Medications

Prepared by:

Aleli R. Cheng, RN,MAN

• A medication is a substance administered for the diagnosis, cure, treatment, or relief of a
symptom or for prevention of disease. In the health care context, the words medication
and drug are generally used interchangeably.
• Prescription- the written direction for the preparation and administration of a drug is
called
generic name is assigned by the United States Adopted Names (USAN) Council and is used
throughout the drug’s lifetime.
trade name (sometimes called the brand name) is the name given by the drug
manufacturer and identifies it as property of that company.
official name -the name under which a drug is listed in one of the
official publications (e.g., the United States Pharmacopeia).
chemical name - the name by which a chemist knows it; this name
describes the constituents of the drug precisely. Ex. N-Acetyl-p-
aminophenol (Paracetamol)
Pharmacology -is the study of the effect of drugs on living organisms.
Pharmacy is the art of preparing, compounding, and dispensing drugs.
The word also refers to the place where drugs are prepared and
dispensed.
Pharmacist- prepares, makes, and dispenses drugs as ordered by the
physician, dentist, nurse practitioner, or physician assistant.
Types of Drug Preparations
Legal Aspects of Drug Administration
• Nurses need to :
• (a) know how nursing practice acts in their areas define and limit their
functions
• (b) be able to recognize the limits of their own knowledge and skill.
 Effects of Drugs
• therapeutic effect -also referred to as the desired effect, is the
primary effect
• side effect, or secondary effect - one that is unintended. Side effects
are usually predictable and may be either harmless or potentially
harmful; tolerated by the patient.
• adverse effects or reactions, are more severe side effects. They may
justify the discontinuation of a drug.
• Drug toxicity (deleterious effects of a drug on an organism or tissue)-
results from overdosage, ingestion of a drug intended for external
use, or buildup of the drug in the blood because of impaired
metabolism or excretion (cumulative effect). Ex. respiratory
depression due to the cumulative effect of morphine sulfate in the
body.
• Drug allergy - is an immunologic reaction to a drug.
• anaphylactic reaction - A severe allergic reaction usually occurs
immediately after the administration of the drug .This response can
be fatal if the symptoms are not noticed immediately and treatment is
not obtained promptly. The earliest symptoms are a subjective feeling
of swelling in the mouth and tongue, acute shortness of breath, acute
hypotension, and tachycardia.
• Drug tolerance -exists in a person who has unusually low
physiological response to a drug and who requires increases in the
dosage to maintain a given therapeutic effect. Drugs that commonly
produce tolerance are opiates, barbiturates, and ethyl alcohol.
• cumulative effect - is the increasing response to repeated doses of a
drug that occurs when the rate of administration exceeds the rate of
metabolism or excretion. As a result, the amount of the drug builds
up in the client’s body unless the dosage is adjusted.
• Drug interaction -occurs when the administration of one drug before,
at the same time as, or after another drug alters the effect of one or
both drugs. Drug interactions may be beneficial or harmful.
• potentiating effect –increases the effect of one drug; may be additive
or synergistic. When two of the same types of drug increase the
action of each other, the effect is known as additive.
• inhibiting effect- decreases the effect of one drug;
• synergistic effect- occurs when two different drugs increase the action
of one or another drug.
• Iatrogenic disease - disease caused unintentionally by medical
therapy. Ex. Hepatic toxicity resulting in biliary obstruction, renal
damage, and malformations of the fetus as a result of specific drugs
taken during pregnancy.
Drug Actions in the Body
Onset of action: The time after administration when the body
initially responds to the drug
Peak plasma level: The highest plasma level achieved by a single
dose when the elimination rate of a drug equals the ab- sorption rate
Drug half-life (elimination half-life): The time required for the
elimination process to reduce the concentration of the drug to one-
half what it was at initial administration
Plateau: A maintained concentration of a drug in the plasma during a
series of scheduled doses.
• Pharmacodynamics - is the mechanism of drug action and relationships between drug
concentration and the body’s responses. Such responses require that the drug interact
with specific molecules and chemicals normally found in the body
• Pharmacokinetics is the study of the absorption, distribution, biotransformation, and
excretion of drugs.
a. Absorption- is the process by which a drug passes into the blood- stream. For
absorption of a drug to occur, the correct form of the drug must be administered through
the correct route.
- Rate of absorption of drugs in the stomach is affected by : food, gastric acid secretion
- Fastest route of absorption is intravenously
b. Distribution - is the transportation of a drug from its site of absorption to its site of
action. When a drug enters the blood- stream, it is carried to the most vascular organs—
that is, liver, kidneys, and brain. Body areas with lower blood supply—that is, skin and
muscles—receive the drug later. The chemical and physical properties of a drug largely
determine the area of the body to which the drug will be attracted. Example: fat- soluble
drugs will accumulate in fatty tissue, whereas other drugs may bind with plasma
proteins.
c. Biotransformation, also called detoxification or metabolism, is a
process by which a drug is converted to a less active form. Most
biotransformation takes place in the liver, where many drug-
metabolizing enzymes in the cells detoxify the drugs.
d. Excretion is the process by which metabolites and drugs are
eliminated from the body. Most drug metabolites are eliminated by the
kidneys in the urine; however, some are excreted in the feces, the
breath, perspiration, saliva, and breast milk.
Factors Affecting Medication Action
1. Developmental Factors- pregnant, infant, older adults
2. Gender-men and women respond to drugs are chiefly related to the
distribution of body fat and fluid and hormonal differ- ences.
3. Cultural, Ethnic and Genetic
4. Diet
5. Environment
6. Psychological Factors
