Download Injectable Medications

Medication Management Policy / Procedure
TITLE: INJECTABLE MEDICATIONS
Effective Date:
NUMBER: 20.10
August 2014
Pages 5 (+ Appendix A)
Applies To: Programs, Pharmacy
POLICY
This policy applies to all patient care areas. However, individual care areas may have
unit specific injectable drug policies and protocols that extend beyond limitations set
by this policy.
This policy defines the various routes of administration of injectable medications and identifies
whether or not a nurse may administer the medications by various routes.
Before administering an injectable medication a nurse must ensure that he/she is authorized
to administer via that route and also ensure that it is a recommended route for the individual
drug ordered.
DEFINITIONS
Continuous Intravenous Infusion:
Administration of a medication at a constant rate in a set volume,of intravenous.fluid.
Direct Intravenous Injection:
Administration of a prescribed medication via a syringe directly into the injection site of
intravenous tubing (below the drip chamber), directly into a vein or through an intermittent
infusion device [heparin/saline lock].)
Intermittent Intravenous Infusion:
Administration of a medication infused on a prescribed set schedule.
Rapid Direct (IV Push):
Administration of a medication by direct intravenous injection over 10 to 60 seconds.
Slow Direct:
Administration of a medication by direct intravenous injection over more than 60 seconds,
but usually over 3 to 5 minutes.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled
and should be checked against the server version prior to use.
Injectable Medications – Policy 20.10
Page 3 of 6
PROTOCOL
General Information:
Initial calculations for injectable medications administered to neonates and children must be
independently checked by a second nurse, physician, or pharmacist.
A calculation on the MAR (medication administration record) may be used as a second check
for subsequent doses provided the calculation has been checked and signed by Health Care
Providers. Calculations on the MAR must include math, concentration of drug used to prepare
dose, and initials of each nurse who did initial calculation.
Two nurses must sign the medication administration record and check current order, dosage,
frequency, route and calculations for each administration of high alert drugs as per Policy
25.05.
Intradermal:
A nurse may administer all intradermal medications after receiving
appropriate instruction and supervision.
Intramuscular: A nurse may administer all intramuscular medications.
(For recommended volumes per site and needle gauge, see Appendix I)
Intra Peritoneal: A nurse may administer intra peritoneal medications following certification
in peritoneal dialysis procedures.
Intrathecal:
A nurse may NOT administer intrathecal medications without having
gained certification.
Intravenous:
General IV Information:
Refer to the parenteral drug references:
 Parenteral Drug Therapy Manual, The Ottawa Hospital (available on adult
patient care areas)
 Pediatric Injectable Drugs, The Teddy Bear Book, Ninth Edition, American
Society of Health Systems Pharmacists, Inc. 2014 (available within
Children’s Health or on-line edition accessed through IWK Health Services
Library)
 Micromedex (IV Compatibility Section)
 Compatibility charts available in all areas
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled
and should be checked against the server version prior to use.
Injectable Medications – Policy 20.10
Page 4 of 6

Contact the Pharmacy Department for the following information:
- mixing, reconstitution instructions not found on package insert, Pulse or charts
- compatibility
- dosing (not included in on-line formulary)
- stability

All intravenous solutions with medication added must be labelled with the IWK
IV additive label, with the following information included:
o name of patient and room number
o date and time medication added
o name of medication
o concentration or amount of medication added (as appropriate to medication
added)
o primary solution and volume remaining if medication is added to a bag that is
not full
o special storage conditions, if applicable eg. Protect From Light
o signature and status of person adding medication
o signature and status of person checking preparation (if applicable)

When injectable medications are prepared on the care area they should be
prepared just prior to administration. Preparing doses ahead of time can lead to
inadvertent administration of wrong product, wrong dose or wrong patient and also
may affect chemical stability and/or sterility.

When medications are prepared for infusion in a syringe and a particular final
concentration is ordered or desired, add the required amount of medication and q.s
(add sufficient quantity to prepare the final volume with the infusion solution.
For example, if a medication order reads:
Morphine 50 mg/50 mL D5W, this means morphine 50 mg in a TOTAL volume of
50 mL and NOT morphine 50 mg added to 50 mL D5W. This is especially
significant when the volume of medication added is large.

A nurse may administer heparin lock (10-100 units/mL) or 0.9% NaCl into an
intermittent IV cannula between medications to prevent clotting and blockage of the
IV cannula. (For volume and frequency of heparin lock, see Heparin Lock
Intermittent Infusion Device - Children, Policy 30.26; For 0.9% NaCl, see Saline
Lock Intermittent Infusion Devices - Adults and Children, Policy 30.09.)

A nurse may not add any medication to blood or blood products. Contact
hematologist for approval before mixing any medication with blood products.

A nurse may add or increase the concentration of dextrose in intravenous solutions
(see Medication Management - 90.04 Appendix IV, Section D and E).

A nurse may add any compatible medication to a basic IV solution as ordered.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled
and should be checked against the server version prior to use.
Injectable Medications – Policy 20.10
Page 5 of 6

A nurse may withdraw from the basic IV solution if necessary to prepare solution as
ordered. Manufacturer published overfill should be considered when preparing
doses.

