Injection Teaching Packet

The following section is all information pertaining the medications used in this office and how they are used. This section is used for both nursing education, as well as patient information. These pages may be photocopied and given to patients when they attend an injection teaching class, but are the primary resource for nurses when they are unsure of a medication and how it is used.

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This section includes:
  1. A summary of what the medications are and how they work.
  2. Side effects of the medication
  3. How to mix medications (with itself and other medications)
  4. Discusses different injection techniques
  5. Education Class acknowledgement statement
For further education on injectable medication & injection techniques you can also go to our website @ www. DVIFG.com. Go to “Patient Info” then “Helpful Links” then “Freedom Med Teach” (Med Teaching Video). If your medications were ordered through Freedom, you can use your RX #. Otherwise enter RX# 09654321.

MEDICATIONS

Gonadotropins, Follistim, Gonal-F, Bravelle
Gonadotropins stimulate your ovaries to produce follicles that contain the developing eggs. Your ovaries will enlarge and you may experience what is often described as “twigging and pulling” in the pelvis. Other side effects you may experience include frontal headache, mood swings, and increased vaginal mucus.

You may experience some tingling or burning at the time of injection with some of the injectable medication. This should subside soon after you are finished. If you continue to have burning for hours after the injection, reddened areas and/or rash, or a hard lump, PLEASE notify the doctor or one of the nurses.

This medication is a daily injection until HCG is administered. The dosage is referred to as “AMPS” OR “VIALS”. You will be told the number of AMPS/VIALS of the medication (powder) to take. Take this medication around the same time every day as directed. Mix the medication just prior to using. DO NOT PREMIX AND PLACE IN THE REFRIGERATOR.

HCG

HCG is the medication that matures the follicles and prepares them for ovulation. You will be given instructions regarding the date and time you must take the injection. This injection is taken one time during each cycle.

PROGESTERONE

This medication is a natural, plant-derived hormone used to treat many conditions, some of which are: abnormal periods, aiding conception, maintaining pregnancy, hormone replacement therapy and other conditions as determined by your physician. You will have your progesterone level checked one week after you take the HCG injection. This is done in the office along with your ultrasound and blood work. Any of these medications will prolong the onset of your period.

There are different types of progesterone supplementation:

Prometrium 100/200 mg tablets: This medication is supplied in tablet form. You will be told how many tablets to take and when to take them. These are to be taken after meals. You may start this medication three days after HCG injection. Continue this medication until you are told to stop. This medication can cause you to feel tired, sleepy and dizzy at times. This is usually worse one hour after you take the medication. This common side effect can be lessened when the medication is taken with food. There will be a label on the bottle that tells you not to take it if you think you might be pregnant. Please note that this office would NOT give you anything that might harm you or your possible pregnancy.

Progesterone in Oil: This medication is taken in an injection. The dose is 50-mg/1 cc. This medication will be taken intramuscularly until you are told to stop. You may experience soreness at the injection sites. It is recommended that after each injection that the area be massaged for several minutes after, this may help to alleviate “knots” at area of injection. Remember to rotate butt cheeks with each injection. If you experience a rash, reddened areas or itchiness, PLEASE notify a doctor or one of the nurses.

LUPRON

Lupron is a multidose vial. You will use the same vial over and over several times during the cycle. The amount of liquid in the vial should be enough for one entire cycle. Once the lupron vial has been opened for more than 28 days it needs to be discarded.

Lupron is an agonist, a synthetic medication used to suppress your reproductive system. This means we do not want your body to control your menstrual cycle. Therefore, we give you a medication that temporarily stops your body’s ability to control the menstrual cycle. Once you stop this medication your body will resume its normal action and your menstrual cycle will start again. Lupron achieves this by initially stimulating and subsequently depleting the pituitary gland from the release of hormones (LH & FSH) from the pituitary gland that control your menstrual cycle. This way Lupron prevents the communication between the pituitary gland and the ovaries and allows the gonadotropin injections to be the sole source of follicle stimulation. Because of its way of action, it is characterized as an agonist.

CETROTIDE & ANTAGON

Cetrotide and Antagon are packaged in single dose kits. You will use one kit per injection of either Cetrotide or Antagon.