7. Illness and Disease
8. Time of Administration
 Pharmacokinetics of an Oral Medication
• GI SYSTEM: STOMACH,
SMALL INTESTINE
The oral medication reaches the systemic circulation through the GI
system. As a result, numerous factors can affect the absorption of the
pill.
CARDIOVASCULAR SYSTEM
• Once the pill is absorbed into the bloodstream, it is carried or
delivered to the sites of pharmacologic action where the drug
produces its effects.
LIVER
• Most biotransformation takes place in the liver. Any decrease in the
ability of the liver to metabolize medication could lead to an
accumulation of the active drug in the bloodstream. This could put
the client at risk for toxic effects and adverse reactions.
KIDNEYS
• Drug excretion occurs mainly through the kidneys into the urine. If
there is any impairment in kidney function, medications may not be
excreted at the anticipated speed. Subsequent medication
administration may lead to accumulation and potential toxicity.
Routes of Administration
Route Advantages Disadvantages
Route Advantages Disadvantages
Sublingual Route Buccal Route
Parenteral Route
The following are some of the more common routes for parenteral
administration:
•Subcutaneous (hypodermic)—into the subcutaneous tissue, just
below the skin
•Intramuscular (IM)—into a muscle
•Intradermal (ID)—under the epidermis (into the dermis)
•Intravenous (IV)—into a vein.
Types of Medication Orders
1. A stat order indicates that the medication is to be given immediately and only once
2. Single order –or one-time order is for medication to be given once at a specified time
(e.g., Seconal 100 milligrams at bedtime before surgery).
3. Standing order -may or may not have a termination date. e.g., KCl twice daily for 􏰓 2
days
4. Prn order- as-needed order,permits the nurse to give a medication when, in the nurse’s
judgment, the client re- quires it (e.g., Amphojel 15 mL prn). The nurse must use good
judgment about when the medication is needed and when it can be safely
administered.
Essential Parts of a Medication Order
Units of Measurement
1. Metric System
Basic units of measurement are the meter, the liter, and the gram.
Prefixes derived from Latin designate subdivisions of the basic unit:
deci (1/10 or 0.1), centi (1/100 or 0.01), and milli (1/1,000 or 0.001).
Multiples of the basic unit are designated by prefixes derived from
Greek: deka (10), hecto (100), and kilo (1,000).
Basic Measurements of Volume & Weight
2. Apothecaries System
• The basic unit of weight in the apothecaries’ system is the grain (gr), likened to a grain
of wheat, and the basic unit of volume is the minim, a volume of water equal in weight
to a grain of wheat.
Ex. gr 1/6.
• units of weight are the scruple, the dram, the ounce, and the pound. Today, the scruple
is seldom used.
• units of volume are, the fluid dram, the fluid ounce, the pint, the quart, and the gallon.
3. Household -may be used when more accurate systems of measure
are not required. Included in household measures are drops,
teaspoons, tablespoons, cups, and glasses. Although pints and quarts
are often found in the home, they are defined as apothecaries’
measures.
The 10 Rights of Medication Administration
• medications are contraindicated when a client is vomiting, has gastric
or intestinal suction, or is unconscious and unable to swallow. Such
clients in a hospital are usually on orders for “nothing by mouth” (the
Latin is nil per os: NPO).
Oral Medications
Equipment
Disposable medication cups: small paper or plastic
cups for
tablets and capsules, plastic calibrated medication
cups for liquids
Pill crusher/cutter
Straws to administer medications that may discolor
the teeth or to facilitate the ingestion of liquid
medication for certain clients
Drinking glass and water or juice
 Color Coding of Medication Cards
Color Frequency
1. White- once a day/OD ( 8 am)
2. Blue- 2x a day/ q 12 hrs/BID ( 8am-6pm)
3. Orange- 3x a day/q 8 hrs./TID ( 8am-1pm-6pm)
4. Pink- 4x day/ every 6 hrs./QID (8am-12pm-4pm-8pm)
5. Red- q 4 hrs/RTC
6. Green- prn Paracetamol 500 mg 1 tab. Q 4 hrs prn for t=37.8C&
above
7. Yellow- ac , pc, hs Paracetamol 500 mg. 1 tab OD pc
ac OD- 6 am. OD pc- 8am OD hs-9pm
IMPLEMENTATION
Preparation
1. Know the reason why the client is receiving the medication, the drug
classification, contraindications, usual dosage range, side effects, and
nursing considerations for administering and evaluating the intended
outcomes for the medication.
2. Verify the client’s ability to take medication orally.
•Determine whether the client can swallow, is NPO, is nauseated or
vomiting, has gastric suction, or has diminished or absent bowel
sounds.
3. Organize the supplies.
• Rationale: Organization of supplies saves time and reduces the
chance of error.
Performance
1. Perform hand hygiene and observe other appropriate infection
control procedures.
2. Obtain the appropriate medication.
Check the expiration date of the medication. Return expired
medications to the pharmacy. Rationale: Outdated medications are
not safe to administer.
Use only medications that have clear, legible labels. Rationale: This
ensures accuracy.
3. Prepare the medication.
Calculate the medication dosage accurately.
Prepare the correct amount of medication for the
required dose, without contaminating the
medication. Rationale: Aseptic technique maintains
drug cleanliness.
Tablets or Capsules
• Place packaged unit-dose capsules or tablets directly into
the medicine cup. Do not remove the medication from
the package until at the bedside. Rationale: The wrapper
keeps the medication clean. Not removing the medication
facilitates identification of the medication in the event the
client refuses the drug or assessment data indicate to
hold the medication. Unopened unit-dose packages can
usually be returned to the medication cart.
• If using a stock container, pour the required number into
the bottle cap, and then transfer the medication to the
disposable cup without touching the tablets.
 Keep narcotics and medications that require specific
assessments, such as pulse measurements, respiratory
rate or depth, or blood pressure, separate from the
others. Rationale: This reminds the nurse to complete the
needed assessment(s) in order to decide whether to give
the medication or to withhold the medication if indicated.
Break only scored tablets if necessary to obtain the correct dosage.
Use a cutting or splitting device if needed. If the client has difficulty
