Download Patient Age Injection Site Needle Size

MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
TRAINING MODULE
VACCINE AND MEDICATION
PREPARATION AND
ADMINISTRATION
Presented by:
Marie C. Regis DNP, RN
Regional Immunization Nurse
Metro Boston Region
Massachusetts Department of Public Health
November 9, 2010
4/30/2017
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Learning Objectives
 Understand general guidelines of
vaccine/medication preparation and
administration
 Describe four different administration routes
 Describe infection control principles
 Describe patient preparation, comfort and safety
 Describe response to emergencies, adverse
events, and errors
 List federal and state requirements for
documentation and record keeping
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Correct Administration of
Vaccines/Medications
 Keep current with best practices of
vaccine/medication preparation and
administration
 Adhere to agency policies for safety
 Use available resources and guidelines
 Complete accurate and legible documentation
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CDC
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Administration/Dispensing
Best Practice
Use 5 Rights of Medication Administration:
 Right Patient: verify name and age, screen for
contraindications and precautions
 Right Drug: check label, review package insert, verify
for appropriate patient/age
 Right Dose: determined by age and/or weight
 Right Route: e.g. IM, subcutaneous, PO, intranasal
 Right Time: refer to dosing schedules and minimum
intervals between doses
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Standing Orders
 Use current medication and emergency standing orders
that are reviewed and signed by a physician or Medical
Director (vaccine/medication specific & emergency
orders)
 Have signed orders at clinic site
 Orders should include: name of vaccine/medication,
dose, route/method of administration and
inclusion/exclusion criteria
 Model vaccine standing orders available at:
http://www.mass.gov/dph/imm
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Confidentiality and Privacy
 Assure the confidentiality of patients’
information and their rights to privacy
 Provide privacy at stations with screens
and adequate space
 Ask only what you “need to know” for safe
administration of vaccine or medication
 Comply with HIPAA and FERPA
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Vaccine Information Statement (VIS)
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Developed by CDC
Conveys risks and benefits of vaccine
Required by federal law
Vaccine specific
Must use current edition (unaltered)
Must be given before each dose of each vaccine
Provide an opportunity for questions
Available in multiple languages at:
www.immunize.org/vis
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Medication Information Sheet
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Name and formulation of medication
Directions for use
Dosing administration information
Signs & symptoms of adverse
reactions/side effects
 Provide an opportunity for questions
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Screening for
Contraindications and Precautions
 Use appropriate screening tool
 Limit questions to “need to know”
 Vaccinator/dispenser responsible for final
review of screening questions
 Protect confidentiality and privacy
 Sample immunization screening tools
available at http://www.immunize.org
 Request an interpreter if needed
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Screening for
Contraindications and Precautions (cont.)
 Know your package insert!
 Some important considerations are:
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Anaphylaxis/Allergy
Age
Acute illness
Underlying medical conditions
Pregnancy
Vaccination history
Current medications
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Vaccine Formulations
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CA DPH
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Injectable Vaccine Preparation
 Always use sterile technique
 Check expiration date, color and consistency
 Follow package insert instructions
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Preparation:
Reconstituting Vaccine/Medication
 Clean diluent vial stopper with alcohol and place vial on
flat surface
 Instill air equal to dosage into vial
 Invert vial and withdraw diluent
 Clean vaccine/medication vial stopper with alcohol and
place vial on flat surface
 Inject diluent into vaccine/medication vial
 Mix vaccine/medication and diluent per package insert
instructions. When mixed, it should look as described in
the package insert (e.g. color, no extraneous
particulate matter, etc.)
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CA DPH
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Preparation:
Drawing up Injectable Vaccine/Medication
 Clean vial stopper with alcohol between each
needle insertion and place vial on flat surface
 Instill air equal to dosage into multidose vial
 Invert vial and withdraw dose into syringe
 Expel bubbles and excess liquid while needle
in vial
 Recap needle, and label syringe if not using
immediately (initials, contents, time, and date)
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Multi-Dose Vial
 Contains a preservative
 Good until expiration date unless
contaminated, or manufacturer or package
insert states otherwise
 Date, time and initial vial after opening
 Use open vial first and rotate stock
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CDC
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Vaccinator Prefilling of Syringes
 In order to reduce the risk of medication
administration errors and ensure vaccine viability,
providers should avoid pre-filling syringes, and
this practice is strongly discouraged.
