Information related to Parenteral Injections

2. Is injection an
invasive procedure?
Parenteral injections can be
considered as minimally invasive.
Minimally invasive surgery is when
a small incision or injection is made
into the skin so that the proper
medications may be applied
directly to the affected area.

3. Identify the advantages of the parenteral route of
drug administration
List the basic guidelines for administering an injection
Prepare a patient for an injection
Demonstrate the proper procedure to be used when
giving parenteral injections
OBJECTIVES

4. Parenteral Injections
The term parenteral in medical terminology means beyond
the intestine (par = beyond, enteral = intestines)
An injection is a shot, or a dose of medicine given by way of
a syringe and a needle.
DEFINITIONS

5. Rapid
Produces a direct result
Drugs are absorbed directly into the
bloodstream
Types of injections
Intravenous fastest effects
Intramuscular next fastest result
Subcutaneous slower than other two
WHY PARENTERAL ROUTE?

6. • Effective route for drug delivery when the
patients physical or mental state would make
other routes difficult
• Do not irritate the digestive system
• Can deliver a precise dose to a targeted area of
the body (i.e. into a joint or within the spinal
canal)
ADVANTAGES OF PARENTERAL INJECTIONS

7. • Patient may have allergic reaction
• Introduction of microorganisms
• Injections can cause injury to tissue, nerves, veins, and
other vessels
• Needle can strike a bone
• Injections can traumatize a vein and cause a possible
hematoma
DISADVANTAGES OF PARENTERAL INJECTIONS

8. PARTS

10. “The SMALLER the
NUMBER, the
LARGER the
GAUGE (inside
diameter)

12. 1. INTRADERMAL (ID)
2. SUBCUTANEOUS (SC or SQ)
3. INTRAMUSCULAR (IM)
4. INTRAVENOUS (IV)
TYPES OF PARENTERAL INJECTIONS

13. INTRADERMAL (ID) INJECTIONS
Intradermal injection (also intracutaneous or
intradermic, abbreviated as ID) is a shallow or
superficial injection of a substance into the
dermis, which is located between the epidermis
and the hypodermis.

14. INDICATIONS
It is commonly used for
tuberculin skin testing (Mantoux Test)
allergy testing
local anesthetics
BCG vaccine
The ID injection route has the longest
absorption time of all parenteral routes

15. SITES FOR ID INJECTIONS

16. The dosage of an ID injection is usually
under 0.5 ml. The angle of administration
for an ID injection is 5 to 15 degrees.

23. EQUIPMENTS FOR ID INJECTION
Hypodermic tray lined with sterile towel.
Tuberculin syringe 1ml
Needle (25-27 gauge)
Aspirating needle
Antiseptic of Alcohol Swab
Medication ampule or vial
Medication ticket
Disposable gloves
Jar CB soaked in 70% ROH
Waste receptacle
Sharps container /Puncture-proof container

24. PROCEDURE
SAFETY
Follow the Six Rights of Medication Administration: right
medication, right dose, right patient, right route, right time,
and right documentation.
Do not aspirate during intradermal injection, because the
dermis is relatively avascular.
Perform hand hygiene & wear clean gloves during
intradermal injection to limit contact with bodily fluids.

25. Use strict asepsis when preparing and administering
an intradermal injection.
Observe a “No Interruption Zone” while preparing
medications.
The skin of older adults is less elastic and must be held
taut to ensure correct administration of the
intradermal injection.

26. Stay with the patient for several minutes after
providing the injection to watch for signs of an allergic
reaction.
Dyspnea, wheezing, and circulatory collapse signify
severe anaphylactic reaction.

27. PROCEDURE
PREPARATION
Check the accuracy and completeness of each medication
administration record (MAR) against the health care
provider’s orders. Confirm the patient’s name, medication
name, dosage, route of administration, and time of
administration. Clarify incomplete or unclear orders with the
health care provider.
Note if the patient has allergies.

28. Review the medication reference information about
expected reactions to skin tests for specific allergens
or medications, and note the appropriate time to read
the site.
Assess the patient’s history of allergies including the
known allergen types, and the patient’s typical allergic
reaction.

29. Ascertain any contraindications to intradermal
injections. Assess for a history of severe adverse
reactions or necrosis following previous
intradermal injection.
Determine if the patient understands the reason
for the skin test and knows what responses to
report.

30. Prepare the medication for injection. Check the label
of the medication against the MAR two times. A third
check will take place at the bedside. Note the
expiration date of the medication.
If the syringe is prepared away from the patient’s
bedside, label it with the name and dose of
medication in the syringe.

