**ADMINISTRATION OF INJECTABLE VACCINES**

**Purpose:** to ensure that subcutaneous (SC), intramuscular (IM) and
intradermal (ID) vaccine injections are administered to patients in a
safe manner consistent with current practice guidelines.

**General guidelines**

1.  Strict attention to sterile technique is required for parenteral
    drug administration.

2.  If unfamiliar with the vaccine, review the drug action, side
    effects, contraindications, dosage, route and other important
    pharmacological information.

3.  Provide the patient with verbal and written information about the
    vaccine. Include the following information:

    -   vaccine name and disease description

    -   vaccine effectiveness level

    -   duration of effectiveness

    -   route of administration

    -   common side effects

    -   possible adverse effects

    -   schedule for administration, if more than one dose

    -   contraindications to administration

4.  As may be required by law, provide the patient with VIMS patient
    information materials.

5.  Interview the patient to determine prior experience receiving
    injections (fainting, adverse reactions, etc.) and any history of
    allergies to medications or preservatives.

6.  Ensure informed consent and witness patient (or caregiver, if
    patient underage or unable to sign) signature to practice document.
    File signed original in patient\'s chart.

7.  Throughout the procedure, try to allay the patient\'s fears and
    anxiety and reduce his or her discomfort.

    -   Be sure the needle is the smallest gauge possible to properly
        deliver the medication.

    -   Consider changing the needle after drawing up the vaccine to
        avoid tracking medication through superficial tissue.

    -   Distract the patient with conversation.

    -   For a very anxious patient, consider numbing the site briefly by
        holding ice on the area.

8.  Verify the medication, and check the drug name, expiration date,
    dose and route of administration: SC, IM, ID.

9.  Sterile drawing up of drug: Immediately before the procedure, wash
    your hands. Inspect the medication for discoloration or
    particulates. Discard PRN.

> If withdrawing vaccine from a vial:

-   Inject air into the vial equal to the amount of vaccine you need.

-   Invert the vial, and remove proper dose of the vaccine.

-   Do not remove the needle during this process, or you will spray the
    vaccine.

-   When reconstituting powdered medication, use the correct diluent.

-   Administer the medication within the prescribed time frame.

-   Discard all expired vaccine.

> When drawing medication from an ampule:

-   Flick the solution to the bottom.

-   Snap the ampule neck, holding ampule away from the body and covering
    it with a 2x2 gauze pad.

-   Withdraw the solution with the ampule straight up to avoid spillage.

10. Carefully follow administration standards (see below) to avoid
    injury to patient and clinician. For a prepackaged syringe,
    carefully read and follow the manufacturer\'s directions for proper
    use.

11. Document all injections in the patient\'s medical record. Include
    the following information:

    -   date of administration

    -   vaccine name

    -   dose

    -   manufacturer

    -   lot number

    -   clinician\'s name

    -   any side effects/adverse effects

12. Observe, respond to, document and report vaccine side effects and
    adverse events PRN.

13. Respond to, document and report needle stick injuries PRN in
    accordance with practice policy.

**ADMINISTRATION OF SUBCUTANEOUS INJECTIONS**

*Administration of vaccine into the tissue that lies between the muscle
and skin*

1.  SC injections are the preferred route for isotonic, non-viscous,
    non-cytotoxic, non-irritating drugs that are well absorbed from
    adipose and connective tissue. The volume of the medication should
    not exceed 1 ml.

> Vaccines administered by the SC route include:

-   Anthrax

-   Japanese encephalitis

-   MMR

-   Meningococcal meningitis (Menomune^®^)

-   Pneumococcal (PPV)

-   Polio (IPV)

-   Varicella

-   Yellow fever

2.  Selecting SC syringe and needle:

    -   Equipment used may depend upon the type of medication to be
        administered.

    -   Most vaccines are given SC using a 1 ml to 3 ml syringe and a
        shorter needle, usually 1/2 to 5/8 inch with a 25-27 gauge and
        medium bevel, since the solutions are not viscous.

