MANUEL V. GALLEGO FOUNDATION COLLEGES, INC.

INSTITUTE OF NURSING AND ALLIED HEALTH SCIENCES

NCM-105 PHARMACOLOGY

BSN-2

Parenteral Administration
Intradermal, Subcutaneous, and Intramuscular Routes
OBJECTIVES

1. Describe the technique that is used to administer a medication via the intradermal route.

2. List the equipment needed and describe the technique that is used to administer a medication via the
subcutaneous route.

3. Describe the technique used to administer medications intramuscularly.

4. Describe the landmarks that are used to identify the vastus lateralis muscle, the rectus femoris
muscle, the ventrogluteal area, and the deltoid muscle sites before medication is administered.

5. Identify suitable sites for the intramuscular administration of medication in an infant, a child, an adult,
and an older adult.

Administration of Medication by the Intradermal Route

1|Page
Perform premedication assessments; see individual drug monographs for details.

Equipment

• Medication to be injected or solutions of suspected allergens

• Tuberculin syringe with 26-gauge, -inch, or 28- gauge, -inch needle, or a special needle and syringe for
allergens

• Metric ruler, if performing skin-testing procedure

• Gloves

• Record for charting data about the substances applied and the patient's responses

• Antiseptic alcohol wipe

• Prescriber's order or medication profile

Sites

Intradermal injections may be made on any skin surface, but the site should be hairless and receive little
friction from clothing. The upper chest, the scapular areas of the back, and the inner aspect of the
forearms are the most commonly used areas (Fig. 10.2A and B).

2|Page
Technique

This example of an intradermal injection technique involves allergy sensitivity testing. Two methods can
be used to administer allergy testing. One method requires the intradermal injection of the allergens;
the other is completed by using the skin prick method.

CAUTION: Do not start any type of allergy testing unless emergency equipment (including epinephrine)
is available in the immediate area in case of an anaphylactic response. Nurses should be familiar with
the procedure to follow if an emergency does arise.

1. Follow the procedure protocol in Chapter 9 (see Preparation of Parenteral Medication).

2. Verify the identity of the patient using two identifiers.

3. Check with the patient before starting the testing to ensure that he or she has not taken any
antihistamines or anti- inflammatory agents (e.g., aspirin, ibuprofen, corticosteroids) and that he or she
has not received immunosuppressant therapy for 24 to 48 hours before the tests. If the patient has
taken antihistamines, certain sleep medications (e.g., doxylamine, diphenhydramine), or anti-
inflammatory agents, check with the healthcare provider before proceeding with the testing.

4. Provide for patient privacy.

5. Perform hand hygiene and apply clean gloves.

6. Cleanse the area selected for testing thoroughly with an antiseptic alcohol wipe. Use circular motions,
starting at the planned site of injection and continuing outward in circular motions to the periphery.
Allow the area to air-dry.

Intradermal Injection Method

• Prepare the designated solutions for injection using aseptic technique. Usual volumes to be injected
range between 0.01 and 0.05 mL. A positive-control solution that contains histamine and a
negativecontrol solution that contains saline or the diluent of the allergen are also administered.

• Insert the needle at a 15-degree angle with the needle bevel upward. (NOTE: There is a controversy
regarding whether the needle bevel should be upward or downward. Check the procedure manual for
facility policy.) The solution being injected is deposited in the space immediately below the skin; remove
the needle quickly. A small bleb will appear on the surface of the skin as the solution enters the
intradermal area (see Fig. 10.1). Be careful not to inject into the subcutaneous space and do not wipe
the site with alcohol after injection.

• Do not recap any needles that have been used. Activate the safety device if on the syringe. Dispose of
used needles and syringes into a puncture-resistant needle disposal container in accordance with
institutional policy.

Skin Prick Test Method

• Make a grid of at least four squares, more if needed, on the test site at 2-cm intervals with a pen.

• Place a drop of each allergen in one of the grid squares of the testing site. A positive-control solution
that includes histamine and a negative-control solution that includes saline or the diluent of the allergen
are also administered.

3|Page
• Using a lancet with a 1-mm point, prick the skin through the allergen drop. Wipe the lancet with dry
gauze between each prick to prevent the carryover of the allergen from the previous site.

• Gently blot the excess allergen off of the site.

• The skin prick test can be read 10 to 20 minutes after administration, depending on protocol.

