Administering Drugs by Injection Handout

INJECTIONS AND
IMMUNIZATIONS
CERTIFICATE
PROGRAM
Administering Drugs by Injection
Christine Knapp RN, MScN

SE Health, Education Liaison
Injections and Immunizations Certificate Program

Disclosures
Presenter Disclosure Commercial Disclosure

• Presenter’s Name: • This program has
Christine Knapp received no financial or
in-kind support from any
• I am a current/past commercial or other
Employee of SE Health organization
• SE Health received a
speaker’s fee from OPA
for this learning activity

Learning Objectives
At the end of this presentation, participants will be able to:
1. Describe injection techniques and considerations,
advantages and limitations using the intramuscular
(IM), subcutaneous (SC) and intradermal (ID) routes
2. Identify the supplies required for delivering injections
(syringes, needles, disposal, documentation, etc.)
3. Demonstrate an understanding of how to manage
challenging patients (fearful, nervous)
4. Demonstrate an ability to provide teaching to patients
for self-administered injections
5. Describe emergency situations and their management

Routes
• Parenteral drugs can be administered through four
different routes:
– Intradermal (ID) injection: injection into the
dermis just below the epidermis
– Subcutaneous (SubCut) injection: injection into
tissues just below the dermis of the skin
– Intramuscular (IM) injection: injection into the
body of a muscle
– Intravenous (IV) injection: administration of a
solution into a vein

Common Themes for All
Parenteral Medications
• Infection control • Right vaccine
practices • Right client
• Right dose
• Patient specific
• Right time
needs
• Right route
• Documentation • Right reason
protocols • Right documentation
• Emergency
management

Considerations
• Failure to inject a medication correctly can result
in complications such as:
– A drug response that is too rapid or too slow
– Nerve injury with associated pain
– Localized bleeding
– Tissue necrosis
– Sterile abscess

Infection Control Practices

Covid – 19 and Hand Washing
• Gloves and permeability
• Washing with sanitizer
• Washing with soap and water
For further resources:

https://www.publichealthontario.ca/en/health-topics/infection-prevention-control/hand-hygiene

Other Covid – 19 Practices
• Physical Distancing
• Personal Protective Equipment
• Screening and Reporting
For further resources:

https://www.opatoday.com/professional/resources/for-pharmacists/tools-and-forms/coronavirus-2

Infection Control Practices
• To protect your client from opportunistic infections,
follow these procedures:
– Hand washing - reduce the transfer of
microorganisms
– Prevent contamination of the solution
– Prevent contamination of the needle
– Properly prepare the skin for the injection

Preparation
• Ensure that you have read the product monograph and are
familiar with medication specific equipment and injection
recommendations
• Confirm the client’s name, drug, dose, time the medication
is to be given, and the route of administration
• Explain what you will be doing and why – allay fears (more
on this later)
• If appropriate, provide privacy
• Provide education on pain management before and on day
of immunization
• Perform hand hygiene
• Apply disposable gloves

Syringes
• Parenteral medications are delivered to a client by
using a syringe and needle. Needles and syringes
come in a variety of sizes. It is important for you to
determine the appropriate size of syringe and length
of needle to use based on:
– The type of medication to be given
– The volume of solution to inject
– The route of the injection
– The client's body size

Syringes
• A syringe consists of a cylindrical barrel, a tip
designed to fit the hub of a hypodermic
needle, and a plunger
• The tips of a syringe are classified as non–
Luer-lok or Luer-lok
– Non-Luer-lok syringe: needle that slips onto the
tip
– Luer-lok syringe: needle twists onto the tip and
locks into place

Parts of Syringe

Needles
• Needles are made of stainless steel and consist of three
parts:
– Hub (which fits onto the syringe tip)
– Shaft
– Bevel (the slanted part at the tip of the needle)
• The shaft and bevel are the parts of the needle that
must remain sterile

Needles
• Gauge – diameter of shaft
– Viscosity of fluid
• Length – 4 mm (5/32”) to ~76 mm (3”)
– Type of injection and site selection
• Long-beveled tips are sharper and
narrower, which decrease client discomfort
during SC and IM injections

Needle Examples

Reconstitution
• The process of adding diluent to the medication
• Note date of expiry and lot number of the diluent and the powder
being reconstituted
• Use recommended diluent for product (sterile water, normal
saline, product-specific)
• Use recommended amount of diluent
• Use aseptic technique
• Insert syringe at 45° angle to vial to reduce risk of coring
• Document expiry date for reconstituted solution by labelling vial
• Follow directions from manufacturer identified within product
monograph (e.g. shake well or shake gently)
• Refer to Canadian Immunization Guide for more information
specific to the reconstitution of vaccines