swallowing, check if the medication can be crushed.
If it is acceptable, crush the tablets to a fine powder with a pill
crusher or between two medication cups. Then, mix the powder
with a small amount of soft food.
Check with the pharmacy before crushing tablets. Sustained-
action, enteric-coated, buccal, or sublingual tablets should not be
crushed.
Tablet cutter
Liquid Medication
Thoroughly mix the medication before pouring. Discard
any medication that has changed color or turned cloudy.
Remove the cap and place it upside down on the
countertop. Rationale: This avoids contaminating the
inside of the cap.
Hold the bottle so the label is next to your palm and pour the
medication away from the label. Rationale: This prevents the label
from becoming soiled and illegible as a result of spilled liquids.
Place the medication cup on a flat surface at eye level and fill it to
the desired level, using the bottom of the meniscus (crescent-
shaped upper surface of a column of liquid) to align with the
container scale. Rationale: This method ensures accuracy of
measurement.
Pouring a liquid medication from a bottle
• Before capping the bottle, wipe the lip with a paper towel.
Rationale: This prevents the cap from sticking.
• When giving small amounts of liquids (e.g., less than 5 mL),
prepare the medication in a sterile syringe without the
needle or in a specially designed oral syringe. Label the
syringe with the name of the medication and the route
(PO). Rationale: Any oral solution removed from the
original container and placed into a syringe should be
labeled to avoid medications being given by the wrong
route (e.g., IV).
• Keep unit-dose liquids in their package and open them at
the bedside.
All Medications
1. Recheck the label on the container before returning the bottle,
box, or envelope to its storage place. Rationale: This third check
further reduces the risk of error.
2. Avoid leaving prepared medications unattended. Rationale: This
precaution prevents potential mishandling errors.
3. Lock the medication cart before entering the client’s room.
Rationale: This is a safety measure because medication carts are not
to be left open when unattended.
4. Check the room number. Rationale: This is another safety measure
to ensure that the nurse is entering the correct client room.
5. Provide for client privacy.
6. Prepare the client.
•Introduce self and verify the client’s identity.. Rationale:
This ensures that the right client receives the medication.
•Assist the client to a sitting position or, if not possible, to a
side-lying position. Rationale: These positions facilitate
swallowing and prevent aspiration.
• If not previously assessed, take the required assessment measures:
pulse and respiratory rates or blood pressure. Take the apical pulse
rate before administering digitalis preparations. Take blood pressure
before giving antihypertensive drugs. Take the respiratory rate prior to
administering narcotics. Rationale: Narcotics depress the respiratory
center. If any of the findings are above or below the predetermined
parameters, consult the primary care provider before administering
the medication.
7. Explain the purpose of the medication and how it will help, using
language that the client can understand. Include relevant
information about effects; for example, tell the client receiving a
diuretic to expect an increase in urine output. Rationale:
Information can facilitate acceptance of and compliance with the
therapy.
8. Administer the medication at the correct time.
• Take the medication to the client within the period of 30 minutes
before or after the scheduled time.
• Give the client sufficient water or preferred juice to swallow the
medication. Before using juice, check for any food and medication
incompatibilities. Rationale: Fluids ease swallowing and facilitate
absorption from the gastrointestinal tract. Liquid medications other
than antacids or cough preparations may be diluted with 15 mL (1/2
oz) of water to facilitate absorption.
• If the client is unable to hold the pill cup, use the pill cup to introduce
the medication into the client’s mouth, and give only one tablet or
capsule at a time.
Rationale: Putting the cup to the client’s mouth maintains the
cleanliness of the nurse’s hands. Giving one medication at a time
eases swallowing.
• If an older child or adult has difficulty swallowing, ask the client to
place the medication on the back of the tongue before taking the
water. Rationale: Stimulation of the back of the tongue produces the
swallowing reflex.
• If the medication has an objectionable taste, ask the client to suck a
few ice chips beforehand, or give the medication with juice,
applesauce, or bread if there are no contraindications. Rationale: The
cold of the ice chips will desensitize the taste buds, and juices or
bread can mask the taste of the medication.
• if the client says that the medication you are about to give is
different from what the client has been receiving, do not give
the medication without first checking the original order.
Rationale: Most clients are familiar with the appearance of
medications taken previously. Unfamiliar medications may signal
a possible error.
• Stay with the client until all medications have been swallowed.
Rationale: The nurse must see the client swallow the medication
before the drug administration can be recorded. The nurse may
need to check the client’s mouth to ensure that the medication
was swallowed and not hidden inside the cheek.
9. Document each medication given.
• Record the medication given, dosage, time, any complaints
or assessments of the client, and your signature.
•If medication was refused or omitted, record this fact on the
appropriate record; document the reason, when possible, and
the nurse’s actions according to agency policy.
10. Dispose of all supplies appropriately.
• Replenish stock (e.g., medication cups) and return the cart to
the appropriate place.
• Discard used disposable supplies.
Evaluation
Return to the client when the medication is expected take
effect (usually 30 minutes) to evaluate the effects of the
medication on the client.
Observe for desired effect (e.g., relief of pain or decrease in
body temperature).
Note any adverse effects or side effects (e.g., nausea,
vomiting, skin rash, or change in vital signs).
Relate to previous findings, if available. Report significant
deviations from normal to the primary care provider.
Lifespan Considerations in Administering Medications Orally