 In situations where pre-filling syringes is
unavoidable, medication administration errors
may be reduced by:
 Storing syringes with vaccine of same type and same
lot number together in separate containers
 Labeling each container and labeling each syringe with:
 Type of vaccine; lot number
 Date and time vaccine was drawn up
 Initials of the person who drew up vaccine
Vaccinator Prefilling of Syringes
 May result in vaccine/medication administration errors
and wastage
 Keep prefilled syringes on cold packs, and protect
from light. If kept at room temperature, discard after
30 minutes
 Discard unused, prefilled syringes at end of the clinic
day
 Consider using manufacturer-supplied prefilled
syringes (if available) for large immunization events
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CDC
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Manufacturer Prefilled Syringes
 Most contain no, or only trace amounts of,
preservative
 Removing the syringe cap or attachment of
a needle breaks the sterile seal
 Do not remove the cap or attach a needle
until ready to use
 Once needle attached, unused syringes
should be discarded at end of the clinic day
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CDC
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Single Dose Vial
 Most contain no, or only trace amounts of,
preservative
 Once opened, vial should be used or
discarded at the end of the clinic day
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CDC
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Other Preparation Issues
 Not necessary to change needles
between drawing up or reconstituting and
administration unless needle is
contaminated or bent
 Never mix different vaccines/medication
in the same syringe unless approved by
the FDA
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CDC
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Inactivated Vaccines
 Made from viruses and bacteria that have
been killed (e.g. Tdap, pneumococcal
vaccine)
 Can be given on same day as any other
vaccine, live or inactivated
 Follow manufacturer’s recommended
schedule for subsequent doses if
applicable (e.g. Hepatitis B series)
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Live Vaccines
 Made from weakened (attenuated) virus in order to
produce immune response without causing severe
effects of disease (e.g. LAIV, MMR, varicella)
 Multiple live vaccines and inactivated vaccines can
be given on same day, depending on administration
route
 When administering live vaccines on different days,
follow manufacturer’s instruction regarding
necessary minimum intervals between doses
(usually 28 days)
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CDC
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General Dosage Guidelines
 With any vaccine/medication
formulation
 Refer to package insert
(e.g. age, weight guidelines)
 Follow current standing orders
 Apply 5 rights of medication
administration
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Administration Routes
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CA DPH
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Intramuscular (IM) Injection Sites
 Site selection depends on person’s age, muscle
development and vaccine/medication
 Preferred vaccine site for children, adolescents
and adults is upper arm (deltoid muscle)
 Vaccine site for toddlers can be either upper arm
(deltoid) or anterolateral thigh (vastus lateralis)
 Vaccine site for infants is anterolateral thigh
(vastus lateralis)
 Use anatomical landmarks to locate site
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CDC
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Intramuscular (IM) Injection Sites
Infant/Child/Adolescent/Adult
Vastus Lateralis - infant
site
Deltoid - child
and adult site
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(alternative site when
deltoid contraindicated)
CDC
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Intramuscular (IM) Tissue
90°Angle
Dermis
Fatty Tissue
Muscle Tissue
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CDC
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Intramuscular (IM) Sites and Needle Sizes
Patient Age
Injection Site
Needle Size
Newborn (0-28 days)
Anterolateral thigh muscle
5/8” (22-25 gauge)
Infant (1-12 months)
Anterolateral thigh muscle
1” (22-25 gauge)
Anterolateral thigh muscle
1-1 ¼” (22-25 gauge)
Alternate site: Deltoid muscle
5/8-1” (22-25 gauge)
Deltoid muscle
5/8-1” (22-25 gauge)
Alternate site: Anterolateral
thigh muscle
1-1 ¼” (22-25 gauge)
Deltoid muscle
1-1 ½” (22-25 gauge)
Alternate site: Anterolateral
thigh muscle
1-1 ¼” (22-25 gauge)
Toddler (1-2 years)
Children (3-18 years)
Adults (19 years and older)
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www.immunize.org
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How to Locate Deltoid Muscle
 The injection site is 2-3
fingerbreadths below the
shoulder tip (acromion),
above level of armpit (axilla)
and on the lateral midline of
the arm.