7. Remove gloves and dispose of them in accordance with institutional policy. Perform hand hygiene.

8. Chart the times, agents, concentrations, and amounts administered (see Fig. 10.2C). Make a diagram
in the patient's chart, and number each location. Record what agent at what concentration was injected
at each site. (Subsequent readings of each area are then performed and charted on this record.)

9. Follow the directions regarding the time of the reading of the skin testing being performed. The
inspection of the injection sites should be performed in good light. Generally, a positive reaction (i.e.,
the development of a wheal) to a diluted strength of a suspected allergen is considered clinically
significant. Measure the diameter of the wheal and any erythema (i.e., redness at the site of injection) in
millimeters, and palpate and measure the size of any induration (i.e., the hardening of an area of the
body in response to inflammation). No reaction to the allergens, especially to the positive control, is
known as an anergic reaction. Anergy is associated with immunodeficiency disorders.

10. Record the information from the skin test reading in the patient's chart. The following is a list of
commonly used readings of reactions and their appropriate symbols:

Generally, a positive reaction to delayed hypersensitivity skin testing (to evaluate in vivo cell-mediated
immunity) requires an induration of at least 5 mm in diameter.

Patient Teaching

1. For intradermal injections, tell the patient the time, date, and place to return to have the test sites
read.

2. Tell the patient not to wash or scrub the area until the injections have been read.

3. If the patient develops an area of severe burning or itching, he or she should try not to scratch it. Tell
the patient to report immediately the development of any breathing difficulty, severe hives, or rashes
and to go to the nearest emergency department if he or she is unable to reach the healthcare provider
who prescribed the skin tests.

Documentation

Provide the right documentation of the allergen testing sites and the patient's responses to the allergens
that were injected.

1. Chart the date, time, allergens (including agent, concentration, and amount), and site of
administration (see Fig. 10.2).

4|Page
2. Perform a reading of each site after the application of the test as directed by the healthcare provider
or the policy of the healthcare agency.

3. Chart and report any signs and symptoms of adverse allergen effects.

4. Perform and validate essential patient education about the testing and other essential aspects of
intervention for the allergy that is affecting the individual.

Administration of Medication by the Subcutaneous Route

Subcutaneous (subcut) injections are made into the loose connective tissue between the dermis and the
muscular layer (Fig. 10.3). Absorption is slower and drug action is generally longer with subcut injections
as compared with intramuscular (IM) or intravenous (IV) injections. If the patient's circulation is
adequate, then the drug is completely absorbed from the tissue.

Many drugs cannot be administered by this route because ordinarily no more than 2 mL can be
deposited at a subcut site. The drugs must be quite soluble and potent enough to be effective in a small
volume without causing significant tissue irritation. Drugs commonly injected into the subcut tissue are
heparin, enoxaparin, and insulin.

Perform premedication assessments; see individual drug monographs for details.

Equipment

• Medication to be injected

• Syringe of correct volume

• Needle of correct length and gauge

• Gloves

• Antiseptic alcohol wipe

• Prescriber's order

5|Page
• Medication profile

Syringe Size

Choose a syringe that corresponds with the volume of drug to be injected at one site. The usual amount
injected subcutaneously at one site is 0.5 to 2 mL. Correlate the syringe size with the size of the patient
and the tissue mass.

Needle Length

Assess each patient so that the needle length selected will deposit the medication into the subcut tissue
rather than the muscle tissue. Needle lengths of 3/8, ½, and 5/8 inch are routinely used. It is prudent to
leave an extra inch of needle extending above the skin surface in case the needle breaks.

Needle Gauge

Commonly used gauges for subcut injections are 25 to 29 gauge.

Sites

Common sites used for the subcut administration of medications include the upper arms, the anterior
thighs, and the abdomen (Fig. 10.4). Less common areas are the buttocks and the upper back or scapular
region.

A plan for rotating injection sites should be developed for all patients who require repeated injections
(see Fig. 10.4). The anterior view (see Fig. 10.4B) illustrates areas that are easily accessible for self-
administration. The posterior view (see Fig. 10.4A) illustrates less commonly used areas that may be
used by a caregiver who is injecting the medication into the patient.