• INFANTS
• Oral medications can be effectively administered in several ways:
• A syringe or dropper
• A medication nipple that allows the infant to suck the medication
• Mixed in small amounts of food
• A spoon or medication cup, for older children.
• Never mix medications into foods that are essential, since the infant
may associate the food with an unpleasant taste and refuse that food
in the future. Never mix medications with formula.
• Place a small amount of liquid medication along the inside of the
baby’s cheek and wait for the infant to swallow before giving more to
prevent aspiration or spitting out.
• When using a spoon, retrieve and refeed medication that is thrust
outward by the infant’s tongue.
• CHILDREN
• Whenever possible, give children a choice between the use of a
spoon, dropper, or syringe.
• Dilute the oral medication, if indicated, with a small amount of
water.
• Oral medications for children are usually prepared in sweetened
liquid form to make them more palatable. Crush medications
that are not supplied in liquid form and mix them with
substances available on most pediatric units, such as honey,
flavored syrup, jam, or a fruit puree.
• Necessary foods such as milk or orange juice should not be used to
mask the taste of medications
• Place the young child or toddler on your lap or a parent’s lap in
a sitting position.
• Administer the medication slowly with a measuring spoon,
plastic syringe, or medicine cup.
• To prevent nausea, pour a carbonated beverage over finely
crushed ice and give it before or immediately after the
medication is administered.
• Follow medication with a drink of water, juice, a soft drink, or a
popsicle or frozen juice bar. This removes any unpleasant
aftertaste.
• For children who take sweetened medications on a long- term
basis, follow the medication administration with oral hygiene.
These children are at high risk for dental caries.
• Older adults usually require smaller dosages of drugs, especially
sedatives and other central nervous system depressants.
• Older adults are mature adults capable of reasoning. The nurse,
therefore, needs to explain the reasons for and the effects of the
client’s medications.
• Socioeconomic factors such as lack of transportation and decreased
finances may influence obtaining medications when needed.
 Parenteral Medications
1. Syringes