Routes of Administration

Needle Selection
Type of Injection Needle Gauge Needle Length Volume
Intradermal (ID) 26-27 ~10 mm (3/8”) 0.1-0.3 mL
Subcutaneous 25-27 10 mm -16 mm 0.1-1.0 mL

(SubCut) 28-32 (insulin) (3/8”-5/8”)
Insulin =
4 mm-12.7 mm
(3/16”-1/2”)
Intramuscular 22-27 16 mm -76 mm 0.1-3.0 mL
(IM) (5/8”-3”)

Intradermal Injections
• Usually for skin testing
• Primary uses are for tuberculin (TB) and allergy testing
• The 1 mL syringe (25 g – 5 mm (½ inch)) holds 1 mL and is
calibrated in 0.1 to 0.01 mL
• 3 fingers below antecubital fossa and 1 hand above wrist
• Inner aspect of the forearm - test results are easily seen
• Inserted bevel upward at a 10 to 15 degree angle
• Insert needle only about 1/8” with entire bevel under the
skin
• Do not aspirate
• Read 48 to 72 hours after the intradermal injection- a
reddened or raised area indicates a positive reaction

Preparation
• You need to have the following items:
– 1-mL syringe
– 26- or 27-gauge needle
– Small gauze pad or cotton ball
– 2 alcohol swabs
– Vial of skin test solution
– Disposable gloves
– Medication record

Outcomes
• Client experiences mild burning sensation during injection
without discomfort after the injection – normal reaction
• Small, light-coloured bleb approximately 6 mm (one quarter
of an inch) in diameter forms at the site and gradually
disappears
• Minimal bruising may be present – minor bleeding from
capillaries
• The client is able to identify signs of a skin reaction and
their significance
• A positive test > 10 mm

Injection Technique
http://upload.wikimedia.org/wikipedia/commons/f/fa/Mantoux_tuberculin_skin_test.jpg

Positive TB Test Result
http://www.uthsc.edu/pulmonary/pathophysiology/TB

Complications
• Assess client for possible allergies prior to administration
• After administration – remain with client to observe for reaction
• Emergency medical attention may be required
• Due to the nature of the injection, it is important to monitor for:
– Rash
– Itching
– Dizziness
– Difficulty breathing
– Discomfort
– Tightness in chest
– Wheezing

Subcutaneous (SC) Injections
• Medication into the loose connective tissue under the dermis
• Poorly supplied with blood vessels - medication absorption is
slower than that of an IM injection (except heparin, which is
quickly absorbed)
• Anything that affects local blood flow to tissues may alter drug
absorption:
– Physical exercise
– Application of a heat/cold compress
• Contains pain receptors - client may experience some burning
discomfort

• Only small doses of medication (up to 1 mL) should be
given subcutaneously: 45 – 90 degrees angle
• Very sensitive to irritating solutions and large volumes
of medication
• Do not need to aspirate as unlikely to enter a blood
vessel
• Examples of SC injections include insulin, LMWH,
MMR, meningococcal polysaccharide, varicella and
zoster, and vitamin B12

• Types of syringes used for subcutaneous injection
– 1 mL syringe, which is calibrated in 0.1 and 0.01 mL,
– Insulin syringe (generally 100 U – 1 mL) for insulin administration
calibrated in 0.1 and 0.01 units (U)
– 3 mL syringe, which is calibrated in 0.1 mL
• Needle gauge
– 25 or 26 gauge
– 28-32 (insulin)
• Length
– 10 mm - 16 mm (3/8 to 5/8”)
– 4 mm - 12.7 mm (3/16 to ½” - insulin)

Subcutaneous (SC) Injection
http://www.bd.com/resource.aspx?IDX=25063

Site Selection
• Free of infection, skin lesions, bony
prominences, and large underlying muscles or
nerves
• Choice of needle length and angle of needle
insertion
– 25 – 32 gauge, 3 mm – 10 mm (3/16” - 3/8”): 90 degrees
– 25 – 27 gauge, 10 mm – 16 mm (3/8” - 5/ 8”): 45 degrees
– For a child – consider using a shorter needle (3-10 mm)