Cetrotide and Antagon are also used to suppress your reproductive system and allow gonadatropin injections to be the sole source of follicle stimulation. However, Cetrotide & Antagon immediately suppress the release of LH and FSH from the pituitary gland. Because of their way of action Cetrotide and Antagon are characterized as antagonists.

MIXING INSTRUCTIONS

  • Gather all materials needed. Your table will need to be cleaned with alcohol prior to mixing any medication.
  • Wash your hands with antibacterial soap prior to mixing your medications.

Mixing Lupron

You will need the following supplies:
  • Box of Lupron / Luprolide Acetate
  • ½ cc insulin syringes
  • Alcohol pads or bottle of alcohol
  • 2x2 gauze square or cotton balls
  • Band Aids
  • Sharps container
  1. Open vial of Lupron and clean off with alcohol. If you have already used the Lupron you will only need to clean off the top.
  2. Obtain the ½” cc insulin syringe and pull ________units into the syringe.
  3. Put the needle into the vial through the rubber stopper and push on the plunger to put air into the vial.
  4. Turn the syringe and bottle over 180o so bottle is now over the syringe.
  5. Pull back on plunger so the liquid goes into the syringe.
  6. Pull liquid past the amount that you need.
  7. Gently tap syringe so all air bubbles go to the top.
  8. Gently push on plunger to put air back into the bottle and stop when you are at the line with the amount that you will need.
  9. Pull out needle.
  10. Refer to section for subcutaneous injection instruction.

Mixing Lupron Microdose

Same supplies as above

  • Follow the instructions as above steps 1-10
  • The Lupron Microdose is to be kept REFRIGERATED. This is a compounded medication.
  • If the vial has been opened for 28 days or more, it must be discarded.

If you are using Menopur OR Bravelle

You will need the following supplies:
  • 1 vial of 2 cc mixing liquid from Menopur box
  • _______(#) vials of powder from Menopur box
  • 3 cc syringe with
  • QCAPS
  • 27 gauge 3/8” needle
  • Alcohol pads or a bottle of alcohol
  • 2x2 gauze or cotton balls
  • Band Aids
  • Sharps container
  1. Pull tops off vials.
  2. Clean off tops with alcohol.
  3. Using the 3 cc syringe screw on the QCAP
  4. Put 27 gauge 3/8” needle aside to be used later.
  5. Pull back on plunger to pull 1 cc of air into syringe.
  6. Push needle through rubber stopper.
  7. Gently push plunger to put air into vial. This creates a vacuum so the water can be withdrawn easily.
  8. Pull back on plunger to pull all the liquid out into the syringe. This should equal 1 cc of the liquid.
  9. Pull the syringe out of the vial and insert into the vial with the powder.
  10. Gently push on the plunger to push the liquid into the vial. It is important to do this slowly as not to make bubbles.
  11. Keeping the needle in gently swirl the vial to ensure all the medication is mixed thoroughly.
  12. Pull all the liquid back into the syringe.
  13. If you need more than one bottle of the powder repeat steps 5 - 11.
  14. Pull back on the plunger with needle straight up in air to pull all the liquid out of the needle.
  15. Unscrew the QCAP and replace with the 27 gauge 3/8” needle you took off when you started.
  16. The needle should be facing upward so that all the air bubbles go to the top. Gently tap on syringe to help this happen.
  17. Gently push on the plunger to expel all the air.
  18. Replace cap on needle.
  19. Proceed to instructions for subcutaneous injection.


MIXING TWO DIFFERENT MEDICATIONS

Mixing Follistim/ Gonal-F & Menopur:
You will need the following supplies:

  • 1 vial of mixing liquid from Menopur box
  • _______vials from Menopur box and/or Follistim box
  • 3 cc syringe
  • 27 3/8” needle tip
  • QCAPS (These are in the boxes)
  • Alcohol pads or bottle of alcohol
  • 2x2 gauze or cotton balls
  • Band Aids
  • Sharps container
  1. Pull all tops off all vials.
  2. Clean tops with alcohol.
  3. Using the 3 cc 1 ½” 27 gauge needle unscrew needle and replace with the QCAP.
  4. Using the QCAP, pull air back into the syringe to equal 1 cc.
  5. Push needle into vial of liquid from Menopur box.
  6. Pull back liquid to equal 1 cc. Make sure you tap the syringe so all air bubbles go to the top and expel into container.
  7. Push needle into vial of Menopur powder and slowly push on plunger to put liquid into vial. It is important not to do this too quickly so that bubbles do not form.
  8. Gently swirl the bottle to ensure all the liquid and powder are mixed.
  9. Insert needle back into the vial and pull all the liquid back into the syringe.
  10. If you are mixing more than one Menopur bottle repeat steps 4-9. If you are done move on to #11.
  11. Unscrew the QCAP & replace with the 27 gauge 3/8” needle you took off when you started.
  12. The needle should be facing upward so that all the air bubbles go to the top. Gently tap on syringe to help this happen.
  13. Gently push on plunger to expel all the air.
  14. Replace cap on needle.
  15. Proceed to instructions for subcutaneous injection.


MIXING WITH THE MULTI-DOSE KIT

Mixing Gonal-F Multi-Dose Kit Alone:
You will need the following supplies:

  • Gonal-F Multi-Dose Vial
  • Pre-filled syringe of saline (bacteriostatic) solution
  • Gonal-F Multi-Dose custom dosing injection syringe
  • Alcohol pads or bottle of alcohol
  • 2x2 gauze squares or cotton balls
  • Band-Aids
  • Sharps container
  1. Pull top off vial.
  2. Clean top of vial off with alcohol.
  3. Carefully pull rubber cap from the Pre-filled syringe of saline solution.
  4. Put needle through the rubber stopper.
  5. Slowly push down on the plunger to inject water into vial. Do not shake.
  6. After all solution is in vial, remove finger from top of plunger.
  7. Allow plunger to rise to its original position.
  8. Dispose of Pre-filled needle.
  9. Clean top of vial off with alcohol.
  10. Insert custom injection syringe into multi-dose vial, turn it upside down so needle points upward.
  11. Slowly pull plunger back to amount desired.
  12. Allow the air bubbles go to the top. Gently tap on syringe to help this happen.
  13. Gently push on plunger to expel all the air.
  14. You are done; proceed to instructions for subcutaneous injection technique.
    • Medicine is now reconstituted. There is no need to mix any more Gonal-F for the remainder of your cycle. Just insert custom needle in multi-dose vial and expel desired amount.

Using the Gonal-F RFF Pen Alone:

You will need the following supplies:

  • Gonal-F RFF Pen
  • Pen needle
  • Alcohol pads or bottle of alcohol
  • 2x2 gauze square or cotton balls
  • Band-Aids
  • Sharps Container

Priming the Pen: First use only:

  1. Remove pen cap and wipe threaded tip with alcohol.
  2. Remove peel tab from outer cap on needle.
  3. Screw needle on clockwise until needle is secure.
  4. Remove outer needle cap. Do not discard.
  5. Set dose arrow at 37.5 IU.
  6. Pull out injection button until a click is heard.
  7. Remove inner needle cap & hold pen with needle pointing upright.
  8. Keep the needle pointing upright and push in injection button until a click is heard.
  9. A small amount of liquid should appear at the needle tip.
  10. You are ready for use.

Subsequent Use:

  1. Remove pen cap and wipe threaded tip with alcohol.
  2. Remove peel tab from outer cap on needle.
  3. Screw needle on clockwise until needle is secure.
  4. Remove outer needle cap.
  5. Set dose arrow at desired amount & recheck your dosage before you proceed.
  6. Load dosage by pulling out injection button until a click is heard.
    • The last visible flat arrow indicates loaded amount:
    • If set and amount loaded is too low: Turn dosage dial to correct dose and pull out injection button again.
    • If set and amount loaded is too high: Count the number of clicks 75 IU is equal to 2 clicks. Ex: 150 IU = 4 clicks 300 IU = 8 clicks
    • Leave left over amount for next use.
  7. Remove inner needle cap.
  8. Proceed to instructions for subcutaneous injection.
  9. Discard of needle by using the outer needle cap to unscrew the needle from the pen.


