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Fundamental Nursing

Chapter 34

Parenteral Medications

 The needle gauge (diameter) refers to its

width. For most injections, 18- to 27-gauge
needles are used; the smaller the number, the
larger the diameter. For example, an 18-gauge
needle is wider than a 27-gauge needle. A
wider diameter provides a larger lumen, or
opening, through which drugs are administered
into the tissue.

Injection Routes

 There are four injection routes for parenteral

administration: intradermal injections
(between the layers of the skin), subcutaneous
injections (beneath the skin but above the
muscle), intramuscular injections (in muscle
tissue), and intravenous injections (instilled
into veins; Fig. 34-8).

Injection routes: intradermal( A ,)subcutaneous( B ,)intramuscular and
subcutaneous in other than thin persons( C ,)and intravenous( D .)

Intradermal Injections

 Intradermal injections are commonly used for

diagnostic purposes. Examples include
tuberculin tests and allergy testing. Small
volumes, usually 0.01 to 0.05 mL, are injected
because of the small tissue space.

Injection Sites

 A common site for an intradermal injection is

the inner aspect of the forearm. Other areas

that may be used are the back and upper chest.

Injection Equipment

 A tuberculin syringe holds 1 mL of fluid and

is calibrated in 0.01-mL increments (Fig. 34-
9). It is used to administer intradermal
injections. A 25- to 27-gauge needle
measuring a half-inch in length commonly is
used when administering an intradermal

Figure 34-9 • A tuberculin syringe.

Injection Technique

 When giving an intradermal injection, the

nurse instills the medication shallowly at a 10-
to 15-degree angle of entry

Subcutaneous Injections

 A subcutaneous injection is administered more deeply

than an intradermal injection. Medication is instilled
between the skin and muscle and absorbed fairly
rapidly: the medication usually begins acting within
15 to 30 minutes of administration. The volume of a
subcutaneous injection is usually up to 1 mL. The
subcutaneous route commonly is used to administer
insulin and heparin.

Injection Sites

 The preferred site for giving a subcutaneous

injection of insulin and heparin is the
 Additional or alternative injection sites for
insulin are the outer back area of the upper
arm, where it is fleshier, and outer areas of the
thigh and upper buttocks

Injection Sites

 Rotating within one injection site, preferably

the abdomen, is recommended rather than
rotating to a different area with each injection
 The rate of drug absorption at various
subcutaneous sites from fastest to slowest is
abdomen, arms, thighs, and buttocks.

Injection Equipment

 Insulin is prepared in an insulin syringe A 25-

gauge needle is used most often.

Injection Technique

 To reach subcutaneous tissue in a normal-sized

or obese person who has a 2-inch tissue fold
when it is bunched, the nurse inserts the needle
at a 90-degree angle.
 The tissue usually is bunched between the
thumb and fingers before administering the
injection to avoid instilling insulin within the

Figure 34-11 • Angles and needle lengths for subcutaneous injections. 16
Intramuscular Injections

 An intramuscular injection is the

administration of up to 3 mL of medication
into one muscle or muscle group. Because
deep muscles have few nerve endings,
irritating medications commonly are given

Injection Sites

 The five common intramuscular injection sites

are named for the muscles into which the
medications are injected: dorsogluteal,
ventrogluteal, vastus lateralis, rectus femoris,
and deltoid.

Dorsogluteal Site
 The dorsogluteal site is the upper outer
quadrant of the buttocks and is a common
location for intramuscular injections. The
primary muscle in this site is the gluteus
maximus, which is large and therefore can
hold a fair amount of injected medication with
minimal postinjection discomfort. This site is
avoided in clients younger than 3 years
because their muscle is not sufficiently
 If the dorsogluteal site is not identified
correctly, damage to the sciatic nerve with
subsequent paralysis of the leg can result.
 To locate the appropriate landmarks:
• Divide the buttock into four imaginary quadrants.
• Palpate the posterior iliac spine and the greater
• Draw an imaginary diagonal line between the two
• Insert the needle superiorly and laterally to the
midpoint of the diagonal line.
Ventrogluteal Site
 The ventrogluteal site uses the gluteus medius
and gluteus minimus muscles in the hip for
 This site has several advantages over the
dorsogluteal site:
• It has no large nerves or blood vessels.
• It is usually less fatty.
• It is cleaner because fecal contamination is rare at this
• It is safe for use in children.
 To locate the ventrogluteal site:

 Place the palm of the hand on the greater

trochanter and the index finger on the anterior-
superior iliac spine (Fig. 34-15).