Parts of a Syringe
A, 3-mL syringe marked in tenths (0.1) of milliliters and in minims;
B, insulin syringe marked in 100 units;
C, tuberculin syringe marked in tenths and hundredths (0.01) of one milliliter (mL) and in minims.

Types of Syringes
Different insulin syringes based on amount of insulin to be administered
Tips of syringes: A, Luer-Lok syringe (threaded tip)
B, non–Luer-Lok syringe ( smooth graduated tip).
2. Needles

Parts of a Needle
Characteristics of a Needle:
•1. Slant or length of the bevel.The bevel of the needle may be
short or long. Longer bevels provide the sharpest needles and
cause less discomfort. They are commonly used for subcutaneous
and intramuscular injections. Short bevels-for intradermal and IV
injections because a long bevel can become occluded if it rests
against the side of a blood vessel.
•2. Length of the shaft. The shaft length of commonly used
needles varies from 1/2 to 2 inches. The appropriate needle length
is chosen according to the client’s muscle development, the client’s
weight, and the type of injection.
3. Gauge (or diameter) of the shaft. The gauge varies from #18
to #30. The larger the gauge number, the smaller the diameter
of the shaft. Smaller gauges produce less tissue trauma, but
larger gauges are necessary for viscous medications.
For an adult requiring a subcutaneous injection, it is
appropriate to use a needle of #24 to #26 gauge and 3/8 to 5/8
inch long. Obese clients may require a 1-inch needle.
For intramuscular injections, a longer needle (e.g., 1 to 1 1/2
inches) with a larger gauge (e.g., #20 to #22 gauge) is used.
 Preventing Needlestick Injury

Recapping a used needle using the one-handed scoop

method.

Dispose of used syringe and needle in sharps container.

 Preparing Injectable Medications
1. Ampules and Vials
Ampule- is a glass container usually designed to hold a single dose of a
drug. It is made of clear glass and has a distinctive shape with a
constricted neck. Ampules vary in size from 1 to 10 mL or more.
Most ampule necks have colored marks around them, indicating
where they are prescored for easy opening.
Vial- is a small glass bottle with a sealed rubber cap. Vials come in
different sizes, from single-use vials to multiple-dose vials.
Ampule Vial
• Some drugs (e.g., penicillin) may be dispensed as powders in vials. A
liquid (diluent) must be added to a powdered medication before it
can be injected. The technique of adding a diluent to a powdered
drug to prepare it for administration is called reconstitution.
• Commonly used diluents are sterile water or sterile normal saline.
Preparing Medications from Ampules
Assess:
• Client allergies to medication
•Specific drug action, side effects, interactions, and
adverse reactions
•Client’s knowledge of and learning needs about the
medication
•Intended route of parenteral medication to
determine appropriate size of syringe and needle for
the client
•Ordered medication for clarity and expiration date
• Perform appropriate assessments (e.g., vital signs, laboratory results)
specific to the medication.

• Determine if the assessment data influence administration of the

medication (i.e., is it appropriate to administer the medication or
does the medication need to be held and/or the primary care
provider notified?).
Performance
1. Perform hand hygiene
2. Prepare the medication ampule for drug withdrawal.
Flick the upper stem of the ampule several times with a fingernail.
Rationale: This will bring all medication down to the main portion of
the ampule.
Use an ampule opener or place a piece of sterile gauze or alcohol
wipe between your thumb and the ampule neck or around the ampule
neck, and break off the top by bending it toward you to ensure the
ampule is broken away from yourself and away from others. Rationale:
The sterile gauze protects the fingers from the broken glass, and any
glass fragments will spray away from the nurse.
OR
Place the antiseptic wipe packet over the top of the ampule before
breaking off the top. Rationale: This method ensures that all glass
fragments fall into the packet and reduces the risk of cuts.
Dispose of the top of the ampule in the sharps container.

Breaking the neck of an ampule using a gauze pad Breaking the neck of an ampule using an ampule opener .
3. Withdraw the medication.
Place the ampule on a flat surface.
Attach the filter needle/straw to the syringe.
Rationale: The filter needle/straw prevents glass
particles from being withdrawn with the medication.
Remove the cap from the filter needle and insert the needle into
the center of the ampule. Do not touch the rim of the ampule with
the needle tip or shaft. Rationale: This will keep the needle sterile.
Withdraw the amount of drug required for the dosage.
 Withdrawing a medication from an inverted ampule