Using the Gonal-F RFF Pen OR Follistim Pen with Menopur:

You will need the following supplies:

  • 1 vial of mixing liquid from Menopur box
  • _______vials from Menopur box
  • Gonal-F RFF Pen or Follistim Pen
  • Pen needle
  • 3 cc syringe with
  • QCAP
  • Gonal F Needles ( These are in the box)
  • Alcohol pads or bottle of alcohol
  • 2x2 gauze square or cotton balls
  • Band-Aids
  • Sharps container
  1. Pull tops off vials of Menopur
  2. Clean off tops with alcohol.
  3. Using the 3 cc syringe unscrew needle and replace with QCAP
  4. Pull back on plunger to pull 1 cc of air into syringe.
  5. Push needle through rubber stopper.
  6. Gently push plunger to put air into vial. This creates a vacuum so the water can be withdrawn easily.
  7. Pull back on plunger to pull all the liquid out into the syringe. This should equal 1cc of the liquid.
  8. Pull the syringe out of the vial and insert into the vial with the powder.
  9. Gently push on the plunger to push the liquid into the vial. It is important to do this slowly as not to make bubbles.
  10. Keeping the needle in gently swirl the vial to ensure all the medication is mixed thoroughly.
  11. If you need more than one bottle of the powder repeat steps 5 - 11.
  12. Remove the needle without drawing up any medication. Leave last mixed amount of med in vial.
  13. Now move onto the Gonal-F RFF Pen OR Follistim Pen
  14. Remove pen cap and wipe threaded tip with alcohol.
  15. Remove peel tab from outer cap on needle.
  16. Screw needle on clockwise until needle is secure.
  17. Remove outer needle cap.
  18. Set dose arrow at desired amount & recheck your dosage before you proceed.
  19. Load dosage by pulling out injection button until a click is heard.
  20. Remove inner needle cap.
  21. Insert the Gonal-F RFF OR Follistim pen into the last bottle of Menopur mix and push down on the injection button.
  22. You will now have a mixture of Menopur and Gonal-F OR Follistim in the vial.
  23. Insert the QCAP in the vial.
  24. Pull back on the plunger with needle straight up in air to pull all the liquid out of the needle.
  25. Unscrew the QCAP and replace with the 27 3/8” gauge needle you took off when you started.
  26. The needle should be facing upward so that all the air bubbles go to the top. Gently tap on syringe to help this happen.
  27. Gently push on the plunger to expel all the air.
  28. Proceed to instructions for Subcutaneous injection.


Using the Follistim Pen Alone:

You will need the following supplies:

  • Follistim Pen
  • Follistim AQ cartridge
  • Pen needle
  • Alcohol pads or bottle of alcohol
  • 2x2 gauze square or cotton balls
  • Band-Aids
  • Sharps container

Priming the Pen:

  1. Remove pen cap.
  2. Unscrew the pen body from the cartridge holder.
  3. Take Follistim AQ cartridge from packaging and clean the rubber stopper with alcohol.
  4. Insert cartridge into cartridge holder.
  5. Screw pen body onto cartridge holder. The blue arrow should align with the yellow dash. 5. Again, clean the Follistim AQ cartridge rubber stopper with alcohol.
  6. Remove peel tab from outer cap on needle.
  7. Screw needle on clockwise until needle is secure.
  8. Remove outer needle cap. Do not discard.
  9. Remove the inner cap and discard.
  10. Turn the dosage knob to 25 IU.
  11. With the needle pointing upwards, hold pen and gently tap syringe to have all the air go to the top.
  12. Press down on dosage knob.
  13. You may see a small amount at the tip of the needle.
  14. You are ready for use. You may need to repeat this step more than once for each Follistim AQ cartridge.
  15. Once done priming the pen, discard of needle by using the outer needle cap to unscrew the needle from the pen.

Subsequent Use:

  1. Remove pen cap.
  2. Clean the rubber stopper of Follistim AQ cartridge with alcohol.
  3. Remove peel tab from outer cap on needle.
  4. Screw needle on clockwise until needle is secure.
  5. Remove outer needle cap. Do not discard.
  6. Remove the inner cap and discard.
  7. Dial the amount of medicine, with the dosage knob, desired by turning the knob until the dot beside the correct number on the dosage scale is sitting in the middle of the dosage window.
    • If you over dial the amount of medicine, do not turn the dial back down to the lower dosage, you will lose medicine. Instead you must turn the dosage knob past the 450 IU mark, until it cannot turn any more. The dosage scale will then move freely and redial from the “0” mark.
  8. Proceed to instructions for subcutaneous injection.
  9. Discard of needle by using the outer needle cap to unscrew the needle from the pen.


