ADMINISTERING SUBCUTANEOUS INJECTION

4 = Competent 3 = Very Good 2 = Good 1 = Needs Improvement

PROCEDURE
Sites: Upper arm, Buttocks, abdomen, thigh 4 3 2 1
1. Using a T-syringe, 2.5 ml or 3 ml syringe with needle, aspirate the
computed dose of medication ordered by the doctor.
2. Remove the needle from the vial of the drug and withdraw the plunger a
little to make sure all drug from the needle will move down to the barrel.
3. Recap the needle using scooping motion and remove the needle and
place a new needle 25G by 5/8 inch.
4. Carefully push the plunger to remove excess air from the needle.
5. Introduce yourself, identify the client using 2 identifiers and explain the
procedure. Ensure the 10 rights of medication safety
6. Inform the patient that the injection may cause a slight burning or
stinging. Answer any question
7. Place the patient in sitting position.
8. Wear clean gloves.
9. Expose the site of injection.
10. Disinfect the site using an alcohol swab in circular motion working from
inner to outer direction. Place a cotton ball with alcohol between the 3rd
& 4th fingers of your non- dominant hand.
11. Grasp the syringe with your dominant hand and remove the needle cap.
12. Using your non-dominant hand, slightly pinch or spread the site of
injection depending on the size of the patient.
13. Introduce the needle at 45-degree angle for lean patients and 90-degree
angle if the patient’s subcutaneous tissue is around 2-inch thick.
14. Inject the medication.
15. Remove the needle quickly with the same angle you introduced it.
16. Apply pressure using the cotton ball between the fingers of your non-
dominant hand.
17. Do not recap the needle. Dispose syringe and needle base on hospital
policy.
18. Make the patient comfortable.
19. Remove gloves and perform hand hygiene
20. Document the procedure as to the date and time, the dose of the drug,
site of injection.
Total = 80

Name ___________________________________________ Score ______________________

Year and Section __________________________________ Clinical Instructor_____________
Pearson My Lab: Course Resources: Videos & Animation: Watch: Medication Administration:
Administering a Subcutaneous Injection
Module 9-10, Medication Administration
 ADMINISTERING INTRAMUSCULAR INJECTION
4 = Competent 3 = Very Good 2 = Good 1 = Needs Improvement

PROCEDURE
ASSESSMENT: 4 3 2 1
• Client allergies to medication(s) • Specific drug action, side effects, and
adverse reactions • Client’s knowledge of and learning needs about the
medication • Tissue integrity of the selected site • Client’s age and weight to
determine site and needle size • Client’s ability or willingness to participate
PLANNING:
Intramuscular injections is an invasive technique that involves the application of
nursing knowledge, problem-solving, and sterile technique.
IMPLEMENTATION:
Check the label on the medication carefully against the MAR to make sure that
the correct medication is being prepared. Do 3 checks (1) when it is taken from
the medication cart, (2) before withdrawing the medication, and (3) after
withdrawing the medication.
Organize the equipment: Sterile medication (ampule or vial or prefilled syringe)
Syringe and needle of a size appropriate for the amount and type of solution to
be administered, Antiseptic swabs, Clean gloves
PERFORMANCE:
1. Perform hand hygiene and observe other appropriate infection
prevention procedures.
2. Prepare the medication from the ampule or vial. Using a vial inject air
with the same amount of drug to be administered.
3. Change the needle on the syringe before the injection. Rationale:
Because the outside of a new needle is free of medication, it does not
irritate subcutaneous tissues as it passes into the muscle.
4. Invert the syringe needle uppermost and expel all excess air.
5. Provide for client privacy.
6. Introduce self and verify the client’s identity using agency protocol.
Rationale: This ensures that the right client receives the medication
7. Explain the purpose of the medication administration.
8. Choose the site of injection: The deltoid muscle is use by placing four
fingers across the deltoid muscle with the first finger on the acromion
process. A triangle within these boundaries indicates the deltoid muscle
about 5 cm (2 in.) below the acromion process. If the Ventrogluteal
muscle is used. have the client in the supine position flex the knee(s); in
the lateral position, flex the upper leg; and in the prone position, toe in.
Rationale: Appropriate positioning promotes relaxation of the target
muscle
9. Apply clean gloves
10. Clean the site with an antiseptic swab. Using a circular motion, start at
the center and move outward about 5 cm (2 in.). Rationale: This
prevents entry of bacteria into the injection site
 11. Transfer and hold the swab between the third and fourth fingers of your
nondominant hand in readiness for needle withdrawal, or position the
swab on the client’s skin above the intended site. Allow skin to dry prior
to injecting medication. Rationale: This reduces the stinging sensation
from the antiseptic upon injection
12. Holding the syringe between the thumb and forefinger (as if holding a
pen), pierce the skin quickly and smoothly at a 90° angle, and insert the
needle into the muscle. Rationale: Using a quick motion lessens the
client’s discomfort. Holding the syringe like a pen or pencil reduces
accidental depression of the plunger and administration of the
medication while the needle is being inserted.
13. Hold the barrel of the syringe steady with your nondominant hand and
aspirate by pulling back on the plunger with your dominant hand.
Aspirate for 5 to 10 seconds. Rationale: If the needle is in a small blood
vessel, it takes time for the blood to appear. If blood appears in the
syringe, withdraw the needle, discard the syringe, and prepare a new
injection.
14. Withdraw the needle smoothly at the same angle of insertion. Rationale:
This minimizes tissue injury. Release the skin.
15. Apply gentle pressure at the site with a dry sponge. Rationale: Use of an
alcohol swab may cause pain or a burning sensation.
16. It is not necessary to massage the area at the site of injection. Rationale:
Massaging the site may cause the leakage of medication from the site
and result in irritation.
17. Activate the needle safety device and discard the attached syringe into
the proper receptacle.
18. Remove and discard gloves. And perform hand hygiene.
19. Document all relevant information. Include the time of administration,
drug name, dose, route, and the client’s reactions.
Total = 76

