4. An adjuvant is a vaccine component distinct from the antigen that enhances the immune response to the antigen, but might also increase risk of adverse reactions. The anterolateral thigh also can be used. Refer to agency policy regarding specifications for infants, children, adolescents, and immunizations. 14. The nurse measures 2 to 3 finger widths4 down from the acromion process and visualizes a triangle, with the base at the acromion process and the apex pointing toward the elbow. For non-live vaccines, manufacturers typically recommend use within the same day that a vaccine is withdrawn or reconstituted. Assistance is sometimes necessary to hold and properly position the child. Clinical nursing skills & techniques (10th ed.). Patient complains of localized pain, bleeding, or continued burning at injection site, indicating potential injury to nerve or vessels. A vapocoolant spray (e.g., ethyl chloride) may also be used just before injection to decrease pain. 13. Discard the uncapped needle (or needle enclosed in a safety shield) and the attached syringe into a puncture-proof and leakproof receptacle. WebIn general, for an adult male weighing 60 to 118 kg (130 to 260 lbs), a 25 mm (1 inch) needle is sufficient. To decline or learn more, visit our cookies page. Assess the patients symptoms, knowledge of the medication to be received, history of allergies, drug allergies, and types of allergic reactions. Always compare MAR to the practitioners original orders to ensure accuracy and completeness. The injection site is generally three finger widths below, in the middle of the muscle. If injecting into the vastus lateralis, ventrogluteal, gluteus medius, or Assess for factors such as muscle atrophy, reduced blood flow, skin condition, and circulatory shock. Review the patients previous verbal and nonverbal responses to injections. Administering a vaccine containing an adjuvant either subcutaneously or intradermally can cause local irritation, induration, skin discoloration, inflammation, and granuloma formation. Source: Adapted from Minnesota Department of Health. These cookies may also be used for advertising purposes by these third parties. The act directed OSHA to strengthen its existing bloodborne pathogen standards. A -inch, 23- to 25-gauge needle should be inserted into the subcutaneous tissue (Figures 4and 5) (4). Insert the needle with a dart-like motion. 16. The middle third of the muscle is used for injections. The site involves the gluteus medius and minimus muscle and is the safest injection site for adults and children. 21. CDC twenty four seven. Medications left unattended may lead to medication errors. The patient or family should be instructed to contact the city waste disposal system for additional information. Allow site to dry completely. For the ventrogluteal muscle of an average adult, give up to 3 ml of medication. Because unused prefilled syringes also typically must be discarded if not used within the same day that they are filled, vaccine wastage might occur. Potential complications include lingering pain, tissue necrosis, abscesses, and injury to blood vessels, bones, or nerves. Providers should address circumstances in which dose(s) of these vaccines have been administered subcutaneously on a case-by-case basis. Although policy may vary from place to place, the CDC recommends wearing gloves if there is potential for contact with blood and body fluid. If a vaccine and an immune globulin preparation are administered simultaneously (e.g., Td/Tdap and tetanus immune globulin [TIG], hepatitis B and hepatitis B immunoglobulin [HBIG]), separate limbs should be used for each injection (29-30). The Z-track method can be used (except with infant vaccination where skin is compressed) provided that the overlying tissue can be displaced. Injection technique is the most important parameter to ensure efficient intramuscular vaccine delivery. In order to accurately determine the amount of medication to administer, the nurse must first calculate the total daily dose. Assemble medication, non-sterile gloves, alcohol swabs, syringes, needles, and sharps container. Non-Parenteral Medication Administration. To relax this site, the patient lies on the side or back, flexing the knee and hip. Assess patients response to the medication after the appropriate time frame. The deltoid muscle is preferred for adolescents 11-18 years of age. Hold syringe between thumb and forefinger on dominant hand as if holding a dart. For all intramuscular injections, the needle should be long enough to reach the muscle mass and prevent vaccine from seeping into subcutaneous tissue, but not so long as to involve underlying nerves, blood vessels, or bone (15,19-22). Recognize and immediately treat respiratory distress and circulatory collapse, which are signs of a severe anaphylactic reaction. Begin by having the patient relax the arm. Hepatitis A vaccine and meningococcal conjugate vaccine do not need to be repeated if administered by the subcutaneous route (55-56). Intramuscular injections are administered at a 90-degree angle to the skin, preferably into the anterolateral aspect of the thigh or the deltoid muscle of the upper arm, depending on the age of the patient (Table 6-2). Instruct the patient and a family member to observe injection sites for complications and to report complications to the practitioner immediately. However, for DTaP, Hib, and PCV13, there is no evidence related to immunogenicity of these 3 vaccines given subcutaneously. For toddlers, the anterolateral thigh muscle is preferred, and when this site is used, the needle should be at least 1 inch long. More research is needed to investigate the practice of aspiration before administering an IM injection with medications other than vaccines.8 The recommended route and site for each vaccine is included in the manufacturers instructions for use.2. 