Site Selection
• Obese client – the amount of adipose tissue on a
client's body does NOT necessarily alter the
technique, but suggest:
– Gently bunch and hold or spread the tissue and use needle long
enough to insert into the SC tissue
– 25 – 27 gauge, 10 mm – 16 mm (3/8” - 5/8”): 45 – 90 degrees
• Thin or cachectic clients:
– Gently bunch and hold the skin and inject the SC medication at a
45-degree angle
• Ensure site rotation

Sites for SC Injections

Preparation
• Review the client's medical history, history of allergies, diet,
and medication histories
• Current foods and medications that the client is receiving
may cause a drug interaction
• History of factors that may contraindicate a SC injection
(e.g. reduced local tissue perfusion such as with scar
tissue)
• Assess the client's knowledge regarding the medication
• Observe the client's verbal and nonverbal responses
toward receiving the injection

Preparation
• In preparation for giving a SC injection, you need to have
the following items:
– Syringe (1 to 3 mL)
– For precise dose, a 1 mL syringe
– Needle (25 to 27 gauge, 10 mm – 16 mm [3/8” – 5/8”])
– Small sterile gauze pad (optional) or cotton ball
– Bandage
– 2 alcohol swabs
– Vial or ampoule of medication (*if amp – need a filter needle to
draw up medication)
– Medication administration record

Outcomes
• Expected outcomes after completion of the
procedure include:
– Mild burning at the injection site – normal
– Effect of the medication is achieved without
signs of allergies or undesired effects
– The client understands the purpose, dosage,
and effects of the medication

Complications
• The client may experience a vasovagal
response to the injection
• The client may develop the following signs of an
allergic reaction:
– Urticaria
– Eczema
– Pruritus
– Wheezing
– Dyspnea

Intramuscular (IM) Injection

Intramuscular (IM) Injection
• Placing medication into deep muscle tissue
• IM route provides faster medication absorption – greater
vascularity
• Absorbed in 10 to 30 minutes, as opposed to at least 30
minutes for a SC injection
• Less danger of tissue damage from an IM injection as compared
with a SC injection
• IM route poses a risk of medication being inadvertently injected
directly into a blood vessel (especially ventrogluteal)
• Immunizations given by the IM route include tetanus and
diphtheria, Tdap, inactivated influenza, pneumonoccal
polysacchride, meningococcal conjugate, hepatitis A & B, IPV,
Hib and combination vaccines

IM Injection

Needle Selection
• To penetrate deep muscle tissue a standard 25mm
(1”) needle is used for the average adult*
• Clinical judgment should be used when selecting
needle length for IM injections as consideration
should be given to vaccine recipient’s weight,
gender and age
– Males weighing >260lbs (118kg) and females weighing
>200lbs (90kg) - 38 mm (1½ inch)
* Males weighing 130-260 lbs (60-118kg) and females weighing 130-200 lbs (60-90kg)
Canada Immunization Guide (2018) https://www.canada.ca/en/public-health/services/canadian-immunization-guide.html

Needle Selection
• IM injections can deliver larger volumes (up to 3
mL)
– Older infants and children under the age of 2 years
can receive up to 1 mL
• IM injections should be administered at a
90o angle.
• The skin should be stretched flat (between
thumb and forefinger) at the time of
administration.
Canada Immunization Guide (2018) https://www.canada.ca/en/public-health/services/canadian-immunization-guide.html

Site Selection
• Select site - free from infection, necrosis,
bruising, and abrasions
• Must be aware of bony landmarks and the
location of underlying nerves and major
blood vessels - it is important to choose
the correct injection site to prevent nerve
damage

Site Selection
• Three common sites are chosen for IM injections:
– Ventrogluteal muscle is the preferred injection site for
toddlers over 18 months and adults
– Vastus lateralis muscle are situated away from major
nerves and blood vessels. The vastus lateralis is the
preferred site for infants receiving immunizations and may
also be used for toddlers, older children, and adults
– Deltoid muscle is used only for small medication volumes
(0.5 to 1 mL) or when other sites are inaccessible. It is the
recommended site for hepatitis B vaccine and rabies
immune globulin and vaccine injections

Ventrogluteal Site
• The ventrogluteal site is the preferred site for adults and for
children over age 18 months
• Infants over age 7 months may also receive large volumes of
immune globulin injections at this site; it is considered the
safest of all the sites because the muscle is deep and away
from major blood vessels and nerves
• In general, the total volume for an IM injection is
– 3 mL in adults of average weight. Volumes in excess of 3 mL
should be administered in divided doses at different sites.
– Infants (birth to 1 year) is 0.5 mL
– Children 1–2 years, 1 mL
– Children 2–12 years, 2 mL