 Move the middle finger away from the index

finger as far as possible along the iliac crest.

 Inject into the center of the triangle formed by the

index finger, middle finger, and iliac crest.
Figure 34-14 • Dorsogluteal site.
Figure 34-15 • Ventrogluteal site .
Vastus Lateralis Site

 The vastus lateralis site uses the vastus lateralis

muscle, one of the muscles in the quadriceps
group of the outer thigh. Large nerves and blood
vessels usually are absent in this area.
 The nurse locates the vastus lateralis site by
placing one hand above the knee and one hand
just below the greater trochanter at the top of the
thigh (Fig. 34-16). He or she then inserts the
needle into the lateral area of the thigh (Fig. 34-
Figure 34-16 • Locating the vastus lateralis muscle .

Figure 34-17 • Spreading the skin at the vastus lateralis site and darting the tissue

Rectus Femoris Site

 The rectus femoris site is in the anterior

aspect of the thigh. This site may be used for
infants. The nurse places an injection in this
site in the middle third of the thigh, with the
client sitting or supine (Fig. 34-18).

Figure 34-18 • Location of rectus femoris injection site .
Deltoid Site
 The deltoid site in the lateral aspect of the
upper arm (Fig. 34-19) is the least-used
intramuscular injection site because it is a
smaller muscle than the others.

 It is used only for adults because the muscle is

not sufficiently developed in infants and
children. Because of its small capacity,
intramuscular injections into this site are
limited to 1 mL of solution.
Figure 34-19 • Deltoid site.

 There is a risk for damaging the radial nerve and
artery if the deltoid site is not well identified. To use
this site safely:
 Have the client lie down, sit, or stand with the
shoulder well exposed.

 Palpate the lower edge of the acromion process.

 Draw an imaginary line at the axilla.

 Inject in the area between these two landmarks.

Injection Technique

 When administering intramuscular injections,

nurses use a 90-degree angle for piercing the
skin (Skill 34-3).

Reducing Injection Discomfort
 Use the smallest-gauge needle that is appropriate.
 Change the needle before administering a drug that is irritating
to tissue.
 Select a site that is free of irritation.
 Rotate injection sites.
 Numb the skin with an ice pack before the injection.
 Insert and withdraw the needle without hesitation.
 Instill the medication slowly and steadily.
 Use the Z-track method for intramuscular injections.
 Apply pressure to the site during needle withdrawal.
 Massage the site afterward, if appropriate.

Z-track technique

 It’s pretty simple.

 It reduces leakage of medication through

subcutaneous tissue and decreases skin lesions at
the injection site. So, the patient gets the full dose
of medication.

 It doesn’t hurt patients quite as much as a regular

I.M. injection.
How to do it?

 Verify the drug order on the patient’s chart.

 Wash your hands.
 Reconstitute the drug as needed. Check the
drug’s colour, clarity, and expiration date.
 Draw the correct amount of drug into the
syringe using aseptic technique.
 After drawing up the dose, replace the original
needle with a sterile needle of the appropriate
length for the patient’s size.
How to do it? Cont…

 Put on gloves.
 Confirm the patient’s identity using two
 Select an injection site: the ventrogluteal or
deltoid site in adults, the vastus lateralis site in
infants and toddlers, and the vastus lateralis or
deltoid site in children.
 Position the patient so that the muscle at the
injection site relaxes.
How to do it? Cont…

 Clean the site with an alcohol pad and let it

thoroughly dry.
 Use your non-dominant hand to pull the skin
downward or laterally to displace the tissue
about 1 inch (2.54 cm).
 With the needle at a 90-degree angle to the
site, pierce the skin using a smooth, steady

How to do it? Cont…

 Aspirate for 5 to 10 seconds to ensure that you

haven’t hit a blood vessel.
 Inject the drug slowly at a rate of 10
seconds/mL of medication.
 Once the drug is completely instilled, wait 10
seconds before withdrawing the needle.
 Withdraw the needle with a smooth, steady
motion and release the skin to its original
How to do it? Cont…

 Use dry gauze to apply very gentle pressure to

the puncture site.
 Never massage a Z-track injection site. This
may cause irritation or force the drug into
subcutaneous tissue.
 Assess the site immediately after administering
the injection and again 2 to 4 hours later.
 Properly dispose of all used equipment and
Nursing Implications

 Acute Pain
 Anxiety
 Fear
 Risk for Trauma
 Deficient Knowledge
 Ineffective Therapeutic Regimen Management