4. Move dominant hand to end of plunger. Compare the medication label with the MAR one final time at the patients bedside. This confirms the correct identity of the patient. Explain the procedure and the medication, and give the patient time to ask questions. 0. what is the maximum volume for intramuscular injection pediatric WebThe injection site must be cleaned before administering the injection, and the injection is then administered in a fast, darting motion to decrease the discomfort to the individual. Remove needle cap by pulling it straight off the needle. Thank you for taking the time to confirm your preferences. For immunizations, a smaller 22to 25 gauge needle should be used. 22. The right hand is used for the left hip, and the left hand for the right hip. The dorsogluteal site should be avoided for intramuscular injections. Inactivated influenza vaccine is immunogenic when administered in a lower-than-standard dose by the intradermal route to healthy adult volunteers. Anatomically safe sites for intramuscular injections: A cross-sectional study on young adults and cadavers with a focus on the thigh. Retrieved February 11, 2023, from, Lilley, L.L., Rainforth Collins, S., Snyder, J.S. Although policy may vary (for example, if you are in an acute setting compared to a community setting), the CDC recommends wearing gloves if there is potential for contact with blood and body fluids. WebAdminister vaccine using either a 1-mL or 3-mL syringe. The site provides the greatest thickness of gluteal muscles, is free from penetrating nerves and blood vessels, and has a thin layer of fat. Ensure the six rights of medication safety: right medication, right dose, right time, right route, right patient, and right documentation. Engineering controls means controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate orremove the bloodborne pathogens hazard from the workplace). The length will be shorter for infants and children; see agency guidelines. The ventrogluteal site involves the gluteus medius and minimus muscles and is a safe injection site for adults and children.5 This site provides the greatest thickness of gluteal muscle, is free of penetrating nerves and blood vessels, and has a narrower layer of fat. For live vaccines that require reconstitution, manufacturers typically recommend the vaccine be used as soon as possible after reconstitution and be discarded if not used within 30 minutes after reconstitution. If worn, gloves should be changed between patients. Perform hand hygiene before patient contact. 20. Unused syringes that are prefilled by the manufacturer and activated (i.e., syringe cap removed or needle attached) should be discarded at the end of the clinic day. The revised standards became effective in 2001 (2). Patient experiences no pain or only mild burning at injection site. For women under 60 kg (130 lbs), a 16 mm (5/8 inch) Verify the correct patient using two identifiers. Options for safe sharps disposal at home include allowing patients to transport their own sharps containers from home to collection sites (e.g., practitioners office, hospital, pharmacy), mailing their used syringes to a collection site (mail-back programs), participating in syringe exchange programs, or using special devices that destroy the needle on the syringe, rendering it safe for disposal. 15. The thumb is pointed toward the patients groin, with the index finger pointing to the anterior superior iliac spine, and the middle finger is extended back along the iliac crest toward the buttock. The deltoid should not be used. To help relax the patient, ask the patient to lie flat with knees slightly bent, or have the patient in a sitting position. The anterolateral thigh can also be used. Begin by having the patient relax the arm. Evidence indicates that this cream does not interfere with the immune response to MMR (45). If a needle hits the sciatic nerve, the patient may experience partial or permanent paralysis of the leg.5 The rectus femoris is no longer considered a safe injection site because of the risk of damage to the descending branch of the lateral circumflex femoral artery and the muscle branch of the femoral nerve to the vastus lateralis.6. This technique, pulling the skin laterally before injection, prevents medication leakage into subcutaneous tissue, seals medication in the muscle, and minimizes irritation.5 To use the Z-track method in an adult, the appropriate-size needle is attached to the syringe, and an IM site is selected. Topical lidocaine-prilocaine emulsion should not be used on infants aged <12 months who are receiving treatment with methemoglobin-inducing agents (e.g., acetaminophen, amyl nitrate, nitroprusside, dapsone) because of the possible development of methemoglobinemia (50). In the pediatric population, a mean volume of 365 mL of hyaluronidase-facilitated isotonic solution was infused for a mean 3.1 hours. Verify the patients actual admission weight in kilograms. (b) If skin is stretched tightly and