Ventrogluteal Site
• Not practical for an open setting where privacy
may not be possible
• Requires the client to lower or remove
undergarments and to be in a laying position

Ventrogluteal Site
• With the palm of your hand, locate the greater trochanter
of the femur
• Spread your index and middle fingers posteriorly from
the anterior superior iliac spine to the furthest area
possible
• Insert the needle at a 90 degrees angle
http://books.mcgraw-hill.com/medical/NursesDrugHandbook/safe_drug_admin/identifying_injection_sites/IdentifyingInjectionSites.php

Ventrogluteal Site
Sitehttps://evolve.elsevier.com/objects/elr/Canada/Lilley/pharmacology2e/IC/images/010053.jpg

Vastus Lateralis (Leg)
• Good choice for infants and children
• May be appropriate for some adults
Adult Toddler

Vastus Lateralis (Leg)
• Muscle is well developed and not located near major
nerves or blood vessels – preferred for infants under 18
months of age
• The client may be sitting or lying supine; if supine, have the
client bend the knee of the leg in which the injection will be
given
• To find the correct site of injection
– Place one hand above the knee and one hand below the greater
trochanter of the femur
– Locate the midline of the anterior thigh and the midline of the
lateral side of the thigh
– The injection site is located within the rectangular area

Deltoid Site

Deltoid
• The deltoid injection site is easily accessible but
should only be used for small volumes of
medication (0.5 to 1 mL)
• Assess the site carefully – this muscle may not
be well developed in some adults
• The client may be
– sitting or lying down
– remove clothing to expose the upper arm and shoulder - tight-
fitting sleeves should not be rolled up
– have the client relax his or her arm and slightly bend the elbow

Deltoid
• Palpate the lower edge of the acromion process - becomes the
base of an imaginary triangle
• Place three fingers below this edge of the acromion process.
Find the point on the lateral arm in line with the axilla. The
injection site will be in the centre of this triangle, 3 finger-widths
(3 to 5 cm) below the acromion process
• In children and smaller adults:
– Gently pinch the underlying tissue together before giving the injection
and/or use a shorter needle (25mm [1”] or less)
• In larger clients:
– Gently stretch the skin and hold and/or use a longer needle (25 mm or
more – site dependant)
• To reduce anxiety, have the client look away before giving the
injection

Positioning a Child - Options
• Straddle a younger child on their parent’s lap
so that they are facing the parent and the
child’s limbs on are on each side of the
parent. The parent should embrace the child.
• Have the child sit on their parent’s lap, facing
outwards. Have the parent anchor both of the
child’s legs between their thighs and have the
parent embrace the child during the process.

Proper Influenza Vaccine
Administration Technique
 Always practice hand hygiene before and after
administration to each patient.
 Cleanse the skin with an alcohol swab.
 For all patients ≥ 5 years old, a 1’’ needle to be used
unless patient’s muscle warrants a 1 ½ ’’ needle.
 Define the site by drawing a triangle with its base at the
lower edge of the acromion and its peak above the
insertion of the deltoid muscle. The injection site is in the
centre of the triangle, which in most children and adults
would be approximately three finger widths below the
acromial process.
 The needle should be positioned at a 90 degrees angle to
the skin and administered deep into the deltoid muscle.
 The vaccine should be administered rapidly without
aspiration.
People who receive vaccines that are not administered correctly can experience
increased localized reactions and have reduced immune response to the vaccine.
Simcoe Muskoka District Health Unit: www.smdhu.org/PCPortal

Preparation
• Review the client's medical history, history
of allergies, diet, and medication histories
• Current foods and medications that the
client is receiving may cause a drug
interaction
• History of factors that may contradict an IM
injection (i.e. reduced local tissue perfusion)
• Assess the client's knowledge regarding the
medication
• Observe the client's verbal and nonverbal
responses toward receiving the injection

Preparation
• In preparation for giving an IM injection, you need to
have the following items:
– Syringe (1 to 3 mL)
– Needle (25 mm - 38 mm [1”- to 1.5”], 21 to 25 gauge)
– Small sterile gauze pad (optional)
– 2 alcohol swabs
– Bandage
– Medication administration record

Outcomes
• Expected outcomes after completion of the procedure
include:
– The client experiences temporary mild burning at the
injection site - normal
– No allergic reaction and/or undesired effects occur
– The client understands the purpose and effects of the
medication
– The client demonstrates calm and non-anxious
behaviour