 Draw an imaginary inverted
triangle below the shoulder
tip, using the above
anatomical landmarks.
 The deltoid site for injection
is the middle of the muscle
(triangle).
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clavicle
acromion
axilla
humerus
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Intramuscular (IM) Injection Technique
 Assess patient’s muscle mass
 Clean injection site with alcohol; allow to air dry
 With your dominant hand, insert needle at a 90-degree
angle to the muscle
 Push down on plunger and inject entire contents of
syringe
 Remove/retract needle and briefly apply light pressure
to injection site with dry cotton ball or gauze
 Immediately put used syringe in sharps container
 Cover injection site with bandage if indicated
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CDC
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Intramuscular Injection (IM) Technique
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CDC
Intramuscular (IM) Injection Site Infant
Anterolateral Thigh
(vastus lateralis muscle)
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CDC
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How to Locate Vastus Lateralis
 The anterolateral thigh
 Position client in supine or
sitting position
 The upper landmark is the
greater trochanter of the
femur
 Injection site is the middle
third and anterior lateral
aspect of thigh
 The lower landmark is the
lateral femoral condyle
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X Marks the Spot!
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Australian Gov’t Health & Aging
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Subcutaneous (SC) Injection
 Injection into the fatty tissue below
the dermis and above the muscle
 Usual sites are thigh and upper
outer triceps area of the arm
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CDC
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Subcutaneous Tissue
45° Angle
Dermis
Fatty
Tissue
Muscle
Tissue
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CDC
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Subcutaneous (SC) Sites and Needle Sizes
Patient Age
Injection Site
Needle length
Birth to 12 months
Fatty tissue over
the anterolateral
thigh muscle
5/8” (23-25 gauge)
12 months and
older
Fatty tissue over
anterolateral thigh
or fatty tissue over
triceps
5/8” (23-25 gauge)
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www.immunize.org
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Subcutaneous Injection Sites
4/30/2017
CDC
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Subcutaneous Injection Technique
 Clean injection site with alcohol; allow to air dry
 With thumb and index finger of your non-dominant
hand, bunch fatty tissue of injection site
 With your dominant hand, insert needle at a 45-degree
angle to skin; insert entire needle
 Push down on plunger and inject entire contents of
syringe
 Remove needle and briefly apply light pressure with dry
cotton ball or gauze to injection site
 Immediately put used syringe in sharps container
 Cover injection site with bandage if indicated
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CDC
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Subcutaneous Injection Technique
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CDC
Injectable Administration Issues
 Aspiration not required for vaccines
 No reports of injury from failure to aspirate
 Can result in vaccine wastage
 When administering multiple doses at the
same time, it is preferable to use separate
limbs
 Injection sites in same limb should be
separated by at least 1 inch if possible
 Use safety syringes/needles or needle-free
devices to reduce risk of injury
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Oral (PO) Vaccine Administration
4/30/2017
MERCK
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Oral (PO) Administration
 Follow instructions per package insert
 Assess ability to swallow
 Assess for allergies/contraindications and
precautions
 Assess fluid needs and restriction
 Remain with client until all medication is
swallowed
 If patient spits up, do not re-administer medication
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Intranasal Injection Technique
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CA DPH
Intranasal Administration
 Administer as directed according to package
insert
 If dose is divided in the sprayer, half the contents
of the dose should be sprayed into each nostril at
the same visit
 Tell the patient to breathe normally (do not sniff)
 Do not repeat if the person sneezes, coughs or
some dribbles out after administration
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Infection Control
 Hand Hygiene
 Required between patients and before
vaccine/medication administration
 Alcohol-based hand sanitizer can be used when
soap and water unavailable
 Gloves not required unless:
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potential for exposure to blood or body fluids
open lesions on hands
agency policy
If you do wear gloves, change between each patient
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Infection Control (cont.)
