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Chapter 35
Administering Intradermal,
Subcutaneous, and Intramuscular
Injections
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Learning Objectives
Theory
1)
Identify the principles for safe and effective
administration of intradermal, subcutaneous,
and intramuscular injections.
2)
List the routes used for administering
parenteral medications and the advantages
and disadvantages of each route for
pediatric, adult, and elderly patients.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 2
Learning Objectives
Clinical Practice
1)
Choose the appropriate syringe and needle
for the type of injection ordered.
2)
Follow Standard Precautions when
administering injections and disposing of
used equipment.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 3
Injections




Often necessary to inject medication into
tissue
Injections cause pain to the patient
Student nurses often uncomfortable with
causing the patient discomfort
Students should learn and practice this skill in
the laboratory to minimize their and patient’s
discomfort
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 4
Figure 35-1: Structure of the skin
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 5
Principles of Parenteral Injections

Use when:



Use to:



Patient is NPO
Digestive juices counteract oral drugs
Hasten the action of the drug
Ensure the delivered dose is accurate
Always:


Select the correct site
Use sterile equipment
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 6
Safe, Effective Administration of
Parenteral Medications




Use only sterile needles and syringes
Use appropriate-length needle to reach the
proper tissue layer
Select injection site carefully to avoid major
nerves, blood vessels, and underlying organs
Select injection site relatively free from hair,
lesions, inflammation, rashes, moles, and
freckles
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 7
Safe, Effective Administration of
Parenteral Medications (cont’d)



Establish a plan for rotating injection sites for
patients receiving repeated injections
Obtain assistance as needed in giving an
injection when the patient is a frightened child
or an uncooperative adult
Aspirate by pulling back the plunger to avoid
injecting medications into a blood vessel
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 8
Safe, Effective Administration of
Parenteral Medications (cont’d)


Check for drug allergies before you
administer an injection
Know the medication you will administer and
observe for side effects and therapeutic
action
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 9
Routes for Parenteral Administration:
Intradermal



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Medication is deposited into layers of skin
Usually used for skin testing for TB or other
diseases (allergy testing)
Use a small needle, with a 15-degree angle
of insertion (24, 27, or 29 gauge)
Use a tuberculin syringe
Forms a skin bleb or small bump
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 10
Routes for Parenteral Administration:
Subcutaneous


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Injects small amount of medication (0.5-1 mL)
into tissue below the dermal layer into
subcutaneous fat
Usual sites: upper outer portion of the arm,
anterior surface of the thigh, or the abdomen
25- or 27-gauge needle, 3/8- to 1/2-inch long
Insulin syringe or tuberculin syringe usually used
A 45- or 90-degree angle used, depending on
the amount of subcutaneous tissue on the
patient
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 11
Figure 35-17: Subcutaneous
injection sites
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 12
Routes for Parenteral Administration:
Intramuscular


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Injected into muscle layer at 90-degree angle
Most common sites: deltoid, dorsogluteal,
ventrogluteal, vastus lateralis, and rectus
femoris
Needle usually 19-23 gauge, 1-3 inches long
Volume up to 3 mL for most IM injections, nurse
aspirates for blood before injecting medication
to avoid injecting directly into a blood vessel
The absorption time for IM medications chiefly
depends on the form of the drug
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 13
Intramuscular Route: Z-Track
Method

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May be used any time an intramuscular
injection is given
Used for deep IM injections of drugs such as
iron dextran or Vistaril
Reduces pain caused by irritating drugs
leaking into subcutaneous tissue
Seals the medication in the muscular layer
See Step 35-5
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 14
Figure 35-2: Injection routes
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 15
Syringes

Composed of barrel and plunger with a needle tip made
of plastic (disposable) or glass

3-mL syringe
• Popular because large enough for subcutaneous and most
IM injections

U-100 syringe
• Used with U-100–strength insulin
• Calibrated in units
 Tuberculin syringes
• 1 mL in size
• Calibrated to measure as small as 0.01-mL drug doses
 Unit-dose cartridge
• Requires a special holder for the cartridge and needle
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 16
Figure 35-3: Parts of a syringe
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 17
Figure 35-7: Measurement scale on
a 3-mL syringe
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 18
Figure 35-5: Insulin syringes
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 19
Figure 35-6: Tuberculin syringe
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 20
Needle Gauge and Length
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Available in standard sizes from 13 to 30
The larger the number, the smaller the needle
25, 27, or 29 gauge for intradermal injections;
25 gauge for subcutaneous injections
21 to 23 gauge for intramuscular injections
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 21
Figure 35-8: Needle sizes
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 22
Preparing the Syringe for Use


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Use aseptic technique in handling the syringe
and needle
Protect surfaces that must remain sterile: the
needle, tip, inner barrel, and plunger
Discard syringe or needle if it becomes
contaminated during drug preparation for
administration
Label the syringe with the patient’s name,
name of medication, and dose
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 23
Figure 35-9: Needle with
protective sheath
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 24
Filter Needles
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Medications drawn from an ampule may have
glass in them from the breaking of the ampule
Filter needles should be used when
medication is withdrawn from ampule to trap
the glass particles
Filter is discarded and new needle attached
to syringe for injecting medication into the
patient
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 25
Figure 35-10: Discarding used syringe
into a sharps biohazard container
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 26
Needle Sticks