Mixing Cetrotide:

You will need the following supplies:

  • Box of Cetrotide
  • Alcohol bottle or alcohol pads
  • 2x2 gauze or cotton balls
  • Band Aids
  • Sharps container
  1. Pull out prefilled syringe and bottle of powder from box.
  2. Pull off white cap from syringe and attach the 20 gauge 1 ½” needle.
  3. Put needle through the rubber stopper and push liquid into the bottle.
  4. Gently swirl the bottle to ensure all of the medication is mixed.
  5. Pull all the liquid back out of the bottle.
  6. With the needle facing upward pull all liquid out of needle by pulling back on plunger.
  7. Replace 20 gauge 1 ½” needle with 27 gauge ¾” needle.
  8. Gently tap syringe to have all the air go to the top and gently push on plunger to expel air.
  9. Proceed to subcutaneous injection instruction.

 

Mixing Antagon or Ganirelix

You will need the following supplies:

  • Box of Antagon or Ganirelix
  • Bottle of alcohol or alcohol pads
  • 2x2 gauze or cotton balls
  • Band Aids
  • Sharps container
  1. Open and remove prefilled syringe from box.
  2. Pull off rubber covering from syringe.
  3. Gently tap syringe to have all the air go to the top and gently push on plunger to expel air.
  4. Proceed to subcutaneous injection instruction.



Mixing HCG (Novarel, Pregnyl) 10,000 units:

You will need the following supplies:

  • 1 box of HCG 10,000 units
  • 3 cc syringe with 18 gauge ½” needle
  • 25 gauge 1 ½” needle
  • >Alcohol pads or a bottle of alcohol
  • 2x2 gauze or cotton balls
  • Band-aids
  • Sharps container

Instructions to mix 10,000 units of HCG:

  1. Pull plastic tabs off the top of HCG powder and HCG water (diluent).
  2. Clean tops (rubber stoppers) with alcohol.
  3. Take out 3 cc 25gauge 1 ½” syringe and 18 gauge 1 ½” needle (for mixing). Unscrew 25 gauge 1 ½” needle from syringe and attach the 18 gauge 1 ½” mixing needle onto the 3 cc syringe. Place the 25 gauge 1 ½” needle aside. You will have to put in back onto the 3 cc syringe when it is time for your injection.
  4. Draw back 2 cc of air into the 3 cc syringe. Then inject the air directly into the HCG liquid. (This is done to create a vacuum so that the water can easily be drawn into syringe).
  5. Pull back 2 cc of water (a whole syringe full) into the syringe. Push needle into the bottle with powder and gently push the medication into the bottle. It is important to do this slowly as not to make bubbles.
  6. Swirl mixture around gently until all of the HCG powder is liquefied. (DO NOT SHAKE). Draw liquefied HCG back into 3 cc syringe.
  7. Unscrew 18 gauge 1 ½” needle and attach 25 gauge 1 ½” needle.
  8. The needle should be facing upward so that all air bubbles go to the top.
  9. Gently tap on syringe to have all the air go to the top and gently push the plunger to expel air.
  10. Proceed to intramuscular injection site and administer injection.

Instructions to mix 5,000 units HCG:

  1. Pull plastic tabs off the top of HCG powder and HCG water (diluent).
  2. Clean tops (rubber stoppers) with alcohol.
  3. Take out 3 cc 25 gauge 1 ½” syringe and 18 gauge 1 ½” needle (for mixing). Unscrew 25 gauge 1 ½” needle from syringe and attach the 18 gauge 1 ½” mixing needle onto the 3 cc syringe when it is time for your injection.
  4. Draw back 2 cc of air into the 3 cc syringe. Then inject the air directly into the HCG liquid. (This is done to create a vacuum so that the water can easily be drawn into syringe).
  5. Pull back 2 cc of water into the syringe. Push needle into the bottle with powder and gently push the medication into the bottle. It is important to do this slowly as not to make bubbles.
  6. Gently swirl bottle to ensure all is mixed.
  7. Pull back on plunger to pull 1 cc liquid back into syringe
  8. Pull needle out of bottle and carefully recap needle.
  9. Carefully unscrew 18 gauge mixing needle and replace with 25 gauge 1 ½” injection needle.
  10. With the needle facing upward gently tap on syringe to encourage air bubbles to go to the top of the syringe.
  11. Gently tap on syringe to have all air go to the top and gently push the plunger to expel air.
  12. You are now ready for injection. Proceed to instructions for intramuscular injection.