31. PROCEDURE
FOLLOW-UP
Return to the patient’s room in 15 to 30 minutes, and ask her if she feels any
acute pain, burning, numbness, or tingling at the injection site.
Ask the patient to discuss the implications of skin testing and the signs of
hypersensitivity.
Inspect the bleb. As an option, use a skin pencil and draw a circle around the
perimeter of the injection site.
Read a tuberculin (TB) test site at 48 to 72 hours; look for induration—a hard,
dense, raised area—around the injection site.

32. The dosage of an ID injection is usually
under 0.5 ml. The angle of administration
for an ID injection is 5 to 15 degrees.

33. PROCEDURE
DOCUMENTATION
Record the drug, dose, route, site, time, and date on the MAR immediately
after administering the intradermal injection, and not before. For hard-copy
documentation, include the time and your initials or signature per agency
policy.
Record the location of the intradermal injection and the appearance of the
patient’s skin afterward.
Document any adverse effects according to your agency’s policy, and report
them to the health care provider.
Record any patient teaching, validation of understanding, and the patient’s
response to the intradermal injection.

34. SUBCUTANEOUS (SC OR SQ) INJECTIONS
Subcutaneous (SQ or Sub-Q) injection means the
injection is given in the fatty tissue, just under
the skin.
In this type of injection, a short needle is used to
inject a drug into the tissue layer between the
skin and the muscle.

35. INDICATIONS
small volumes of drugs that require slow absorption and
long duration of action
for medications that must be absorbed into the
bloodstream slowly and steadily
i.e. heparin growth hormones
insulin Live, attenuated injectable vaccines (MMR, varicella)
These injections are given because there is little blood flow to fatty tissue, and
the injected medication is generally absorbed more slowly, sometimes over 24
hours.

36. SITES FOR SC OR SQ INJECTIONS

37. Subcutaneous injections
are usually given at a 45-
to 90-degree angle. The
angle is based on the
amount of subcutaneous
tissue present. Generally,
give shorter needles at a
90-degree angle and
longer needles at a 45-
degree angle (Lynn,
2011).

38. EQUIPMENTS FOR SC OR SQ INJECTION
Hypodermic tray lined with sterile towel.
Tuberculin syringe 1ml
Needle (28-31 gauge)
Aspirating needle
Antiseptic of Alcohol Swab
Medication ampule or vial
Medication ticket
Disposable gloves
Jar CB soaked in 70% ROH
Waste receptacle
Sharps container /Puncture-proof container

39. PROCEDURE
SAFETY
Ensure that the Six Rights of Medication Administration are
observed: right medication, right dose, right patient, right route,
right time, and right documentation.
Do not administer volumes greater than 2 mL at a single injection
site. For infants and children, the volume injected should not exceed
0.5 mL.
.

40. Perform hand hygiene & wear gloves to reduce the risk of contact
with bloodborne pathogens.
Follow the principles of sterile technique when administering a
subcutaneous injection.
In older adult patients with less elastic skin and reduced
subcutaneous skinfold thickness, select the upper abdominal site.

41. PROCEDURE
PREPARATION
Check the accuracy and completeness of each medication
administration record (MAR) against the health care
provider’s orders. Confirm the patient’s name, medication
name, dosage, route of administration, and time of
administration. Clarify incomplete or unclear orders with the
health care provider.
Note if the patient has allergies.

42. Observe the patient’s previous verbal and nonverbal
responses to the injection.
Assess for contraindications to subcutaneous
injections, such as reduced peripheral circulation to
the injection site area.
Review the MAR to note the locations of previous
injections.

43. Assess the adequacy of the patient’s adipose
tissue.
When drawing up medication for injection away
from the patient bedside, be sure to label the
syringe with the name and amount of medication
it contains.

44. PROCEDURE
FOLLOW-UP
Return to the patient’s room in 15 to 30 minutes, and ask her if she feels any
acute pain, burning, numbness, or tingling at the injection site.
Inspect the site, noting any areas of bruising or induration.
Observe the patient for a therapeutic response to the medication as well as
for any adverse effects.
Confirm the patient’s understanding of the medication’s purpose, action,
possible side effects, and self-administration technique if applicable.

45. PROCEDURE
DOCUMENTATION
Document the medication administered by subcutaneous injection,
its concentration, its dosage or strength, the time of administration,
and the site of administration. This documentation must be made on
the MAR immediately after administration, not before.
Document any patient teaching and validation of the patient’s
understanding.
Document and report to the health care provider any withheld
doses and/or the patient’s response to the medication, including
any side effects.

46. INTRAMUSCULAR (IM) INJECTIONS
The intramuscular (IM) injection route deposits
medication into deep muscle tissue, which has a
rich blood supply, allowing medication to absorb
faster than by the subcutaneous route
An intramuscular injection usually takes 5 to 10 minutes or 1-
2 hours for the muscle to fully absorb the medicine or
vaccine.