Name ___________________________________________ Score ______________________

Year and Section __________________________________ Clinical Instructor_____________

Reference: Berman, Audrey; Snyder Shirliee; Frandse Grealyn: Fundamentals of Nursing, Concept, Processes and
Practice 11th Edition
 ADMINISTERING INTRADERMAL INJECTION
4 = Competent 3 = Very Good 2 = Good 1 = Needs Improvement
PROCEDURE
ASSESSMENT: 4 3 2 1
• Appearance of injection site • Specific drug action and expected response
• Client’s knowledge of drug action and response Check agency protocol about
sites to use for skin tests.
PLANNING:
Intradermal injections is an invasive technique that involves the application of
nursing knowledge, problem solving, and sterile technique.
IMPLEMENTATION:
Check the label on the medication carefully against the MAR to make sure that
the correct medication is being prepared.
 Follow the three checks for administering medications. Read the label
on the medication (1) when it is taken from the medication cart, (2)
before withdrawing the medication, and (3) after withdrawing the
medication.
Organize the equipment. Vial or ampule of the correct medication, sterile 1-mL
syringe, #25- to #27-gauge safety needle that is 1/4 to 5/8 inch long, alcohol
swabs, 2×2 sterile gauze square (optional), Clean gloves (according to agency
protocol)
PERFORMANCE
20. Perform hand hygiene and observe other appropriate infection
prevention procedures.
21. Introduce self and verify the client’s identity using agency protocol.
Rationale: This ensures that the right client receives the medication
22. Explain to the client that the medication will produce a small wheal,
sometimes called a bleb. The client will feel a slight prick as the needle
enters the skin.
23. Provide for client privacy.
24. Select and clean the site. (Forearm about a hand’s width above the wrist
and three or four finger widths below the antecubital space.
25. Avoid using sites that are tender, inflamed, or swollen and those that
have lesions
26. Apply gloves as indicated by agency policy.
27. Cleanse the skin at the site using a firm circular motion starting at the
center and widening the circle outward. Allow the area to dry thoroughly
28. Prepare the syringe for the injection. Remove the needle cap while
waiting for the antiseptic to dry
29. Aspirate 0.9 of PNSS sterile and aspirate 0.1 of drugs to be tested
30. Grasp the syringe in your dominant hand, close to the hub, holding it
between thumb and forefinger. Hold the needle almost parallel to the
skin surface, with the bevel of the needle up. Rationale: The possibility
of the medication entering the subcutaneous tissue increases when using
an angle greater than 15°.
 31. With the nondominant hand, pull the skin at the site until it is taut. For
example, if using the ventral forearm, grasp the client’s dorsal forearm
and gently pull it to tighten the ventral skin. Rationale: Taut skin allows
for easier entry of the needle and less discomfort for the client.
32. Insert the tip of the needle far enough to place the bevel through the
epidermis into the dermis. The outline of the bevel should be visible
under the skin surface.
33. Stabilize the syringe and needle. Inject the medication carefully and
slowly so that it produces a small wheal on the skin. Rationale: This
verifies that the medication entered the dermis.
34. Withdraw the needle quickly at the same angle at which it was inserted
35. Do not massage the area. Rationale: Massage can disperse the
medication into the tissue or out through the needle insertion site
36. Dispose of the syringe and needle into the sharp’s container. Rationale:
Do not recap the needle in order to prevent needlestick injuries.
37. Remove and discard gloves. and Perform hand hygiene.
38. Circle the injection site with ink and label the date and time, name of the
drug and check after 30 minutes to observe for redness or induration
(hardening), itchiness. Notify physician for (+) skin test.
39. Document the procedure including the skin test results. And evaluate
the client’s response to the procedure.
Total = 80

Name ___________________________________________ Score ______________________

Year and Section __________________________________ Clinical Instructor_____________

Reference: Berman, Audrey; Snyder Shirliee; Frandse Grealyn: Fundamentals of Nursing, Concept, Processes and
Practice 11th Edition
 URINARY CATHETERIZATION (INDWELLING)