 Follow blood-borne pathogen policy (including
needle stick policy)
 Use PPE (personal protective equipment) as
required
 Immediately dispose of used or contaminated
syringes, vials, nasal sprayers, and oral
vaccine ampules, as medical waste in
sharps/biohazard container
 Never detach, recap or cut a used needle
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Patient Preparation
 Display confidence and establish a sense of
security and trust with the patient
 Prepare patients for administration; consider
their age and stage of development
 Encourage parents/patients to take active
role before, during and after administration
 Use age-appropriate techniques that provide
distraction and minimize the stress and
discomfort of vaccination
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Patient Comfort & Safety
 Have patients seated for vaccination
 Strongly recommend patients are observed
for 15-20 minutes after they are vaccinated
 If syncope develops, patients should be
observed until symptoms resolve
 Counsel patient about the use of pain
relievers to decrease discomfort and
possible fever post vaccination
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Expect the Unexpected
While anaphylactic/allergic reactions following vaccinations
are rare, you need to be ready to respond with personnel,
facilities and equipment/supplies.
 Emergency Standing Orders need to be current and
signed by physician or Medical Director prior to clinic
 Have emergency supplies available and know how to
use them
 Model Emergency Standing Orders can be found at:
http://www.mass.gov/dph/imm
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Positioning
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CA DPH
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Positioning
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CA DPH
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Suggested Vaccination/Medication
Dispensing Station Supplies
 Vaccine/medication
 Cold packs w/plastic
containers
 Needles (different sizes)
 Safety syringes
 Sharps/biohazard containers
 Latex free gloves
 Hand sanitizer
 Water/cups
 Pill crusher
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Medicine cups
Teaspoons/bowls
Alcohol wipes
Gauze/bandages
Adhesive tape
Tissues/paper towels
Table covering
Trash container/bag
Required forms/pens
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Required Documentation
for Administration of Vaccine
 Patient’s name and age
 Vaccine name, manufacturer, lot number, expiration
date and dose number
 Publication date on VIS, date VIS was given
 Anatomical site, route and dose amount
 Date vaccine administered
 Vaccinator’s name, initials, address, signatures,
and credentials
 Clinic name, address and contact person
 Signed consent is not required except when a
parent/guardian is not present
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Emergency Supplies
 BP and stethoscope
(child & adult, extralarge cuffs)
 Cell phone or access to
an on-site phone
 3x3 gauze pads
 Alcohol wipes
 Bandages
 Hand sanitizer
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 Latex free vinyl gloves
(small, medium, large &
extra large)
 Flashlight & batteries
 Thermometer & probe
covers
 Instant cold packs
 Cots, Blankets, Pillows
 Wrist watch with second
hand
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Emergency Supplies (cont.)
 Acetaminophen 325 mg
tablets
 Ibuprofen 200mg tablets
 Diphenhydramine 25 mg
tablets
 Diphenhydramine 50 mg
injectable-(carpujet)
 Epipen & Epipen Jr. &
Aqueous Epinephrine
1:1000 injectable 1mg/ml
 Diphenhydramine elixir
12.5 mg/5ml
suspension 25 mg/5ml
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 Syringes-3mL-1” 23g, 5/8”
25g, 1mL
 Ammonia inhalant
 Airways (large & small)
 Pocket masks with one
way valve (adult &
pediatric)
 Tongue depressors
 AED
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Vaccine/Medication Errors
 Report error immediately to direct supervisor
 Monitor client for adverse reaction (if appropriate)
 Frequently seen errors:
 Wrong vaccine, medication
 Wrong dose for age
 Wrong site, route or needle length
 Expired/recalled vaccine, medication or diluent
 Wrong time, errors in spacing of doses
 Report vaccine/medication administration errors to the
Institute for Safe Medication Practices www.ismp.org
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ISMP
Institute of Safe Medication Practices
 Report medication/vaccine administration errors
to ISMP online at:
www.ismp.org
Institute for Safe Medication Practices
200 Lakeside Drive; Suite 200
Horsham, PA 19044-2321
Phone: 215-947-7797
Fax: 215-914-1492
VAERS
Vaccine Adverse Event Reporting System
 Report all clinically significant postvaccination events via online, mail, phone
or fax
www.vaers.hhs.gov
VAERS
P.O. Box 1100,
Rockville, MD 20849-1100
1-800-338-2382 (phone)
1-877-721-0366 (fax)
Vaccinator/Dispenser Responsibilities
 Be informed about storage, handling, preparation,
administration and contraindications of
vaccine/medication to be administered/dispensed
 Relay information on the risks and benefits of
accepting or refusing vaccine/medication
 Screen for contraindications and precautions prior to
administration
 Be mindful of security and safety of
vaccine/medication, sharps and biohazards
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Vaccinator/Dispenser Responsibilities (cont.)