Complications
• The client may experience a vasovagal response to the
injection.
• The client may develop the following signs of an allergic
reaction:
– Urticaria
– Eczema
– Pruritus
– Wheezing
– Dyspnea
• Potential complications for IM injections:
– Fibrosis
– Nerve damage
– Abscess
– Tissue necrosis
– Muscle contraction
– Gangrene
– Pain

Z-Track Injections
• Generally utilized when administering irritating
medications (i.e. iron) – prevents irritation to the
SC tissue before reaching a muscle
• When correctly administered, the Z-track leaves
a zigzag path that seals the needle track,
preventing the medication from escaping the
muscle tissue
• Can be used for all IM injections

Z-Track

Air-Lock Technique
• Decrease ‘escape’ of medication
• Draw up 0.2 mL of air and invert syringe so air rises
to top
• Inject medication and air – air becomes a stopper to
prevent medication from leaking into tissues
• Can be used in SC or IM injections
– Generally limited to vaccines, heparin, LMWH

Air-Lock Technique

Safety First

Sharps Safety
• Place sharps container beside the patient and on your
dominant side to reduce risk of needlestick injury
• Use approved rigid sharps container - Do not over-fill
• Work in well-lit areas
• Keep the exposed sharp in view
• Be aware of people around you
• Stop if you feel rushed or distracted - Focus on your
task
• Avoid hand-passing sharps and use verbal alerts when
moving sharps
• Watch for sharps in linen, beds, on the floor, or in
waste containers

Needle Stick Injuries
• The most frequent route of exposure to blood-borne
diseases is from needle-stick injuries
• To reduce this risk, use safety syringe/needles
• Have assistance when administering to children
• Keep sharps container close at hand
• Never attempt to recap a needle
• Should you accidently stick yourself with a needle,
notify Pharmacy Manager/Owner or follow facility
policy

Needle Stick Injuries
• Thoroughly rinse the injury site with running water and gently clean with
soap and water if possible
• Flush splashes to the nose, mouth, or skin with water
• Irrigate eyes with clean water, saline, or sterile irrigants
• Non-intact skin should be rinsed thoroughly
• Report the incident to your supervisor
• Immediately seek medical treatment
• Post-exposure prophylaxis treatment (if required) may need to start within 1-
2 hours of exposure
• Complete your required incident form
– See your HCP for follow-up
– You should have already had your Hepatitis vaccination
• The client – ask if they are willing to be tested for Hepatitis B & C and HIV
(they will need to see their own HCP)
CDC (2016). Emergency Sharps Information. Available at: http://www.cdc.gov/niosh/topics/bbp/emergnedl.html

Considerations
• Types of medications to administer in your
setting
• Infection control policy – hand washing
abilities
• Emergency measure guidelines
• Client comfort during procedure
• Only use safety products – they do make a
difference

Perceptions
Needle you are using Needle they think you are
using!!

Administration to Fearful Clients
• Infants and toddlers
• Children
• Adolescents
• Parents for all of the above!
• Adults

Anaphylaxis
 Anaphylaxis is an acute systemic
(whole body) type of allergic
reaction which occurs when a
person has become sensitized to a
certain substance or allergen and is
again exposed to the allergen.
 Some drugs may cause an
anaphylactoid reaction on first
exposure.
 Histamines and other substances
released into the bloodstream cause
blood vessels to dilate and tissues
to swell.
 Anaphylaxis may be life-threatening
if obstruction of the airway occurs, if
blood pressure drops, or if heart
arrhythmias occur.

Anaphylaxis – Risk Factors
• Risk factors for increased severity of anaphylaxis include:
– Very young or old age
– Pregnancy
– Asthma
– Cardiovascular disease
– Concurrent use of certain medications (i.e. angiotensin-
converting enzyme inhibitors, angiotensin receptor blockers or
beta-blockers).
Canada Immunization Guide (2016). Available at: https://www.canada.ca/en/public-health/services/publications/healthy-

living/canadian-immunization-guide-part-2-vaccine-safety/page-4-early-vaccine-reactions-including-anaphylaxis.html

Anaphylaxis
• Not common (1 out of 1,000,000)
• Life-threatening reaction that involves multiple organ
systems and can progress rapidly
• Symptoms can include:
– Generalized urticaria, wheezing, swelling of the
mouth and throat, difficulty breathing, vomiting,
hypotension, decreased level of consciousness, and
shock
– Red eyes or hoarse voice might occur

Anaphylaxis - Management
1. Assess circulation, airway, breathing, mental status, skin,
and body weight (mass). Secure an oral airway if necessary.
2. Direct someone to call 911(where available) or emergency
medical services.
3. Position the vaccine recipient on their back or in a position
of comfort if there is respiratory distress; elevate the lower
extremities.
– Place the vaccinee on their side if vomiting or unconscious.
– Pregnant anaphylactic vaccinees should be placed semi-
recumbent on their left side with their legs elevated.