subcutaneous tissues are not bunched. Occupational exposure to bloodborne pathogens; needlestick and other sharps injuries; final rule. Chapter 4: Vaccine safety. (2017). After the needle is withdrawn, the skin is released. However, needle sizes from 22 mm to 25 mm can be used for older children. IM injection sites should be rotated to decrease the risk of hypertrophy. Assess the patients history of allergies, including any drug allergies, type of allergens, and normal allergic reaction. Hold the syringe between the thumb and forefinger of the dominant hand as if holding a dart, palm down. Because of the sciatic nerve location, the dorsogluteal muscle is not recommended as an injection site. Alternate sides should be used for subsequent injections. With a new, sterile dose chamber and nozzle for each patient and correct use, these devices do not have the same safety concerns as multiple-use nozzle jet injectors. In certain circumstances in which a single vaccine type is being used (e.g., in preparation for a community influenza vaccination campaign), filling a small number (10 or fewer) of syringes may be considered (5). Using reduced doses administered at multiple vaccination visits that equal a full dose or using smaller divided doses is not recommended (4). If no blood appears, inject the medication. with your non-dominant hand. This allows for easy access to dry gauze after injection. katkonk, BSN, RN 400 Posts Specializes in Occupational health, Corrections, PACU. If multiple vaccines are administered at a single visit, administer each preparation at a different anatomic site (28). (2020). However, this site is not common for self-injection because its small muscle mass limits the volume of medication that can be injected typically no more than 1 Compare Mar to the patients wristband and use two patient identifiers to confirm patient. Aqueous solutions can be given with a 20 to 25 gauge needle; oily or viscous medication should be administered with 18 to 21 gauge needles. (2022). WebRecommended available dose formulations include 50 mg/ml strength, in 3 ml multiple dose vials or 100 mg/ml strength, in 5 ml multiple dose vials. Explain the procedure and the medication, and give the patient time to ask questions. up to 2 weeks after birth When do you give the 1st dose of Hep B 3 How many times do you check a medication before administering it Deviation from the recommended route of administration might reduce vaccine efficacy (14-15) or increase the risk for local adverse reactions (16-18). Assemble appropriate-size needles, syringes, and other administration supplies. If possible, a topical analgesic should be applied to the injection site with sufficient time allowed for peak action before the IM injection. What is the maximum safe and effective volume of oil that can be injected IM in to the delt. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Deltoid muscle: Locate the central and thickest portion of the deltoid muscle above the level of the Intramuscular (IM) injections have been associated with adverse effects and pain, and this route of medication injection should be used as a last resort. Refer to the agency policies regarding needle length for infants, children, and adolescents. 10. Aspiration in injections: Should we continue or abandon the practice? In general, for an adult male weighing 60 to 118 kg (130 to 260 lbs), a 25 mm (1 inch) needle is sufficient. Prepare medication from an ampule or a vial as per hospital policy. Always compare MAR to the practitioners original orders to ensure accuracy and completeness. reduced attenuation of smallpox vaccine virus (9)]. Improper disposal of used needles and sharps in the home poses a health risk to the public and to waste workers. Viscous or oil-based solutions can be given with 18 to 21 gauge needles. The skin is held in this position until the injection has been administered. Can you give 1.5 ml in deltoid? Ask for the patients name as an additional identifier. For men and women who weigh 130-152 lbs (60-70 kg), a 1-inch needle is sufficient. The maximum amount of medication for a single injection is 3 ml. Covering prevents infection at the injection site. This prevents medication errors by providing an additional check. WebInjection (medicine) An injection (often and usually referred to as a " shot " in US English, a " jab " in UK English, or a " jag " in Scottish English and Scots) is the act of administering a liquid, especially a drug, into a person's body using a needle (usually a hypodermic needle) and a syringe. For adults, the deltoid muscle is recommended for routine intramuscular vaccinations (23) (Figure 3). This site is used for small medication volumes (2 ml or less)5 and for administration of routine immunizations in children older than 3 years with acceptable muscle mass and development and when other sites are inaccessible because of dressings or casts.2. Movement of the needle once injected can cause additional discomfort for the patient. Use a quick, darting motion when inserting the needle. (c) Do not withdraw more than 0.5 mL from the reconstituted product, even if some product is left in the vial. 8. NEVER leave the medication unsupervised once prepared. 