When administering insulin subcutaneously, it is important to rotate the injection sites to prevent
lipoatrophy or lipoatrophy, which slows the absorption rate of the insulin. The American Diabetes
Association Clinical Practice Recommendations state that insulin injection sites should be rotated
systematically within one area before progressing to a new site for injection (see Fig. 10.4B); it is

6|Page
thought that this will decrease variations in insulin absorption. Absorption is known to be fastest when
the insulin is administered in the abdomen; this is followed by the arms, thighs, and buttocks. Because
exercise is also known to affect the rate of insulin absorption, site selection should take this factor into
consideration.

Technique

1. Follow the procedure protocol in Chapter 9 (see Preparation of Parenteral Medication).

2. Verify the identity of the patient using two identifiers. Ensure that the patient does not have an
allergy to the medication.

3. Check the accuracy of the drug order against the medication being prepared at least three times
during the preparation phase: (1) when first removing the drug from the storage area, (2) immediately
after preparation, and (3) immediately before administration.

4. Consult the master rotation schedule for the patient so that the drug is administered at the correct
site.

5. Explain carefully to the patient what to expect.

6. Provide for the patient's privacy and position the patient appropriately.

7. Perform hand hygiene and apply clean gloves.

8. Expose the selected site and locate the landmarks.

9. Cleanse the skin surface with an antiseptic alcohol wipe starting at the injection site and working
outward in a circular motion toward the periphery. Allow the area to air-dry.

10. Check the site of injection and the length of the needle. Assess whether the injection is most
appropriately administered at a 45- to 90-degree angle for subcutaneous delivery.

11. Insert the needle quickly at a 45- to 90-degree angle; slowly inject the medication. The American
Diabetes Association Clinical Practice Recommendations state that “thin individuals or children may
need to pinch the skin and inject at a 45-degree angle to avoid IM injection, especially in the thigh area.”

12. Withdraw the needle. Gentle pressure may be applied to the site with an antiseptic alcohol wipe,
but do not rub.

13. Do not recap any needles that have been used. Activate the safety device. Dispose of used needles
and syringes into a puncture-resistant needle disposal container in accordance with institutional policy.

14. Remove gloves and dispose of them according to facility policy. Perform hand hygiene.

Patient Teaching

Perform appropriate patient teaching as described in the related drug monographs. Documentation
Provide the right documentation of the medication administration and the patient's response to drug
therapy.

1. Chart the date, time, drug name, dose, site, and route of administration.

7|Page
2. Perform and record regular patient assessments for the evaluation of the therapeutic effectiveness
(e.g., blood pressure, pulse, output, improvement or quality of cough and productivity, degree and
duration of pain relief).

3. Chart and report any signs and symptoms of adverse drug effects.

4. Perform and validate essential patient education about the drug therapy and other essential aspects
of intervention for the disease process that is affecting the individual.

Administration of Medication by the Intramuscular Route

Intramuscular injections are made by penetrating a needle through the epidermis, dermis, and subcut
tissue into the muscle layer. The injection deposits the medication deep within the muscle mass (Fig.
10.5). Absorption is more rapid than that associated with subcut injections because muscle tissue has a
greater blood supply. Site selection is especially important with IM injections because the incorrect
placement of the needle may cause damage to nerves or blood vessels. Complications from improper
technique of IM injections include hematoma (when a vein is punctured) and pain (when a nerve is
touched). A large, healthy muscle that is free from infections and wounds should be used.

Equipment

• Medication to be injected

• Syringe of correct volume

• Needle of correct length and gauge

• Gloves

• Antiseptic alcohol wipe

8|Page
• Prescriber's order

• Medication profile

Syringe Size

Choose a syringe that corresponds with the volume of drug to be injected at one site. The usual amount
injected intramuscularly at one site is 0.5 to 3 mL. In infants and children the amount should range
between 0.5 and 1 mL, and it should not exceed 1 mL. Correlate the syringe size with the size of the
patient and the tissue mass. In adults, divided doses are generally recommended for amounts in excess
of 3 mL; 1 mL is the maximum amount to be injected in the deltoid area. Other factors that influence
syringe size and needle gauge include the type of medication, the site of administration, the thickness of
the subcut fatty tissue, and the age of the individual.

Needle Length

Assess each patient so that the needle length selected will deposit the medication into the muscular
tissue (see Fig. 10.5). There is a significant difference among the needle lengths that are appropriate for
an obese patient, an infant, or an emaciated or debilitated patient. Needles that are commonly used are
1 to ½ inches long, although longer lengths may be required for obese patients. Needle Gauge
Commonly used gauges for IM injections are 20 to 23 gauge.