Withdrawing a medication from an ampule on a flat

surface
Preparing Medications from Vials
Performance
1. Perform hand hygiene
2. Prepare the medication vial for drug withdrawal.
Mix the solution, if necessary, by rotating the vial between the palms
of the hands, not by shaking.
Rationale: Some vials contain aqueous suspensions, which settle
when they stand. In some instances, shaking is contraindicated
because it may cause the mixture to foam.
Remove the protective cap, or clean the rubber cap
of a previously opened vial with an antiseptic wipe
by rubbing in a circular motion. Rationale: The
antiseptic cleans the cap and reduces the number of
microorganisms.
Withdraw the medication.
Attach an aspirating needle, draw up premixed liquid
medications from multidose vials. Ensure that the needle
is firmly attached to the syringe.
Remove the cap from the needle, then draw up into the
syringe the amount of air equal to the volume of the
medication to be withdrawn.
• Carefully insert the needle into the upright vial through
the center of the rubber cap, maintaining the sterility of
the needle.
• Inject the air into the vial, keeping the bevel of the needle
above the surface of the medication. 􏰌 Rationale: The air
will allow the medication to be drawn out easily because
negative pressure will not be created inside the vial. The
bevel is kept above the medication to avoid creating
bubbles in the medication.
Injecting air into a vial
Withdraw the prescribed amount of medication using either of
the following methods:
a. Hold the vial down (i.e., with the base lower than the top),
move the needle tip so that it is below the fluid level, and
withdraw the medication. Avoid drawing up the last drops of the
vial. 􏰍 Rationale: Proponents of this method say that keeping the
vial in the upright position while withdrawing the medication
allows particulate matter to precipitate out of the solution.
Leaving the last few drops reduces the chance of withdrawing
foreign particles.
or
Withdrawing a medication from a vial that is held with the base down.
• Invert the vial, ensure that the tip is below the fluid level; and
gradually withdraw the medication.
􏰎 Rationale: Keeping the tip of the needle below
the fluid level prevents air from being drawn into
the syringe.

Withdrawing a medication from an inverted vial .

