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BCG Vaccine Administration Checklist

The nursing procedure checklist outlines the 21 steps for correctly administering a BCG vaccination to a newborn patient. Key steps include gathering the necessary equipment including the BCG vaccine, syringe, and needle; preparing the medication by withdrawing 0.05mL of BCG; cleaning the injection site; inserting the needle just under the skin in an intradermal manner to form a small bleb; and documenting the procedure. The checklist is used to evaluate whether a nursing student correctly, incorrectly, or did not perform each step of the BCG administration process.

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BSN 1A- Serrano Evytte Joy B.
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1K views2 pages

BCG Vaccine Administration Checklist

The nursing procedure checklist outlines the 21 steps for correctly administering a BCG vaccination to a newborn patient. Key steps include gathering the necessary equipment including the BCG vaccine, syringe, and needle; preparing the medication by withdrawing 0.05mL of BCG; cleaning the injection site; inserting the needle just under the skin in an intradermal manner to form a small bleb; and documenting the procedure. The checklist is used to evaluate whether a nursing student correctly, incorrectly, or did not perform each step of the BCG administration process.

Uploaded by

BSN 1A- Serrano Evytte Joy B.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Nursing Procedure Checklist: Details the complete procedure checklist for BCG administration, including steps for correctly performing the skill and scoring the execution.

Nursing Procedure Checklist

BCG ADMINISTRATION

Instruction: Check under Correctly Done if identified skill is Correctly Incorrectly Not
correctly performed; Incorrectly Done if skill is not performed Done Done Done
correctly; and Not Done if the student failed to perform the skill.
PROCEDURE

1. Gather equipment. Check each medication order against the


original physician’s order according to agency policy. Clarify any
inconsistencies. Check the patient’s chart for allergies.
 BCG vaccine
 Special BCG syringe (0.1ml) and special BCG needle (10mm,
26 gauze).
 Antiseptic swabs or cotton balls with alcohol
 Disposable gloves
2. Know the action, special nursing consideration, dose, purpose of
administration, and adverse effects of the vaccine to be administered
for this patient.
3. Wash hands and observe other appropriate infection control
procedures. Wear disposable gloves.
4. Prepare medication (BCG):
 Follow medication preparation standards
 Using a special BCG syringe (0.1ml) and special BCG needle
(10mm, 26 gauze), withdraw 0.05mL of BCG only.
5. Close the door to the room or pull the bedside curtain.
6. Identify the patient. Check the name and identification number on
the patient’s identification band.
7. Complete necessary assessment before administering medications.
Check allergy bracelet. Explain the purpose and action of the vaccine
to the SO
8. Assess:
 Tissue integrity of the selected site usually at the right deltoid

9. Prepare the newborn. Clean the site with an antimicrobial swab or


a cotton ball with alcohol using a firm, circular motion while moving
outward from the injection site. Allow the area to dry.
10. Hold the newborn’s arm with your non- dominant hand grasping
skin. Your thumb and fingers reach around the arm stretching the
skin tight.
11. Hold the syringe using the dominant hand with the bevel facing
up at about 3mm into the superficial layers of the dermis.
12. Lay the syringe and needle almost flat along the newborn’s arm.
(Intradermal Route)
13. Insert the tip of the needle just under the skin- insert only the
bevel. Keep the needle FLAT along the arm, so that it goes into the
top layer of skin only.
14. Do NOT push too far and do NOT point down or the needle will go
under the skin. (If BCG is injected under the skin an abscess or
enlarged glands may result).
15. To hold the needle in position, put your non- dominant thumb on
the lower end of the syringe near the needle, but DO NOT touch the
needle.
16. Hold the plunger end of the syringe between index finger and
middle finger of your dominant hand. Push the plunger with your
thumb (dominant hand). A considerable resistance is felt when the
vaccine is being injected. A bleb should be formed and is typically of
3mm diameter following a 0.05ml intradermal injection.
17. Withdraw the needle in the same angle. Wipe blot or leaks over
Nursing Procedure Checklist

the bleb gently and tenderly. Do not massage the site.


18. Do not recap the used needle. Discard the uncapped needle and
syringe into the appropriate receptacle.
19. Remove gloves and dispose them properly.
20. Wash hands or do hand hygiene.
21. Document.
TOTAL SCORE

Comment:
__________________________________________________________________
____________________________________________________________
__________________________

Score: ____/21

Name of Student:                                                           Date


Performed:                      
                                      (Signature Over Printed Name)
 

Evaluated by:                                                                  Date of Evaluation:                 


                                       (Signature Over Printed Name)

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