A nurse may NOT add any medication additive to total parenteral nutrition (TPN).
This includes the dextrose/amino acid or fat,fish oil or lipid emulsions.
Continuous Intravenous Infusion:

A nurse may administer a medication by continuous intravenous infusion with the
following exceptions:
 Continuous intravenous administration of magnesium sulfate for pregnancy
induced hypertension is only performed by nurses in Birth Unit who have
demonstrated competency. (see Policy 30.06)
 Continuous intravenous administration of oxytocin antenatally, for the
purpose of inducing or stimulating labour or for an oxytocin challenge test.
Oxytocin antenatally may be administered in Birth Unit by nurses who have
demonstrated competency. (see Policy 30.11)
Intermittent Intravenous Infusion:


A nurse may administer medications to adults and children by intermittent
intravenous infusion.
A nurse must be supervised until competent in the administration of intermittent
intravenous infusions for neonates.
Direct Intravenous Injection:
Rapid Direct (IV Push)

A nurse may only administer medication by rapid IV direct under the following
conditions:
 If rapid direct is a manufacturer labeled method of drug delivery, the nurse has
demonstrated competency in rapid direct administration AND the care team
approves of nursing administering the drug over this time frame.
 If a physician is present but unable to give a medication, a nurse may administer
the medication rapid direct over 10-60 seconds.
 WinRho®: by certified nurse. Note: WinRho is a blood product, not a
medication.
Slow Direct

A nurse may administer a medication by slow direct intravenous injection provided
that slow direct is a manufacturer labeled method of drug delivery.
Electronic Infusion Devices (Pumps)
An electronic infusion device shall be used when a patient’s condition is such that
consistent medication administration is required, when achieving and/or maintaining
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled
and should be checked against the server version prior to use.
Injectable Medications – Policy 20.10
Page 6 of 6
fluid balance is essential; or at the discretion of the nurse. A smart pump must be used
for the infusion of all high alert drugs.
Percutaneous Injection:
A nurse may NOT administer percutaneous cell mediated
skin test antigens.
Subcutaneous Injection:
A nurse may administer all subcutaneous medications.
(For recommended volumes per site, see Appendix I)
REFERENCES
Potter, A.G. & Perry, P.A. (2010). Clinical nursing skills and techniques (7th Edition) St. Louis:
Elsevier Mosby.
Parenteral Drug Therapy Manual, 31st Edition, The Ottawa Hospital, General Campus, 2014
Injectable Medicine Administration Guide, Second Edition, Pharmacy Department, University
College London Hospitals 2009
Trissel, LA, Handbook of Injectable Drugs, 17th Edition, American Health System
Pharmacists, 2012
Pediatric Injectable Drugs, The Teddy Bear Book, Tenth Edition, American Society of Health
Systems Pharmacists, Inc 2013 online edition accessed through IWK Health Services Library,
Health Professionals, on-line textbooks
http://www.iwk.nshealth.ca/index.cfm?objectid=80765B3B-C0B0-5A3A29D3AA1F6471D4D0&category=Electronic%20Textbooks&link_id=723
RELATED DOCUMENTS
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Medication Management Policy 10.05 - Verbal / Telephone Orders for Medications
Medication Management Policy 10.15 - Labeling of Injectable Medications by Outside of
Pharmacy
Medication Management Policy 20.05 - Administration of Medications
Medication Management Policy 25.05 – High Alert Medications - Independent Double Check
Medication Management Policy 30.06 - Magnesium Sulfate for Hypertension in Pregnancy
Medication Management Policy 30.09 - Saline Lock Intermittent Infusion Devices - Adults &
Children
Medication Management Policy 30.10 - Drugs & Blood / Blood Products
Medication Management Policy 30.11 – Oxytocin Infusion – Birth Unit
Medication Management Policy 30.26 – Heparin Lock Intermittent Infusion Device – Children
Medication Management Policy 30.35 – Morphine, Continuous Intravenous Infusion for Infants
and Children Over Six Months of Age
Medication Management Policy 30.45 Paraldehyde Intravenous
Medication Management 90.04 Appendix IV – Section D and E
Clinical Policy 1520 25 - Connecting stay-safe Extension Tubing to the PD Catheter
Clinical Policy 1155 – Maintaining Peripheral IV Therapy
Clinical Policy 1810B – TPN – Tubing Change
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled
and should be checked against the server version prior to use.
APPENDIX I - Policy 20.10
SUBCUTANEOUS INJECTIONS
AGE
SITE OF INJECTION
RECOMMENDED MAXIMUM
VOLUME (mL)
Young Infant
all sites
0.2
Older infant & toddler
all sites
0.3
Preschooler to young school-age
all sites
0.5
Older school age to adolescent
all sites
0.75
Older adolescent
all sites
1
INTRAMUSCULAR INJECTIONS
AGE
SITE OF INJECTION
NEEDLE GAUGE/LENGTH
RECOMMENDED
MAXIMUM VOLUME (mL)
Birth-18 months
vastus lateralis
ventrogluteal
dorsogluteal
deltoid
22-25 g / ⅝ - 1" +
not recommended
not recommended
not recommended
1
not recommended
not recommended
not recommended
18 months-3
years
vastus lateralis
ventrogluteal
dorsogluteal
deltoid
22-25 g / ⅝ - 1" +
not recommended*
not recommended*
not recommended except for
immunizations
1
not recommended*
not recommended*
not recommended except for
immunizations
3-6 years
vastus lateralis
ventrogluteal
dorsogluteal
deltoid
22-25 g / ⅝ - 1" +
20-25 g / 1 - 1½"
not recommended*
not recommended except for
immunizations
1.5
1.5
not recommended*
not recommended except for
immunizations
6-15 years
vastus lateralis
ventrogluteal
dorsogluteal
deltoid
22-25 g
20-25 g
20-25 g
22-25 g
/ ⅝ - 1" +
/ 1 - 1½"
/ 1 - 1½"
/ ½ - 1"
2
2
2
0.5
15 years-adult
vastus lateralis
ventrogluteal
dorsogluteal
deltoid
22-25 g
20-25 g
20-25 g
22-25 g
/ ⅝ - 1" +
/ 1 - 1½"
/ 1 - 1½"
/ ½ - 1"
3
3
3
1