Getting the air out of the syringe:

You should have a syringe liquid and all your prescribed amount of medication.
  1. Using your filled syringe pull back on the plunger to pull all the liquid from the needle into the syringe.
  2. If you are using the 3 cc syringe unscrew the mixing needle and replace with the injecting needle 22 gauge. The injection needle should be 22 gauge 1 ½”. NOTE: If you are using the 1 cc syringe skip this step.
  3. While holding the syringe at a 90 o angle, with the needle up, tap on the syringe to get all the air to the top of the syringe. Gently push out all the air by pushing on the plunger until you get a small drop of the liquid at the top of the needle. There should not be any air bubbles in the syringe. If you do have bubbles, repeat steps. You are now ready for the injection.


Subcutaneous injection technique:

  1. Prepare an area for injection along the thigh, the abdomen, upper arms, or upper, outer hips. The injection site should be rotated, i.e., if the thigh is your preferred site rotate from leg to leg and different sites along each leg.
  2. Pinch skin and clean with alcohol and allow it to dry.
  3. Insert the entire needle quickly into the site.
  4. Inject the medicine by pushing on the plunger.
  5. Withdraw the needle and hold pressure with a cotton ball.
  6. Discard the needle, syringe and any glass into a Sharps container.
  7. Some of the following may happen:
    a) You may notice some bleeding at the injection site. Do not worry – just apply pressure until it stops. You can place a Band-aid over the site if needed.
    b) Some clear fluid may leak from the site, which is all right. Just hold pressure to the area with a cotton ball or gauze.
    c) The area may bruise. This is all right. Do not have another injection in that area for two days.
    d) You may notice slight burning or stinging while you are injecting. You can apply ice to the area prior to the injection to help decrease this problem.


Intramuscular Injection Technique

  1. Prepare an area on either hip (upper buttock below hip bone – see diagram). You need to rotate site every day.
  2. Using your thumb and index finger, pull the skin taut.
  3. Cleanse the area with alcohol and allow the skin to dry.
  4. Insert quickly into the cleansed area. The entire needle should be inserted into the skin.
  5. Check to make sure you are in the correct spot by pulling back on the plunger slightly and see if you have a blood return. If you do not have a blood return you can inject the medication.

    If you do have blood in the syringe, DO NOT PANIC. Simply withdraw the needle and insert in an area next to the original injection site and re-check for a blood return.
  6. Discard the used syringe, needles, and any glass into a Sharps container.


For Your Information:

  • Injection site may bleed – HOLD PRESSURE
  • Clear fluid may leak from the injection site – This is O.K. – HOLD PRESSURE
  • The area may bruise, which is O. K. Do not give another injection in that site for 2 days.
  • It you get a blood return and mistakenly still give the medication – It’s O.K. – DO NOT REPEAT WITH A SECOND INJECTION.
  • You may lie down or stand for your injection. If standing, apply your body weight to the leg not getting the injection. Whether lying or standing, turn your toe on the one leg getting the injection, it helps to relax the muscle.



If you are having trouble with your injection or are unsure about how to mix or administer a drug, please call the office to speak with a doctor or nurse.

Subcutaneous Injection Sites

SUBCUTANEOUS INJECTION SITES

The above shaded areas are the proper placements for the SQ (Subcutaneous) injections sites. The preferred sites are the thighs or belly, approximately 2 finger-widths around the belly button. The medications that are SQ injections are: Bravelle, Menopur, Lupron, Antagon or Cetrotide.

 

Intramuscular Injection Sites

INTRAMUSCULAR INJECTION SITES

The above “X” marks are the proper placements for IM (Intramuscular) Injections. Remember after inserting the entire length of the needle to pull slightly back on the plunger to ensure that there is NO blood collection in the hub of the syringe. The medications that are administered IM are: HCG & Progesterone in Ethyl Oleate.

PATIENT EDUCATION CLASS


(see downloadable PDF or MS Word Doc)




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