Subcutaneous Morphine & Intramuscular Ondansetron Administration – Comprehensive Procedure Notes

Patient Identification & Communication

  • Checked patient’s wristband BEFORE any medication preparation
    • Confirmed:
    • Name: Mr. Stuart Russo
    • DOB: 25/03/1947
    • Hospital (URN) No.: 099251
  • Introduced self (Sally) and second nurse (Diane) ‒ explained dual-check procedure
  • Gave clear, step-by-step explanations of:
    • Purpose of each injection (nausea & pain)
    • Injection sites (abdomen for SC morphine, shoulder for IM ondansetron)
    • Expected sensations ("slight sting")
  • Re-explained procedure just before each injection; maintained patient dignity (covering him afterward)

Infection Control & PPE

  • Hand hygiene performed:
    • Prior to preparation
    • Before approaching patient
    • Between injections (removed gloves → hand hygiene → new gloves)
  • Gloves used for both injections because of potential exposure to blood/body fluids
  • Maintained Aseptic Non-Touch Technique (ANTT)
    • Never touched needle tips or syringe tips once opened
  • Disposed sharps immediately after use; sharps container placed on bottom shelf of trolley

Hospital Policy Note

  • Highlighted that site swabbing varies by institution
    • Some policies: no alcohol wipe for IM/SC
    • Demonstrated current policy: alcohol wipe used & allowed to dry for BOTH sites

Equipment & Supplies Checklist

  • Alcohol wipes ×2
  • Sharps container accessible
  • Kidney dishes ×2
  • Ampoule opener (“ampoule popper”)
  • Drawing-up needles (blunt) ×2
  • Administration needles:
    • 25-gauge for subcutaneous (SC) morphine
    • 23-gauge for intramuscular (IM) ondansetron
  • Syringes:
    • 3 mL syringe for ondansetron (IM)
    • 1 mL syringe for morphine (SC)
  • Medication vials kept until AFTER administration as record/evidence

Medication Details & Calculations

  • Ondansetron
    • Strength: 4 mg in 2 mL ampoule
    • Route ordered: IM (deltoid)
  • Morphine
    • Strength on label: 10 mg in 1 mL ampoule
    • Doctor ordered dose: 5 mg (PRN section)
    • Volume required: V = \frac{5\,\text{mg}}{10\,\text{mg/mL}} = 0.5\,\text{mL}
    • Route ordered: SC (abdomen)
  • Double-checked:
    • Dose, route, drug, patient, expiry (both nurses)
    • Sign-out from DD (dangerous drug) cupboard completed BEFORE prep

Drawing-Up Procedure (Step-by-Step)

  • GENERAL
    • Ensure fluid is below ampoule neck line
    • Attach blunt drawing-up needle to appropriate syringe
    • Place ampoule opener over neck → snap away from body → dispose neck in sharps
  • ONDANSETRON (IM)
    • 3 mL syringe used → drew full 2 mL (4 mg)
    • Swapped blunt needle for 23 G administration needle
    • Placed syringe in kidney dish; kept ampoule as evidence
  • MORPHINE (SC)
    • 1 mL syringe used → aimed for 0.5 mL
    • Eliminated air bubbles for accurate reading
    • Expelled excess to reach exact 0.5 mL
    • Second nurse confirmed volume & expiry (2025)
    • Changed to 25 G needle for SC administration

Administration: Subcutaneous Morphine (Abdomen)

  • Site: abdominal SC tissue (exposed & privacy maintained)
  • Alcohol wipe → let dry
  • Needle inserted at 45° angle (typical SC technique)
  • Injected slowly; withdrew needle; applied sterile gauze pressure
  • Observed for bleeding (minimal), covered patient

Administration: Intramuscular Ondansetron (Deltoid)

  • Landmarking:
    • Locate acromion process (bony tip of shoulder)
    • Place index & middle fingers beneath → injection site lies in triangle below
  • Alcohol wipe → let dry; skin held taut
  • Needle held like a dart at 90° angle
  • Aspirated (pulled plunger) to ensure no blood flashback (safety check)
  • Clear chamber → injected slowly
  • Withdrew needle; sterile gauze pressure; minimal/no bleeding

Safety, Ethical & Professional Considerations

  • Two-nurse check essential for Schedule 8/controlled drugs (morphine)
  • Sharps safety: immediate disposal; no re-sheathing
  • Documentation: Doses, time, route, site, batch numbers recorded after administration
  • Patient autonomy & comfort: continuous explanation, reassurance, and coverage for modesty
  • Policy alignment: swabbing, aspiration during IM per local protocol; always verify with current guidelines

Comparison: SC vs IM Techniques (Key Points)

  • Needle gauge: smaller (25 G) for SC, larger (23 G) for IM
  • Angle: 45° (SC) vs 90° (IM)
  • Tissue target: subcutaneous fatty layer vs muscular layer
  • Volume typically lower for SC; absorption rate slower than IM

Potential Complications & Monitoring

  • SC morphine:
    • Watch for respiratory depression, sedation, hypotension
    • Pain/itching or localized swelling at site
  • IM ondansetron:
    • Monitor for headache, constipation, QT prolongation (rare)
  • Injection site issues: bleeding, hematoma, nerve injury (IM), infection → monitor

Real-World Relevance & Integration to Previous Learning

  • Reinforces 6 Rights of Medication Administration
  • Demonstrates difference between controlled drugs (morphine) and regular PRN meds (ondansetron)
  • Illustrates practical ANTT and PPE principles studied in foundational infection-control lectures
  • Case provides context for pharmacology: opioid analgesia vs anti-emetic therapy

Key Take-Home Messages

  • Perform thorough identity check & informed explanation every time
  • Prepare with the correct syringe size & change from drawing-up to administration needle
  • Maintain aseptic technique, follow local policy on site preparation & aspiration
  • Double-check calculations; document & dispose sharps safely
  • Tailor angle, gauge, and landmarking to injection type (SC vs IM)
  • Monitor patient for therapeutic effect & adverse reactions post-administration