Anaphylaxis - Treatment
4. Inject epinephrine intramuscularly in the mid-
anterolateral aspect of the thigh.
– Treatment with epinephrine and inhaled beta-agonists
(salbutamol)
– May also include antihistamines and corticosteroids
• ADOLESCENT or ADULT ( 13 years): maximum - 0.5 mg
• CHILD (5-12 years): maximum - 0.3 mg
– Repeat every 5 to 15 minutes as needed, for a maximum
of three doses

– Epinephrine will maintain BP, antagonize the
effects of the released mediators and inhibit
further release of mediators
– No absolute contraindications to epinephrine
and usually tolerated well
– Potentially lifesaving
delayed administration = Anaphylactic deaths

5. Stabilize vaccinee; perform
cardiopulmonary resuscitation if necessary,
give oxygen and establish intravenous
access if available and give adjunctive
treatment (i.e. diphenhydramine
hydrochloride or Benadryl®) if indicated.
6. Monitor vaccinee’s blood pressure, cardiac
rate and function, and respiratory status.
7. Transfer to hospital for observation.

• May also include antihistamines and corticosteroids.
• Antihistamines have a much slower onset of action than
epinephrine.
• Administer an H1 blocker and an H2 blocker, because studies
have shown the combination to be superior to an H1 blocker
alone in relieving the histamine-mediated symptoms.
• Diphenhydramine and ranitidine are an appropriate
combination.
• Oral or IM administration of antihistamines may be effective
for milder anaphylaxis.

Anaphylaxis - Kit
• Table of dosage recommendations for epinephrine and diphenhydramine
hydrochloride (e.g. benadryl) by age/weight
• Two vials of aqueous epinephrine 1:1000 or a range of autoinjectors of
epinephrine labelled by age and weight
• One vial of injectable diphenhydramine hydrochloride
• Injection supplies (syringes, needles, alcohol pads)
• One nasopharyngeal airway and one oropharyngeal airway for each age
range anticipated in the clinic
• Pocket mask, stethoscope and sphygmomanometer, tongue depressors,
flashlight, scissors
• Wristwatch with second hand to measure pulse
• Cell phone if no easy access to onsite phone
Canada Immunization Guide (2016). Available at: https://www.canada.ca/en/public-health/services/publications/healthy-
living/canadian-immunization-guide-part-2-vaccine-safety/page-4-early-vaccine-reactions-including-anaphylaxis.html

Urticaria
• Hives are raised red welts of
various size on the surface of
the skin, often itchy, which
come and go
• Also called urticaria, hives is
usually part of an allergic
reaction to drugs or food
• The term "dermatitis"
describes an inflammatory
response of the skin, caused
by contact with allergens or
irritants, exposure to sunlight,
or by poor circulation, even
stress

Urticaria
• Release of histamine, bradykinin, leukotriene, prostaglandin,
and other vasoactive substances from mast cells and
basophils in the dermis
• These substances cause plasma to leak into the dermis -
urticarial lesion
• The intense pruritus (itching) of urticaria is a result of
histamine released into the dermis
• Urticaria is an IgE-related (type 1) allergic reaction that may
be the first symptom of an emerging anaphylactic reaction.
• Can be an isolated event without systemic reaction or it can
be a prelude to the development of an anaphylactic reaction

Urticaria - Treatment
• Antihistamines are the primary agents used to
treat urticaria
• Diphenhydramine is effective in reducing the
lesions and pruritus
– May cause drowsiness
– Caution against driving

Urticaria - Treatment
• The efficacy of epinephrine in acute
urticaria is controversial
• If angioedema (swelling around the eyes,
hands, feet) is present with urticaria,
epinephrine should be administered via
the IM route

Fainting
• Vaso-vagal reactions
• More common in adolescent
boys than girls
• Consider if you are able to
appropriately respond to or
prevent this situation if the
client is known to have vaso-
vagal reactions
• Consider the use of lidocaine- Buzzy combines the use of cold
prilocaine cream/patch (if not and vibration to block the
contraindicated as per product sensation of the needle
monograph) procedure