 Understand documentation used for
administration/dispensing
 Complete required documentation accurately and
legibly
 Be able to access and use emergency equipment
 Hold current licensure and/or certification (e.g. CPR)
 Report adverse events (ISMP & VAERS)
 Report vaccine/medication errors
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Medication Storage and Handling
 Follow package insert and manufacturer’s
instruction
 Be mindful of security and safety of
medication at your station
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Vaccine Storage and Handling
 The cold chain begins with the manufacturer and ends
with administration of the vaccine to the patient
 Proper storage temperatures must be maintained per
manufacturer recommendations
 Injectable vaccine syringes/vials maximum 30 minutes
at room temperature
 IN sprayers kept at 2 - 8° C (35 - 46°F)
 Protect vaccine from exposure to light
 Keep vaccine on cold packs at stations
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CDC
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MDPH Contact Numbers
 MDPH Epidemiology/Immunization
Program
617-983-6800 (24x7)
888-658-2850
 MDPH Vaccine Unit
617-983-6828
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Please join us for the other training
modules!
 Planning a Clinic/EDS/POD: November
12th, 3:00-4:30
 All-Staff Briefing & Just-In-Time Training:
November 15th, 3:00-4:30
 Vaccine Management, Storage and
Handling: November 16th, 3:00-4:00
4/30/2017
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Vaccine Key Resources

MDPH Guidelines for Compliance with Federal and State
Vaccine Administration Requirements
http:/www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/guidelines_v
accine_compliance.pdf

MDPH General Protocols for Vaccine Storage,
Administration, Standing Orders, and Mass Immunization Clinics,
Sept 2009
http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/mso_protoc
ols_general.pdf
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MMWR: General Recommendations on Immunization,
Recommendations of the Advisory Committee on
Immunization Practices (ACIP), December 2006
http://www.cdc.gov/mmwr/pdf/rr/rr5515.pdf
Epidemiology and Prevention of Vaccine-Preventable Diseases
(The Pink Book) from the CDC
http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm#download
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Online Resources
 Massachusetts Department of Public Health, Immunization Program
www.mass.gov/dph/imm
 CDC: Vaccines and Immunizations
http://www.cdc.gov/vaccines
 World Health Organization: Department of Immunization, Vaccines
and Biologicals
http://www.who.int/immunization/en
 National Vaccine Program Office (NVPO) @ HHS
http://www.hhs.gov/nvpo
 Red Book: 2009 Report of the Committee on Infectious Diseases of
the American Academy of Pediatrics
http://aapredbook.aappublications.org/
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Online Resources
 Massachusetts Department of Public Health,
School Health Division
http://mass.gov/dph/fch/schoolhealth
 California Department of Public Health,
Immunization Branch
http://www.eziz.org
 Immunization Action Coalition
http://www.immunize.org
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Online Resources
 MDPH: Recommendations for Drawing-Up Vaccine and Other
Documentations Requirements for Clinical Sessions or Large
Clinics (Nov 2009)
http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/mso_r
ecommendation_drawing_up_vaccine.pdf
 CDC’s Guide to Vaccine Contraindications and Precautions
http://www.cdc.gov/vaccines/recs/vacadmin/downloads/contraindications-guide-508.pdf
 Institute for Safe Medication Practices
http://www.ismp.org
 Vaccine Adverse Events Reporting System (VAERS)
http://www.vaers.hhs.gov
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QUESTIONS??
Thank You !
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