47. INDICATIONS
less painful administration of irritating drugs
rapid absorption of the drug compared to subcutaneous injection
administer large doses (up to 5 ml in appropriate sites) of the
medication
Alternative route for clients cannot take medications orally and
for drugs that are degraded by the digestive juices
The most common medications given by IM route include:
Antibiotics- penicillin G benzathine penicillin, streptomycin.
Biologicals- immunoglobins, vaccines, and toxoids.
Hormonal agents- testosterone, medroxyprogesterone[2]

48. SITES FOR IM INJECTIONS

49. Insert needle at a 90° angle to the skin
with a quick thrust. Retain pressure on
skin around injection site with thumb
and index finger while needle is inserted.

50. EQUIPMENTS FOR ID INJECTION
Hypodermic tray lined with sterile towel.
Prescribed medication Vial or ampule of medication
Medication ticket
Sterile needles for aspirating and for injecting G.20-21 ½
Sterile syringes
Clean gloves
Small gauze pad
Jar CB soaked in 70% ROH
Waste receptacle
Sharps container /Puncture-proof container

51. PROCEDURE
SAFETY
Ensure that the Six Rights of Medication Administration are
observed: right medication, right dose, right patient, right
route, right time, and right documentation. Follow the
principles of sterile technique when administering an
intramuscular injection.

52. Perform hand hygiene & wear gloves to reduce the risk of
contact with bloodborne pathogens.
Do not use an injection site in an area with bruising,
induration, muscular atrophy, reduced blood flow, or signs of
infection.
Ensure that the position for injection is not contraindicated
by the patient’s medical condition.

53. To prevent administration of the medication directly
into a blood vessel, aspirate when giving all
intramuscular injections except vaccines.
Rotate intramuscular injection sites to decrease the
risk of tissue hypertrophy.

54. In older adults and thin patients, do not administer a
volume of more than 2 mL by intramuscular injection.
In infants and small children, do not administer a
volume of more than 1 mL.

55. PROCEDURE
PREPARATION
Check the accuracy and completeness of each medication
administration record (MAR) against the health care
provider’s orders. Confirm the patient’s name, medication
name, dosage, route of administration, and time of
administration. Clarify incomplete or unclear orders with the
health care provider.
Note if the patient has allergies.

56. Review the medication reference information for
medication action, purpose, normal dose, side effects, time
of peak action and nursing implications.
Review the patient’s previous verbal and nonverbal
responses to the injection.
Assess for contraindications to intramuscular injections,
such as muscle atrophy, reduced blood flow, and circulatory
shock.

57. Review the MAR to note the locations of previous
injections.
When drawing up medication for injection away from
the patient’s bedside, label the syringe with the name
and amount of medication it contains

58. PROCEDURE
FOLLOW-UP
Return to the patient’s room in 15 to 30 minutes, and ask her if she feels any
acute pain, burning, numbness, or tingling at the injection site.
Inspect the site, noting any bruising or induration. Apply a warm compress if
necessary.
Observe the patient for a therapeutic response to the medication as well as
for any adverse effects.
Confirm the patient’s understanding of the medication’s purpose, action,
possible side effects, and self-administration technique if applicable.

59. PROCEDURE
DOCUMENTATION
Document the medication administered by intramuscular injection,
its concentration, its dosage or strength, the time of administration,
and the site of administration. This documentation must be made on
the MAR immediately after administration, not before.
Document any patient teaching and validation of the patient’s
understanding.
Document and report to the health care provider any withheld
doses and/or the patient’s response to the medication, including
any side effects.

60. Z – Technique of Intramuscular Injection
Z – technique intramuscular injection
is the introduction of oily or viscous medication deep into the
muscle tissue.
The technique seals the medication in the chosen muscle site.
Indication:
It is used for certain drugs that irritate and discolor the
subcutaneous tissues. It provides less discomfort
and decrease the occurrence of lesions at the injection site (Potter
p.890)

62. INTRAVENOUS (IV) INJECTIONS
Some medications must be given by an
intravenous (IV) injection or infusion. This
means they’re sent directly into your vein using a
needle or tube. In fact, the term “intravenous”
means “into the vein.”
Drugs administered via intravenous (IV) injection or
infusion do not need to be absorbed, as they are delivered
directly into the bloodstream.

63. INDICATIONS
Hydration
Emergency medications
Electrolyte replacement
Nutrition (PPN or TPN)
Medication administration
Blood Products Transfusion
Radiological contrast agents
Chemotherapy

64. About standard IV lines
used for short-term needs
they may be used during a short hospital stay to administer medication
during surgery or to give pain medications, nausea medications, or
antibiotics
used for up to 4 days
Types:
IV push
An IV “push” or “bolus” is a rapid injection of medication. A syringe is
inserted into your catheter to quickly send a one-time dose of a drug into your
bloodstream.
IV infusion
controlled administration of medication into your bloodstream over time.