• Hold the syringe and vial at eye level to determine that the correct dosage of
drug is drawn into the syringe. Eject air remaining at the top of the syringe into
the vial.
• When the correct volume of medication plus a little more (e.g., 0.25 mL) is
obtained, withdraw the needle from the vial, and replace the cap over the needle
using the scoop method, thus maintaining its sterility.
• If necessary, tap the syringe barrel to dislodge any air bubbles present in the
syringe. Rationale: The tapping motion will cause the air bubbles to rise to the
top of the syringe where they can be ejected out of the syringe.
• If giving an injection, replace the filter needle, if used, with a regular or safety
needle of the correct gauge and length. Eject air from the new needle and verify
correct medication volume before injecting the client.
Intradermal Injections
• is the administration of a drug into the dermal layer of the skin just
beneath the epidermis. Usually only a small amount of liquid is used,
for example, 0.1 mL.
• This method of administration is frequently used for allergy testing
and tuberculosis (TB) screening. Common sites for intradermal
injections are the inner lower arm, the upper chest, and the back
beneath the scapulae
Body sites commonly used for intradermal injections.
Equipment
Medication to be tested -Cotton ball
Sterile water for injection
Tuberculin syringe
Aspirating needle
Alcohol wipes
Ballpen
Micropore tape
Wheal- aka bleb. A wheal is a small raised area, like a blister.
Performance:
•Select and clean the site.
• Select a site (e.g., the forearm about a hand’s width above the wrist and
three or four finger widths below the antecubital space).
• Avoid using sites that are tender, inflamed, or swollen and those that
have lesions.
• Cleanse the skin at the site using a firm circular
motion starting at the center and widening the circle outward. Allow the
area to dry thoroughly.
• Prepare the syringe for the injection:
• Aspirate 0.1 of the medication and 0.9 distilled water
• Remove the needle cap while waiting for the antiseptic to dry.
• Expel any air bubbles from the syringe. Small bubbles that adhere to
the plunger are of no consequence. Rationale: A small amount of air
will not harm the tissues.
• Grasp the syringe in your dominant hand, close to the hub, holding it
between thumb and forefinger. Hold the needle almost parallel to the
skin surface, with the bevel of the needle up. Rationale: The possibility
of the medication entering the subcutaneous tissue increases when
using an angle greater than 15 degrees.
The needle enters the skin at a 5- to 15-degree angle
• Inject the fluid.
• With the nondominant hand, pull the skin at the site until it
is taut. Rationale: Taut skin allows for easier entry of the
needle and less discomfort for the client.
• Insert the tip of the needle far enough to place the bevel
through the epidermis into the dermis. The outline of the
bevel should be visible under the skin surface.
• Stabilize the syringe and needle. Inject the medication
carefully and slowly so that it produces a small wheal on the
skin. Rationale: This verifies that the medication entered the
dermis.
The medication forms a bleb or wheal under the epidermis.
• Withdraw the needle quickly at the same angle at which it was
inserted.
• Do not massage the area. Mark the size of the wheal with a ballpen.
Rationale: Massage can disperse the medication into the tissue or out
through the needle insertion site.
• Cut a micropore tape and place the time started and ending time.
Stick adjacent to the wheal.
• Dispose of the syringe and needle into the sharps container.
Rationale: Do not recap the needle in order to prevent needlestick
injuries.
Evaluation
Evaluate the client’s response to the medication
Evaluate the condition of the site after 30 minutes, or 24 or 48 hours,
depending on the test. Measure the area of redness and induration in
millimeters at the largest diameter and document findings.
Subcutaneous Injections
• Among the many kinds of drugs administered
subcutaneously (just beneath the skin) are vaccines,
insulin, and heparin.
• Common sites for subcutaneous injections are the
outer aspect of the upper arms and the anterior
aspect of the thighs. These areas are convenient and
normally have good blood circulation. Other areas
that can be used are the abdomen, the scapular
areas of the upper back, and the upper ventrogluteal
and dorsogluteal areas
• Only small doses (0.5 to 1 mL) of medication are
usually injected via the subcutaneous route.
• #25-gauge, 5/8-inch needle is used for adults of normal weight and
the needle is inserted at a 45-degree angle; a 3/8-inch needle is used
at a 90-degree angle. A child may need a 1/2-inch needle inserted at a
45-degree angle.
• Subcutaneous injection sites need to be rotated in an orderly fashion
to minimize tissue damage, aid absorption, and avoid discomfort.
Body sites commonly used for subcutaneous injections.
 Administering a Subcutaneous Injection
• Assist the client to a position in which the arm, leg, or abdomen
can be relaxed, depending on the site to be used. Rationale: A
relaxed position of the site minimizes discomfort.
• Obtain assistance in holding an uncooperative client. Rationale:
This prevents injury due to sudden movement after needle
insertion.
• Explain the purpose of the medication and how it will help, using
language that the client can understand. Include relevant
information about effects of the medication. Rationale:
Information can facilitate acceptance of and compliance with the
therapy.
• Select and clean the site.
• Select a site free of tenderness, hardness, swelling, scarring, itching, burning,
or localized inflammation. Select a site that has not been used frequently.
Rationale: These conditions could hinder the absorption of the medication
and may also increase the likelihood of injury and discomfort at the injection
site.
• clean the site with an antiseptic swab. Start at the center of the site
and clean in a widening circle to about 5 cm (2 in.). Allow the area to
dry thoroughly. Rationale: The mechanical action of swabbing
removes skin secretions, which contain microorganisms.
• Place and hold the swab between the third and fourth fingers of the
nondominant hand, or position the swab on the client’s skin above
the intended site. Rationale: Using this technique keeps the swab
readily accessible when the needle is withdrawn.
Prepare the medication to be injected.
Inject the medication.
Grasp the syringe in your dominant hand by holding it between your
thumb and fingers. With palm facing to the side or upward for a 45-
degree angle insertion, or with the palm downward for a 90-degree
angle insertion, prepare to inject.
Using the nondominant hand, pinch or spread the skin at the site, and
insert the needle using the dominant hand and a firm steady push.
Inserting a needle into the subcutaneous tissue using 90- and 45-degree angles.
• When the needle is inserted, move your nondominant hand to the
end of the plunger. Some nurses find it easier to move the