Fainting - Prevention
• Reduce triggers - reduce the likelihood of an individual
fainting
• Implement measures that lower stress in those
awaiting immunization:
– Short waiting times
– Comfortable room temperature
– Preparation of vaccines out of view of recipients
• Ensure the individual has had something to eat/drink

Fainting - Prevention
• Reduce the risk of injury due to fainting:
– Patients should be immunized while seated.
– For those at risk of fainting, consider a recumbent
position.
– Educate vaccinees on avoiding unsafe activities, such
as stair climbing or driving immediately after
immunization.
– Have patient remain in the pharmacy/clinic area for
10-15 minutes

Fainting - Management
• Lay person down (recumbent position) –
prevent head injury
• Watch for vomiting, any difficulty breathing
(turn to side)
• If does not wake within 3-4 min – call 911
– Monitor for signs of anaphylaxis
• Fully recovers – tell them to contact their
primary HCP and inform them

Sterile Abscess
• Can occur with SC or IM injections
– Most common with IM
• Not an infection
• Thought to be:
– Associated with oil-based injections (i.e. penicillin)
– Liquefaction of fat cells
– Accidental injection into SC tissue vs IM
• Treated with warm compress and OTC analgesic – generally
resolves over 2 weeks
• Seek further treatment if no improvement after 2 weeks or
signs of infection (redness, heat, drainage)

Case Study #1
Your client is a 10 yr old male who has come in
with a parent for his flu vaccine. He has no
previous history of problems with immunizations,
although this is his first flu vaccine.
You administer the vaccine and the client stands

up to move to a different chair to wait. He becomes
pale and lightheaded and falls to the ground. He
has fainted.

Properties
On passing, 'Finish' button: Goes to next slide
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Case Study #2
Your client is a 14-year-old female who has come

in with a parent for her flu vaccine. She has never
had a flu vaccine prior to this. She has no known
allergies. She receives her vaccine and is waiting
the required 15 min. Her parent comes to you and
says “my daughter is very itchy”.

Properties

Case Study #3
You are administering a flu vaccine to a new
client. You enter the deltoid and the client
moves suddenly. The needle comes out and
sticks in your hand. The client is upset that
this has happened.

Properties

Documentation and Reporting
• Please consider the following:
– Documentation systems in place
– Achieving consent
– Post-administration documentation
requirements
– Complications documentation, if applicable
– ADR reporting required

Teaching patients to
self-administer injections
• Cognitive ability • Mobility
• Developmental stage • Nutritional status
• Emotional status • Past and present
• Ethno-cultural experiences
background • Readiness to learn
• Health beliefs • Sensory status
• Pre-existing • Support systems
knowledge • Limitations (include
• Language literacy)

Sites for SC injections

How to choose?
• For short term administration (e.g.
enoxaparin) consider abdominal site
• For longer term administration (e.g.
insulin) consider the rotating site process

Abdominal injections
• To teach patients to self-administer injections,
you will need:
– Written patient information – language specific
– Supplies (same as if you were administering)
– Time – this may take awhile
– Privacy for patient teaching
– Innovative teaching abilities to allow for practice
and return demonstration

Teaching
• Written patient information should be
– At a grade 6 level (no higher)
– If children – have these resources available
– Short, clear and concise
– Visual aids should be available
– Appropriate videos to support your teaching
– May need several teaching sessions
• Must determine if the patient is able to perform the skill
(psychomotor abilities)
• Teaching should include a demonstration and reverse demonstration

Teaching
• If administering a pre-packaged device – teach the
patient how to:
– Open the package
– Handle the syringe in a safe manner
– Select the site
– Clean the site
– Remove the needle cap
– Self-administer medication
– Dispose of syringe and other biohazardous materials

Teaching
• If administering a medication which needs to be drawn up –
teach the patient how to:
– Clean the vial
– Draw up the medication appropriately
– Safely recap the needle
– Handle the syringe in a safe manner
– Select the site
– Clean the site
– Self-administer the medication
– Dispose of the syringe and other biohazardous materials
– Store the medication vial

Practising
• Provide patient an opportunity to practice
• Consider the use of a fruit
(orange/grapefruit), injection pad, or warm
moist cloth in a non-sterile glove
• Patients will need to actually perform the
injection at the end of the session(s)

Considerations – all patients
• May need home care/additional resources if there are
on-going concerns
• You must be comfortable that the patient knows and
understands the medication and process of
administration
• Anxiety (more than expected) may be a factor – patient
teaching and acceptance of anxiety will be important
• Time for discussion is critical – cannot be rushed
• Must provide patient with contact person in case of
questions