MALE AND FEMALE CATHETERIZATION

4 = Competent 3 = Very Good 2 = Good 1 = Needs Improvement

PROCEDURE
4 3 2 1
Size of catheter 14-16 Fr (for women) 12 Fr for young girls (16-18 Fr (for men)
Balloon size is important in selecting an indwelling catheter
1. Verify the doctor’s order for catheterization.
2. Prepare the necessary materials: Catheter size 12-14, urine bag, KY
Jelly, syringe 10ml., sterile water, kidney dish, tape, drape, forceps,
cotton ball, betadine.
3. Perform hand washing
4. Identifies the patient using 2 identifiers and explains the procedure.
5. Provide Privacy
6. Raise bed to appropriate height, raise side rail on opposite side, lowered
on working side
7. Place waterproof underpad
8. Wash hands
9. Open tubing with collection bag
10. Organize sterile field – add catheter, lubricant, syringe and sterile water,
test balloon, pour cleaning solution over cotton balls
11. Apply sterile gloves
12. Lubricate catheter (2.5 to 5 cm for women) and (12.5 to 17.5 cm for
men)
13. There may be an order for lubricant containing local anaesthetic*
14. Apply sterile drapes keep gloves sterile
15. Women: under buttocks and fenestrated over perineum
16. Men: over thighs and fenestrated over penis
17. Place sterile tray and contents between legs
18. Female: dorsal recumbent (supine with knees flexed) or Sims position
(side-lying with upper leg flexed at knee and hip)
19. Male: supine position
20. Cleanse meatus:
Women: with nondominant hand, expose meatus, maintain position of
hand, cleanse with forceps, wipe from front to back,new cotton ball each
swipe, far labial fold, near, and directly over meatus
Men: retract foreskin, hold penis below glans, maintain position of hand,
with forceps clean in a circular motion from meatus down to base of
glans, repeat three more times
21. Women: ask client to bear down as if to void, insert 5 to 7.5 cm or until
urine flows, then advance another 2.5 to 5 cm
Men: hold penis perpendicular, ask client to bear down, insert 17 to 22.5
cm or until urine flows, then advance to bifurcation
22. Then connect to collecting bag (attach to bed frame)
 23. Dispose supplies in receptacle
24. Measure urine and record the amount
25. Removed gloves, performed hand hygiene
26. Accurately records the procedure done. The size of catheter used. Patient
response to the procedure
REMOVAL OF FOLEY CATHETER
PROCEDURE
4 3 2 1
1. Verify Doctors order
2. Prepare equipment: clean gloves, syringe, under pads
3. Identify patient using 2 identifiers
4. Performed hand hygiene, apply gloves
5. Apply waterproof under pads
6. Insert the syringe into the balloon insertion port and slowly withdraw all
of the solution to deflate the balloon.
7. Pull the catheter appropriately, ensured catheter as a whole, do not use
force
8. Emptied, measured and recorded urine present in the bag
9. Record the time the catheter removal, condition of urethra and
characteristics of urine
10. Remove gloves and perform hand hygiene

Name ___________________________________________ Score ______________________

Year and Section __________________________________ Clinical Instructor_____________
 ADMINISTRATION OF ENEMA
4 = Competent 3 = Very Good 2 = Good 1 = Needs Improvement

PROCEDURE
4 3 2 1
1. Verify the doctor’s order of administering enema to the client.
2. Prepares the needed materials and solutions
Enema can or bag, rectal tube, water soluble lubricant, under pads,
bedpan, clean gloves. Rectal tube size: Adult: Fr. 22-30 Children: Fr. 14-
18 Infant: Fr. 12
3. Performs handwashing before and after the procedure.
4. Identifies patient and explains the procedure.
5. Provides privacy to the client throughout the procedure.
6. Places the water proof pad under the client’s buttocks.
7. Positions the client in left Sim’s position.
8. Prepares the irrigating can, tubing and solutions. Hangs the enema can
on the IV stand about 18-24 inches above the level of the patient’s
rectum.
9. Prepare solution, making sure that temperature of solution is lukewarm
(about 105-110 F) Warming the solution prevent chilling of the patient,
adding to the discomfort of the procedure.
10. Lubricates the rectal tube and allows a small amount of solution to flow
through the tubing into the bedpan.
11. Dons glove and lift the upper buttocks of the patient
12. Inserts the tube slowly and smoothly around 3-4 inches into the
patient’s anus
13. Administer the solution slowly. If the patient complains of fullness or
pain, use the clamp to stop the flow for 30 seconds, and then restart the
flow at a slower rate
If patient complaints of cramping, extreme anxiety or inability to retain
solution:
a. Lower solution container
b. Clamp or pinch tubing for few minutes
14. Closes the clamp after all the solutions has been administered or when
the client cannot hold anymore and wants to defecate.
15. Removes the rectal tube and places it in a disposable towel.
16. Encourages the patient to retain the enema solution.
17. Assist the patient to defecate
18. Assists the patient with the necessary cleansing.
19. Makes the patient comfortable
20. After care of the unit and materials used.
21. Document the procedure done. Record the kind and amount of stool and
solution used and the character of the return flow.

Name ___________________________________________ Score ______________________

Year and Section __________________________________ Clinical Instructor_____________