Sites

Vastus Lateralis Muscle

The vastus lateralis muscle is located on the anterior lateral thigh, away from nerves and blood vessels
(Fig. 10.6). The midportion is one handbreadth below the greater trochanter and one handbreadth
above the knee (see Fig. 10.6B). This is generally the preferred site for IM injections in infants because it
has the largest muscle mass for that age group. This muscle is also a good choice for an injection site in
healthy, ambulatory adults. It accommodates a large volume of medication, and it allows for good drug
absorption. In the older, debilitated, or non - ambulatory adult, the muscle should be carefully assessed
before injection because significantly less muscle mass may be present. If muscle mass is insufficient, an
alternative site should be selected.

9|Page
Rectus Femoris Muscle

The rectus femoris muscle (Fig. 10.7) lies just medial to the vastus lateralis muscle, but it does not cross
the midline of the anterior thigh. The injection site is located in the same manner as is used for the
vastus lateralis muscle. This muscle may be used in both children and adults when other sites are
unavailable. A primary advantage to its use is that it may be used more easily by patients for self-
administration. A disadvantage is that the medial border is close to the sciatic nerve and major blood
vessels (see Fig. 10.7). If the muscle is not well developed, injections into this site may also cause
considerable discomfort and potential injury.

Life Span Considerations

Injection Sites

• The vastus lateralis site is preferred in infants. In the older, debilitated, or non-ambulatory adult,
carefully assess the sufficiency of the muscle mass before using this site for injection.

• The ventrogluteal site is also appropriate for infants and adults, and it may be used as often as needed
because of the convenience of the thigh muscle.

• The deltoid site is preferred when administering 1 mL or less because of the convenience of the arm
muscle.

Gluteal Area

The gluteal area is a commonly used site of injection because it is free of major nerves and blood
vessels. The dorsogluteal area must not be used in children who are less than 3 years old because the
muscle has not yet been well developed from walking. The ventrogluteal area is an appropriate site for

10 | P a g e
injections in children who are less than 3 years old; however, this site is not used as often as the vastus
lateralis muscle because of the convenience of the that muscle. The area may be divided into two
distinct injection sites: (1) the ventrogluteal area and (2) the dorsogluteal area.

Ventrogluteal area.

The ventrogluteal area is easily accessible when the patient is in a prone, supine, or side-lying position. It
is located by placing the palm of the hand on the lateral portion of the greater trochanter with the
thumb pointing toward the groin, the index finger on the anterior superior iliac spine, and the middle
finger extended to the iliac crest. The injection is made into the center of the “V” that is formed
between the index and middle fingers, with the needle directed slightly upward toward the crest of the
ilium (Fig. 10.8). Pain on injection can be minimized if the muscle is relaxed. The patient can help with
this relaxation by pointing the toes inward while lying in a prone position (Fig. 10.9) or by flexing the
upper leg if lying on his or her side (Fig. 10.10).

11 | P a g e
Dorsogluteal area

The use of this site is discouraged and not practiced to any great extent because of the possible damage
to the sciatic nerve.

Deltoid Muscle

The deltoid muscle is often used because of the ease of access to this area when the patient is in the
standing, sitting, or prone position. However, it should be used in infants only when the volume to be
injected is small, the drug is nonirritating, and the dose will be quickly absorbed. In adults, the volume
should be limited to 1 mL or less and the substance must not cause irritation. Caution must also be
exercised to avoid the clavicle, the humerus, the acromion, the brachial vein and artery, and the radial
nerve. The injection site (Fig. 10.11) of the deltoid muscle is located by palpating the acromion process
or top of the shoulder and measuring down two to three fingerbreadths. It is advisable to palpate the
muscle of the deltoid, which is roughly triangular in shape, to determine the thickest part of the muscle,
which will then be the area for the injection.

12 | P a g e
Site Rotation A master plan for site rotation should be developed and used for all patients who require
repeated injections (Fig. 10.12).

13 | P a g e
Technique

Standard Method

1. Follow the procedure protocol in Chapter 9 (see Preparation of Parenteral Medication).

2. Verify the identity of the patient using two identifiers. Ensure that the patient does not have an
allergy to the medication.

3. Check the accuracy of the drug order against the medication being prepared at least three times
during the preparation phase: (1) when first removing the drug from the storage area, (2) immediately
after preparation, and (3) immediately before administration.