Considerations
• Patients with short term medications
– May need 1-2 teaching sessions
– Should receive information about medication
(side effects, concerns etc)

Considerations
• Patients with long term medications
– May need a minimum of 2 sessions depending on
complexity (e.g. if drawing up medications)
– Needs in-depth medication information (insulin for
example)
– May need additional teaching (eg: diabetic
teaching)
– Use available outside resources

Points to Ponder
• Be competent in administration of parenteral

medications before teaching patients
• Have time to spend with patients – minimum
30 minutes for each session
• You will need privacy
• They will have questions – be prepared, have
information available, go to your sources

Consider
• Information pamphlets
• Quiet areas
• Seating
• Potential for clients to need to lay down
before, during and after injections

Case Study #4
Your client is a 24 yr old female who is pregnant (16
week gestation) and requires long term
administration of enoxaparin due to a past history of
deep vein thrombosis (DVT) associated with the use
of oral birth control.
She has come in with her prescription and requires

instruction on how to administer the medication. She
is visibly upset. Her husband is in attendance. She
has already received her dose for today.

Properties

Case Study #5
Your client is an 8 yr old female who has been
diagnosed with type I diabetes and requires
insulin injections. She is accompanied by her
mother who wants to be the person who gives
the insulin. The child would prefer to self-
administer the medication.

Properties

Real-Life Scenarios – Don’ts
• Do not use the same syringe twice despite
changing the needle
• Do not wipe blood with your hands even if
wearing gloves
• Do not inject the patient from across the
table/desk

Upcoming Live Event
• To provide pharmacists with the knowledge and skills
required to safely and effectively administer drugs by
injection for education/demonstration and injection
purposes
– Participants will become familiar with the steps necessary for
preparing and delivering an injection (e.g. preparing the syringe,
preparing the vial/ampoule, withdrawing the drug, land marking,
injection)
– Participants will be able to identify appropriate sites for
administering common medications and best practices in aseptic
technique

References
• Centers for Disease Control and Prevention. Bloodborne Infectious Diseases: HIV/AIDS.
Heptatitis B, Hepatitis C. http://www.cdc.gov/niosh/topics/bbp/emergnedl.html. Accessed April
2015.
• Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-
Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public
Health Foundation, 2015.
• Immunization Action Coalition. Ask the Experts: Topics.

http://www.immunize.org/askexperts/administering-vaccines.asp. Accessed April 2015.
• Law R, Law T. in Dipiro ed Pharmacotherapy: A Pathophysiologic Approach 9e. eChapter 23.

Dermatologic Drug Reactions and Common Skin Conditions.
• Lilley, L. L., Harrington, S., & Snyder, J. S. (2010). Pharmacology and the nursing process in
Canada (B. Swart, Canadian Ed.). Toronto, ON: Mosby.
• Muscari ME. What can I do to help patients with belonephobia (fear of needles)? Available at
http://www.medscape.com/viewarticle/555513.

References
• Potter, P. A., & Perry, A. G. (2009). Canadian fundamentals of nursing (4th ed.) (J. C. Ross-Kerr &
M. J. Wood, Canadian Eds.). Toronto, ON: Mosby.
• Potter, P. A., & Perry, A. G. (2009). Nursing skills online for Fundamentals of Nursing (7th ed.)
• Public Health Agency of Canada (2014). Canadian Immunization Guide (the Guide). Evergreen
Edition. http://www.phac-aspc.gc.ca/publicat/cig-gci/.
• Taddio A, Appleton M, Bortolussi R, et al. Reducing the pain of childhood vaccination: an

evidence-based clinical practice guideline CMAJ 2010; 182:18 E843-E855
• Taylor, C. (2004). Taylor’s video guide to clinical nursing skills – injectable medications. Toronto,
ON: Lippincott
• Workman B (1999) Safe injection techniques. Nursing Standard. 13, 39, 47-53.

Administering Drugs by Injection Handout

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INJECTIONS AND

Administering Drugs by Injection

Christine Knapp RN, MScN

Injections and Immunizations Certificate Program

Presenter Disclosure Commercial Disclosure

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

For further resources:

Injections and Immunizations Certificate Program

For further resources:

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Intradermal (ID) 26-27 ~10 mm (3/8”) 0.1-0.3 mL

Subcutaneous 25-27 10 mm -16 mm 0.1-1.0 mL

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Canada Immunization Guide (2018) https://www.canada.ca/en/public-health/services/canadian-immunization-guide.html

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program

Injections and Immunizations Certificate Program