nondominant hand to the barrel of the syringe and the dominant
hand to the end of the plunger.
• Inject the medication by holding the syringe steady and depressing
the plunger with a slow, even pressure. Rationale: Holding the syringe
steady and injecting the medication at an even pressure minimizes
discomfort for the client.
Intramuscular Injection
• are absorbed more quickly than subcutaneous injections because of
the greater blood supply to the body muscles.
• An adult with well-developed muscles can usually safely tolerate up to
3 mL of medication in the gluteus medius and gluteus maximus
muscles. A volume of 1 to 2 mL is usually recommended for adults
with less developed muscles. In the deltoid muscle, volumes of 0.5 to
1 mL are recommended.
• a 3- to 5-mL syringe is needed. The size of syringe used depends
on the amount of medication being administered. The standard
prepackaged intramuscular needle is 1 1/2 inches and #21 or
#22 gauge.
• Several factors indicate the size and length of the needle to be
used:
• The muscle
• The type of solution
• The amount of adipose tissue covering the muscle
• The age of the client.
A major consideration- selection of a safe site located away
from large blood vessels, nerves, and bone. Contraindications
for using a specific site include tissue injury and the presence
of nodules, lumps, abscesses, tenderness, or other pathology.
1. Ventrogluteal Site
The ventrogluteal site is in the gluteus medius muscle, which
lies over the gluteus minimus. The ventro-gluteal site is the
preferred site for intramuscular injections be- cause the area:
Contains no large nerves or blood vessels.
Provides the greatest thickness of gluteal muscle consisting of
both the gluteus medius and gluteus minimus.
■
• Is sealed off by bone.
Contains consistently less fat than the buttock area, thus
eliminating the need to determine the depth of subcutaneous
fat.
• the safest site of choice for an IM injection of more than 1 mL in
clients older than 7 months
• client position for the injection can be a back, prone, or side-
lying position. The side-lying position, however, helps locate the
ventrogluteal site more easily. Position the client on his or her
side with the knee bent and raised slightly toward the chest.
Lateral view of the right buttock showing the three gluteal muscles used for intramuscular injections.
• The trochanter will protrude, which facilitates locating the
ventrogluteal site. To establish the exact site, the nurse places the
heel of the hand on the client’s greater trochanter, with the fingers
pointing toward the client’s head. The right hand is used for the left
hip, and the left hand for the right hip. With the index finger on the
client’s anterior superior iliac spine, the nurse stretches the middle
finger dorsally (toward the buttocks), palpating the crest of the ilium
and then pressing below it. The triangle formed by the index finger,
the third finger, and the crest of the ilium is the injection site
Landmarks for the ventrogluteal site for an intramuscular injection.
Administering an intramuscular injection into the ventrogluteal site.
2. Vastus Lateralis Site
•is usually thick and well developed in both adults and children. It is
recommended as the site of choice for intramuscular injections for
infants 1 year and younger .Because there are no major blood vessels
or nerves in the area, it is desirable for infants whose gluteal muscles
are poorly developed. It is situated on the anterior lateral aspect of the
infant’s thigh.
• The middle third of the muscle is suggested as the site. In the
adult, the landmark is established by dividing the area between
the greater trochanter of the femur and the lateral femoral
condyle into thirds and selecting the middle third. The client can
assume a back-lying or a sitting position for an injection into this
site.
Administering an intramuscular injection at vastus lateralis
3. Dorsogluteal - this site is close to the sciatic nerve and the superior
gluteal nerve and artery. As a result, complications (e.g., numbness,
pain, paralysis) occurred if the nurse injected a medication near or
into the sciatic nerve. In addition, there tends to be more
subcutaneous tissue at the dorsogluteal site. The medication may be
injected into the subcutaneous tissue instead of the muscle, which
can then affect the intended therapeutic effect.
4. Rectus Femoris Site - belongs to the quadriceps muscle group, is
used only occasionally for intramuscular injections. It is situated on
the anterior aspect of the thigh.
- chief advantage is that clients who administer their own injections can
reach this site easily. Its main disadvantage is that an injection here may
cause considerable discomfort for some people.
Landmarks for the rectus femoris muscle of the up- per right thigh, used for intramuscular injections.
5. Deltoid Area - deltoid muscle is found on the lateral aspect of the
upper arm. It is not used often for intramuscular injections because it is
a relatively small muscle and is very close to the radial nerve and radial
artery. It is sometimes considered for use in adults because of rapid
absorption from the deltoid area, but no more than 1 mL of solution
can be administered.
• The upper landmark for the deltoid site is located by the nurse placing
four fingers across the deltoid muscle with the first finger on the
acromion process. The top of the axilla is the line that marks the
lower border landmark
• A triangle within these boundaries indicates the deltoid muscle about
5 cm (2 in.) below the acromion process
• Firmly pressing the injection site for 10 seconds before inserting the
needle is thought to reduce the sensory input from an injection,
regardless of the site
A method of establishing the deltoid muscle site for an intramuscular injection.
Landmarks for the deltoid muscle of the upper arm,
used for intramuscular injections.
 Lifespan Considerations in Giving IM
Injections
1. Infants
• The vastus lateralis site is recommended as the site of choice for
intramuscular injections for infants. There are no major blood
vessels or nerves in this area, and it is the infant’s largest muscle
mass. It is situated on the anterior lateral aspect of the thigh.
• Obtain assistance to immobilize an infant or young child. The parent
may hold the child. This prevents accidental injury during the
procedure.
2. Children
• Use needles that will place medication in the main muscle
mass; infants and children usually require smaller, shorter
needles (#22 to #25 gauge, 5/8 to 1 inch long) for
intramuscular injections.
The vastus lateralis is recommended as the site of choice for
toddlers and children.

• For the older child and adolescent, the recommended sites

are the same as for the adult: ventrogluteal or deltoid. Ask
which arm they would like the injection in.
3. Older Adults
Older clients may have a decreased muscle mass or muscle atrophy. A
shorter needle may be needed. Assessment of an appropriate injection
site is critical. Absorption of medication may occur more quickly than
expected.
END