24. Children and infants will require shorter needles. Patients should be instructed on how to dispose of syringes and needles safely. Vaccine recommendations and guidelines of the ACIP: General best practice guidelines for immunization. People self Hold syringe between thumb and forefinger on dominant hand as if holding a dart. Oral typhoid capsules should be administered as directed by the manufacturer. For IM injections, the nurse selects a site that is free of pain, infection, necrosis, bruising, and abrasions. Multiple use jet injectors using the same nozzle for consecutive injections without intervening sterilization were used in mass vaccination campaigns from the 1950s through the 1990s (33); however, these were found to be unsafe because of the possibility of bloodborne pathogen transmission (34-37) and should not be used. Disclaimer:Always review and follow your hospital policy regarding this specific skill. What is the maximum volume for a deltoid intramuscular injection? There may be exceptions for specific medications. Therefore, doctors do not use it for drugs that require larger quantities. The width of the muscle used extends from the mid-line of the thigh to the mid-line of the outer thigh. In general, the recommended needle length for an adult is 25 mm to 38 mm (1 to 1 1/2 inch). Insulin syringe: This holds a maximum of 1 mL of medicine. Knowledge of body mass can be useful for estimating the appropriate needle length (26). Always wear gloves to administer injections. A thin adult may require a 16 mm to 25 mm (5/8 to 1 inch) needle, while an average adult may require a 25 mm (1 inch) needle, and a larger adult (over 70 kg) may require a 25 mm to 38 mm (1 to 1 1/2 inch) needle. Position the ulnar side of the nondominant hand just below the site and pull the skin laterally. 18. Instruct the patient regarding the potential side effects of the medication. WebIf injecting medication into the deltoid muscle of an adult, the volume of solution should not exceed 1 mL. Administering volumes smaller than recommended (e.g., inappropriately divided doses) might result in inadequate protection. WebFor a well-developed adult, no more than 3 ml of medication should be administered in a single IM injection because the muscle tissue does not absorb it well in larger volumes. When injecting into the deltoid muscle, for adults a measurement of body mass/weight is allowable prior to vaccination, understanding that resources to measure body mass/weight are not available in all clinical settings. To locate the ventrogluteal site, the heel of the hand is placed over the greater trochanter of the patients hip with the wrist almost perpendicular to the femur. A smaller gauge needle (22 to 25 gauge) should be used with children. Placing sharps in appropriate puncture-proof and leak-proof receptacles prevents accidental needle-stick injuries. Deltoid muscle: This is the top, upper part of the arm. Other persons at increased risk for influenza complications can administer LAIV. The total daily dose is 750 mg every four hours, or 3,000 mg per day. Assess for any factors that may contraindicate an IM injection. Follow the organizations practice for emergency response. Vaccine from two or more vials should never be combined to make one or more doses. Avoid moving the syringe. WebLocate the deltoid injection site, as described above. Abstract. For injection into the anterolateral thigh muscle, a 1.5-inch needle should be used, although a 1-inch needle may be used if the skin is stretched tightly and subcutaneous tissues are not bunched. Vaccinations and immunizations given by IM injections are never aspirated (Centers for Disease Control, 2015). Locate correct site using landmarks, and clean area with alcohol or antiseptic swab. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. The injection site is in the middle of the deltoid muscle, about 2.5 to 5 cm (1 to 2 inches) below the acromion process. Compare MAR to patient wristband and use two patient identifiers to confirm patient. Instruct the patient and a family member to observe for effectiveness of the medication and adverse reactions and to report ineffectiveness of the medication and adverse reactions to the practitioner. If 2 vaccines are to be administered in a single limb, they should be spaced an inch apart (4, 24). If the patients shirt cannot be removed, the sleeve should be rolled up so that landmarks can be visualized and used appropriately.4. Using two identifiers improves medication safety by ensuring you have selected the correct patient. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Applying a colorful adhesive bandage or sticker to the injection site should be considered. The needle is inserted at a 90-degree angle; this varies from the angle used for subcutaneous and intradermal injections (Figure 1).undefined#ref2">2,5 The appropriate needle length is determined by the patients weight and age and the amount of adipose tissue in the chosen injection site.2,7 The needle must be long enough to reach the muscle tissue, but not too long to present the risk of hitting underlying neurovascular structures or bone.2, IM injections should be administered so that the needle is perpendicular to the patients body or as close to a 90-degree angle as possible.2 IM injection sites should also be rotated to decrease the risk for hypertrophy. Current practice in the acute care setting is to aspirate IM injections to check for blood return in the syringe. Hands should be cleansed with an alcohol-based waterless antiseptic hand rub or washed with soap and water before preparing vaccines for administration and between each patient contact (1). Per the organizations practice, pull back on the plunger. 