65. Pump infusion. The pump is attached to your IV line and
sends medication and a solution, such as sterile saline, into
your catheter in a slow, steady manner.
Drip infusion. This method uses gravity to deliver a
constant amount of medication over a set period of time.
With a drip, the medication and solution drip from a bag
through a tube and into your catheter.

66. SITES FOR IV INJECTIONS OR INFUSIONS

67. ARTERIAL LINE

68. PROCEDURE
SAFETY
Ensure that the Six Rights of Medication Administration are
observed: right medication, right dose, right patient, right
route, right time, and right documentation. Follow the
principles of sterile technique when administering an
intramuscular injection.

69. Assess patient’s verbal or non-verbal response to needles.
Before inserting a needle into a patient’s vein, you have to assess its
condition first.
Do not use an injection site in an area with bruising,
induration, muscular atrophy, reduced blood flow, or signs of
infection.

70. Perform hand hygiene & wear gloves to reduce the risk of
contact with bloodborne pathogens.
Ensure that the position for the IV injection/insertion is not
contraindicated by the patient’s medical condition.
Attempts to initiate IV access:
total of seven as follows: ( Follow as per facility policy )
First facility nurse- Two (2) attempts
Second facility nurse – Two (2) attempts
IV RN support – Two (2) attempts; one (1) additional if different device is used

71. EQUIPMENTS FOR IV INSERTION/CANNULATION
Hypodermic tray lined with sterile towel.
IV cannula
IV cannula dressing
Sterile syringes
Saline
Clean gloves
Small gauze pad
Tourniquet
Jar CB soaked in 70% ROH
Waste receptacle
Sharps container /Puncture-proof container

72. PROCEDURE
PREPARATION
Check the accuracy and completeness of each medication
administration record (MAR) against the health care
provider’s orders. Confirm the patient’s name, medication
name, dosage, route of administration, and time of
administration. Clarify incomplete or unclear orders with the
health care provider.
Note if the patient has allergies.

73. Explain procedure to resident and assess veins
Wash hands thoroughly
Assemble equipment on a clean surface and prime injection plug
extension tube.
Apply tourniquet to arm and select venipuncture site.
*Care must be taken to apply tourniquet with enough pressure to impede
venous flow and allow arterial flow to be maintained. Palpation of pulse
should be present.
*If limited venous access, apply warm, moist towel around extremity to
aid in vein dilation.
*Start IV Therapy in distal (farthest) point of upper extremities. Avoid bony
prominences and areas of flexion.

74. Cleanse site with povidone-iodine working from the center
outward using a circular motion for 30 seconds. Allow 1-2
minutes to dry.
*Always check for iodine allergy and use alcohol as a substitute
PRN. Povidone-iodine may be removed with an alcohol swab for
better visualization.
Inspect intravenous catheter for any defects. Do not pull stylet
out of catheter, as this will disrupt the manufacturer coating
applied to ease insertion.
Place thumb below intended venipuncture site and gently draw
skin toward to secure vein.

75. (1)Insert catheter through skin and into vein at 10°-30°
angle with bevel up. Decrease angle and advance
about ¼” into vein. *Do not attempt more than one
venipuncture per IV device
(2) Hold the flash chamber of stylet steady and advance
plastic catheter over stylet into vein, up to catheter hub.
*Never re-insert stylet after removal from catheter.
(3) Remove tourniquet

76. (4) Remove stylet from catheter and attach heparin lock
extension tube.
*To maintain a closed system and reduce risk of infection.
(5) Observe for signs of infiltration at venipuncture site.
*Swelling and/or pain indicate that catheter

77. If IV is to be used for intermittent therapy, flush device with 5cc
of Normal Saline 0.9%.
It is necessary to flush with normal saline prior to and after
medication administration, since not all medications are
compatible with heparin. Saline flushing will also allow the nurse
to assess IV patency. Never use force while flushing.
*Always use positive pressure when flushing an IV.
Cover insertion site with transparent dressing, leaving extension
tube connection exposed.

78. Anchor extension tube in a “U” shape with tape
Stabilize extremity on passed arm board or dynamic
wrist/elbow support, if necessary.
*If IV is at point of flexion, immobilization of joint will help
maintain IV site.
Check and regulate flow rate according to physician’s
order

79. Label IV dressing with the following:
(1) Date and Time
(2) Type, length and gauge of needle
(3) Initials of IV nurse
Discard used equipment appropriately.

80. Documentation
Record the procedure in the resident’s medical record.
Include the following:
1) Date and time of insertion
2) Type, length and gauge of catheter
3) Location of insertion site
4) Number of IV attempts
5) Type of dressings applied
6) Resident’s response
7) Nurse’s signature