath C. Mixing ins

56、ulin: shake, rattle or roll? Nursing 2002;32:10.Springs MH. Shake, rattle, or roll?.Challenging traditional insulin injection practices Am J Nurs 1999; 99: 14.,超短效胰島素類似物注射的相關(guān)推薦:,,,超短效胰島素類似物的吸收速率不受注射部位的影響,可以在任何注射部位給藥[1-5

57、] A1盡管有研究表明,超短效胰島素類似物在脂肪組織和非運動狀態(tài)下肌肉組織的吸收率相似,但仍不應(yīng)肌肉注射此類藥物[2,3,6] A2目前,尚無關(guān)于超短效胰島素類似物在運動狀態(tài)肌肉中吸收率的研究,仍需要避免肌肉注射[2,3,6] A2,Mudaliar SR, Lindberg FA, Joyce M, Beerdsen P, Strange P, Lin A, Henry RR. Insulin aspart (B28 asp

58、-insulin): a fast-acting analog of human insulin: absorption kinetics and action profile compared with regular human insulin in healthy nondiabetic subjects. Diabetes Care 1999;22:1501-6.Rave K, Heise T, Weyer C, Herrnb

59、erger J, Bender R, Hirschberger S, et al. Intramuscular versus subcutaneous injection of soluble and lispro insulin: comparison of metabolic effects in healthy subjects. Diabet Med 1998;15:747-51.Frid A. Fat thickness a

60、nd insulin administration, what do we know? Infusystems Int 2006;5:17-9.Guerci B, Sauvanet JP. Subcutaneous insulin: pharmacokinetic variability and glycemic variability. Diabetes Metab 2005;31:4S7-4S24.Braakter EW, Wo

61、odworth JR, Bianchi R. Cermele B. Erkelens DW. Thijssen JH, et al. Injection site effects on the pharmacokinetics and glucodynamics of insulin lispro and regular insulin. Diabetes Care 1996;19:1437-40.Lippert WC, Wall E

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