4. Calculate and draw up the medication. Check the institutional policy regarding whether 0.1 or 0.2 mL
of air should be added to the syringe after accurately measuring the prescribed volume of drug for
administration. (NOTE: The rationale for adding the air is that it will result in the needle being
completely cleared of all medication at the time of injection. Conversely, if the volume is completely
drawn into the syringe before changing the needle, then the drug volume ordered will still be
administered as long as the same size needle is used for drawing up and injection. Thus the needle
should not need to be completely cleared of medication by air during administration. This issue can be
critical when small volumes of potent drugs are repeatedly administered to infants.)

5. Consult the master rotation schedule for the patient so that the drug is administered at the correct
site (see Fig. 10.12).

6. Explain carefully to the patient what will be done.

14 | P a g e
7. Provide for the patient's privacy; position the patient appropriately (see Figs. 10.9 and 10.10 for
relaxation techniques).

8. Perform hand hygiene and apply clean gloves.

9. Expose the selected site and locate the landmarks.

10. Cleanse the skin surface with an antiseptic alcohol wipe starting at the injection site and working
outward in a circular motion toward the periphery. Allow the area to air-dry.

11. Using the nondominant hand, spread the skin and hold down to push subcut tissue away and allow
greater needle penetration.

12. Insert the needle at a 90-degree angle using a quick, dart-throwing action.

13. Inject the medication using gentle, steady pressure on the plunger and wait for a count of 3 before
removing the needle. This will ensure that all the medication has been delivered. (NOTE: The need to
aspirate before injection is no longer practiced; it has been found to cause more damage and is
considered unnecessary.)

14. After removing the needle, apply gentle pressure to the site. Massage can increase the pain if the
muscle mass is stressed by the amount of medication given.

15. Do not recap any needles that have been used. Activate the safety device. Dispose of used needles
and syringes into a puncture-resistant needle disposal container in accordance with institutional policy.

16. Apply a small bandage to the site.

17. Provide emotional support to the patient. Children should be comforted during and after the
injection. Sometimes letting a child hold your hand or say “ouch” helps. Praise the patient for his or her
assistance and cooperation. 18. Remove gloves and perform hand hygiene.

Z-Track Method

The use of a Z-track method (Fig. 10.13) may be appropriate for medications that are particularly
irritating or that stain the tissue. Check facility policy regarding which personnel may administer
medications using this method.

15 | P a g e
1. Provide for the patient's privacy; position the patient appropriately.

2. Perform hand hygiene and apply clean gloves.

3. Expose the ventrogluteal site or vastus lateralis site (Fig. 10.13A). Never inject into the patient's arm.

4. Calculate and draw up the medication; add 0.5 mL of air to ensure that the drug will clear the needle.

5. Cleanse the skin surface with an antiseptic alcohol wipe starting at the injection site and working
outward in a circular motion toward the periphery. Allow the area to air-dry.

6. Stretch the patient's skin approximately 1 inch to one side (Fig. 10.13B).

7. Insert the needle. It is important to choose a needle of sufficient length to ensure deep muscle
penetration.

8. Gently inject the medication and then wait approximately 10 seconds (Fig. 10.13C).

9. Remove the needle and allow the skin to return to its normal position (Fig. 10.13D).

10. Do not massage the injection site.

11. If further injections are to be made, alternate among sites per the master rotation schedule.

16 | P a g e
12. Do not recap any needles that have been used. Dispose of used needles and syringes into a
puncture-resistant needle disposal container in accordance with institutional policy.

13. Remove gloves and dispose of them according to facility policy. Perform hand hygiene.

14. Teach the patient that walking will help with the medication's absorption. Vigorous exercise or
pressure on the injection site (e.g., tight-fitting clothing) should be temporarily avoided.

Patient Teaching

Perform appropriate patient teaching as described in related drug monographs.

Documentation

Provide the right documentation of the medication administration and the patient's response to drug
therapy.

1. Chart the date, time, drug name, dose, site, and route of administration.

2. Perform and record regular patient assessments for the evaluation of the therapeutic effectiveness
(e.g., blood pressure, pulse, output, improvement or quality of cough and productivity).

3. Chart and report any signs and symptoms of adverse drug effects.

4. Perform and validate essential patient education about the drug therapy and other essential aspects
of intervention for the disease process that is affecting the individual

17 | P a g e