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HIV, hepatitis B, and hepatitis C can be spread
by a needle stick from an infected patient
Safety syringes prevent needle sticks to health
care workers and should be used when
available
If regular syringes must be used, the needle
must not be recapped after injection but taken
to the nearest sharps disposal unit and
discarded—never recap a needle
Report all needle sticks
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 27
Question 1
What size and gauge needle are used to give
intramuscular injections?
1)
2)
3)
4)
1/2- to 1-inch needle that is 23 to 25 gauge
1- to 1 1/2-inch needle that is 20 to 23 gauge
1/2- to 5/8-inch needle that is 20 to 23 gauge
2- to 2 1/2-inch needle that is 20 to 23 gauge
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 28
Parenteral Solutions

May be available in:
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
Ampules
Vials
• Single dose and multidose
Mix-O-Vials
• Medication in powder form and diluent present in two
halves of a vial separated by a rubber stopper

Unit-dose cartridges
• Requires Carpuject or Tubex holders
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 29
Figure 35-11: Containers of
parenteral medication
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 30
Ampules
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Glass or polyurethane; consist of body, neck, and
stem; usually contain a single medication dose
All medication must be in the ampule body before
the neck is broken
Before opening, medication must be removed
from the neck or stem


Tap or flick the stem several times with a finger to
free the trapped solution
The open ampule is handled very carefully when
withdrawing the medication with the filter needle
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 31
Figure 35-13: Moving fluid from the
neck of the ampule
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 32
Figure 35-14A: Withdrawing fluid from
an ampule—ampule inverted
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 33
Figure 35-14B: Withdrawing fluid from an
ampule—ampule upright and stabilized
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 34
Vials
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A small bottle with a rubber stopper attached
by a metal band
May contain one or more dosages of
medication
Sizes from 1 to 50 mL
May be in powder form requiring
reconstitution (label or package insert
provides mixing instructions)

Before mixing two medications in a syringe, check
for compatibility
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 35
Figure 35-15: Drawing medication
from a vial
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 36
Reconstituting a Drug
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Drugs that are unstable in liquid form are
prepared in a powdered form
Solute (the powder) is mixed with a diluent to
dissolve the drug before drawing up into the
syringe for injection
Diluents are usually sterile water or saline
Follow directions on the vial or package for
proper reconstitution
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 37
Compatibility of Medications

A reaction occurs when a drug combines with
an incompatible drug


Range from color change, precipitation, and
clouding to invisible chemical changes rendering
the drug inactive
Charts are often available that outline which drugs
are compatible
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 38
Figure 35-16A, B: Mixing doses of
insulin from multidose vials
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 39
Implementation

Intramuscular injections



Used if patient cannot take medicine orally,
medication not prepared in oral form, or faster action
is desired
Improper site selection can result in damaged nerves,
abscesses, necrosis, sloughing of skin, and pain
Injection sites
• The mid-deltoid muscle is a common for IM injection
• The ventrogluteal area involves the gluteus medius and
minimus muscles
• The vastus lateralis muscle
• The rectus femoris muscle
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 40
Figure 35-18: Locating site for a middeltoid IM injection
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 41
Figure 35-21: Locating the rectus
femoris IM injection site
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 42
Implementation (cont’d)

Intramuscular injections

Airlock technique
• Used for IM injection to clear the needle of medication
and to seal the track so the medication does not flow
back

Intramuscular injections in children
• The vastus lateralis and the ventrogluteal sites can be
used
• It is preferable to find another way to give medication to
children because IM injections are painful and traumatic
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 43
Figure 35-19: Locating site for a
Deltoid IM injection
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 44
Figure 35-20: Locating the
ventrogluteal IM injection site
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 45
Implementation (cont’d)

Intramuscular injections

The Z-track technique
• Reduces pain caused by irritating drugs that leak or
escape along the track into subcutaneous tissue when
needle is withdrawn
• Must be used whenever a deep IM injection of iron
dextran (DexFerrum) and other irritating solutions are
given
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 46
Figure 35-22: Z-track technique
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 47
Anaphylactic Shock

Anaphylactic shock


Circulatory failure from an allergic reaction
Symptoms
• Urticaria, bronchiolar constriction, edema, and finally
circulatory collapse


Watch for signs of anaphylactic shock and, if
necessary, administer immediate, lifesaving
treatment
Allergic reactions are more common the second or
successive times the medication is received
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 48
Things to Remember
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Always check for allergies
Know the expected and possible side effects
of all drugs you administer
Date all multidose vials when you open them
Question any order that does not make sense
for your patient
Always follow the Six Rights and five rules
Know your landmarks and injection
techniques for each type of injection
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 49
Question 2
Which of the following is not an appropriate site
for an intramuscular injection?
1)
2)
3)
4)
Dorsogluteal
Deltoid
Vastus lateralis
Dermal
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 50
Question 3
Darlene is about to give her patient an
intramuscular injection. What angle should the
injection be given?
1)
2)
3)
4)
90 degrees
45 degrees
15 degrees
It depends on the size of the needle and size
of the patient
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 51
Question 4
Sylvie is going to give her 1-year-old patient an
IM injection. Which is the preferred IM site?
1)
2)
3)
4)
Deltoid
Vastus lateralis
Dorsogluteal
Ventrogluteal
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 52
Question 5
Michael is going to give his patient an injection of
iron. To help minimize the pain, what can Michael
do?
1)
2)
3)
4)
Use the largest gauge needle that is
appropriate.
Inject the medication quickly.
Use the Z-track technique.
Do not tell the patient when he is going to give
the injection.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Slide 53