19. Extend your index finger to the anterior superior iliac spine and spread your middle finger pointing towards the iliac crest. Alternate sites and use appropriate needles for deep intramuscular injection. Inject medication at 10 seconds/ml. If required by agency policy, aspirate for blood prior to administering an IM medication. Muscle tissue is less sensitive than subcutaneous tissue to irritating and viscous medications. This step prevents the spread of microorganisms. Asked by: Dr. Marietta Kuvalis V. Score: 4.1/5 (56 votes) Injections that occur below the deltoid muscle can hit the radial nerve and injections that are too far to the side of the deltoid muscle can hit the axillary nerve. If no blood appears, inject the medication slowly. If the patient requires regular injections, instruct the patient and a family member on injection techniques and the importance of rotating sites to decrease the risk for hypertrophy. Place safety shield on needle and discard syringe in appropriate sharps container. Cookies are used by this site. This method can be used if the overlying tissue can be displaced (Lynn, 2011). If administering a vaccination, always refer to the vaccination guidelines for site selection. Follow policy for safe medication administration. Explain the procedure and ensure that the patient agrees to treatment. With your nondominant hand, pull the skin taut. Intramuscular injections must be done carefully to avoid complications. Immune responses generated by jet injectors against both attenuated and non-live viral and bacterial antigens are usually equivalent to, and occasionally greater than, immune responses induced by needle injection. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Prepare medication from an ampule or a vial as per hospital policy. Small muscles absorb small volumes. Several of the newer devices have been approved by FDA for use with specific vaccines (33). U.S. Food and Drug Administration (FDA). Deltoid or gluteal injections are both possible; the site can be chosen based on patient preference. To receive email updates about this page, enter your email address: We take your privacy seriously. Assemble medication, non-sterile gloves, syringes, needles, and sharps container. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Injectable immunobiologics should be administered where local, neural, vascular, or tissue injury is unlikely. Pretreatment (30-60 minutes before injection) with a 5% topical lidocaine-prilocaine emulsion might decrease the pain of vaccination by causing superficial anesthesia (43-44). Aspiration refers to the action of pulling back on the plunger for 5 seconds prior to injecting medication (Ipp, Sam, & Parkin, 2006). 17. You may repeat the injection every 5 to 10 minutes as needed. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them. Assess the patient for specific contraindications to receiving IM injections and advise the practitioner accordingly. Recent research has found that there is no evidence to support the practice of aspiration, but despite policy changes, the procedure of aspiration continues to be taught and practised (Canadian Agency for Drugs and Technologies in Health, 2014; Greenway, 2014; Sepah, Samad, & Altaf, 2014; Sisson, 2015). For injection dosage form: For pain: Adults (patients 16 years of age and older)15 or 30 mg, injected into a muscle or a vein four times a day, at least 6 hours apart. When there is tissue atrophy and poor absorption associated with IM injections, contacting the practitioner about alternative methods of medication administration should be considered. and I've been using various different books I've borrowed from friends to study. Thanks. Review medication reference information pertinent to the medications action, purpose, onset of action and peak action, normal dose, and common side effects and implications. The tip should be inserted slightly into the naris before administration. Rot In M.J. Hockenberry, C.C. To locate this area, lay three fingers across the deltoid muscle and below the acromion process. In addition, any factors that impair blood flow to the local tissue will affect the rate and extent of drug absorption. This muscle is located on the anterior lateral aspect of the thigh and extends from one hands breadth above the knee to one hands breadth below the greater trochanter. The ventrogluteal site is a safe injection site for adults and children receiving irritating or viscous solutions and is the site of choice for administering IM injections to adults. Vaccine recommendations and guidelines of the ACIP: Vaccine administration. WebFaro particip en la Semana de la Innovacin 24 julio, 2019. (2023). https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html, https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jan2023.pdf, https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=16265, https://www.cdc.gov/vaccines/pubs/pinkbook/safety.html, https://www.cdc.gov/vaccines/hcp/admin/admin-protocols.html, https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html. Data source: Centers for Disease Control, 2013, 2015; Perry et al., 2014. Even if the person coughs or sneezes immediately after administration or the dose is expelled any other way, the vaccine dose need not be repeated (5). Older adults and thin patients may only tolerate up to 2 ml in a single injection.