3.  Selecting an appropriate SC site:

    -   Choose areas with few sensory nerve endings and without large
        blood vessels or bones near the surface: flabby, nonmuscular
        sites are preferred.

    -   Sites include: lateral aspect of the upper arms and thighs,
        abdomen and back.

    -   Do not select areas that are burned, inflamed, edematous,
        hardened, or diseased.

    -   For multiple SC injections, select sites at least 1 inch apart.

    -   Pinch the subcutaneous tissue to assess the thickness of the
        fatty layer.

    -   The SC injection will be given at any angle that allows the
        medication to reach the fatty tissue between the muscle and the
        skin.

4.  Clean the injection site:

    -   Use an alcohol swab.

    -   Use a circular motion moving outward from the site of the
        injection to a distance of about 2 inches in diameter.

    -   Allow the site to dry to avoid injecting alcohol under the skin.

5.  Administer the injection.

    -   Firmly grasp the skin around the injection site.

    -   With the dominant hand, hold the syringe in a dart-like fashion,
        and quickly insert the needle at an angle to ensure drug
        delivery to the subcutaneous layer. It is customary to angle the
        needle 45 to 90 degrees, depending on the length of the needle
        and the amount and turgor of the tissue.

    -   Release the skin upon insertion.

    -   Steady the lower end of the syringe with the nondominant hand
        and aspirate by pulling back gently on the plunger to determine
        if the needle is in a blood vessel. If the syringe barrel starts
        to fill with blood, remove the needle, place direct pressure
        with a 2x2 piece of gauze over the site, discard the syringe and
        start again.

    -   Slowly inject the medication.

    -   Quickly withdraw the needle at the same angle as inserted, while
        applying countertraction to prevent pulling surrounding tissue.

    -   If there is any bleeding, apply gentle pressure with a dry,
        sterile sponge.

    -   Gently massage the area to distribute the vaccine and promote
        absorption.

6.  Discard the needle and syringe in the proper puncture-resistant
    sharps receptacle.

7.  Document the SC injection per the general guidelines (above) and
    practice policy.

8.  Ask the patient to remain at the office for 15 to 30 minutes to
    assess for any untoward reactions. Check for pain, itching, numbness
    or tingling, bruising, redness, warmth, swelling or induration at
    the injection site. Document PRN.

**ADMINISTRATION OF INTRAMUSCULAR (IM) INJECTIONS\
**

*Administration of vaccine into the skeletal muscle below the
subcutaneous tissue*

1.  The IM route takes effect more quickly than SC and a larger volume
    of drug, up to 3 ml, can be administered into a muscle. The deltoid
    muscle, however, should receive no more than 2 ml.

2.  The IM route is preferred for irritating and concentrated drugs to
    avoid damage to the subcutaneous tissue. The risk of complications
    is greater with this route; inadvertent IV administration, nerve and
    bone damage and paralysis can occur with administration error.

> Vaccines and biologicals administered IM include:

-   DTaP

-   Hepatitis A

-   Hepatitis B

-   Hib

-   Immune Globulin

-   Influenza (injectable)

-   Meningococcal meningitis (Menactra^TM^)

-   Pneumococcal (PCV, PPV)

-   Rabies as PCEC, RVA, or HDCV (IM)

-   Tetanus (Td) and Tdap

-   Typhoid (Typhim Vi^®^)

3.  Selecting IM syringe and needle:

    -   For adults, usually a 3 ml syringe is used with a 5/8 to 1½
        inch, 21 to 25 gauge and medium bevel needle.

    -   For thin adults, a 1-inch needle is used, while a 2-2½ inch
        needle is used for obese patients.

    -   For children, a 5/8-inch needle is used.

4.  Selecting an appropriate IM site:

    -   The choice of IM sites depends upon drug volume, patient\'s age,
        condition of the muscle and how irritating a drug is to the
        tissue. Absorption rates vary among different muscle sites.

    -   Most vaccines can be given IM in the mid-deltoid (rapid
        absorption, easy access, but small muscle mass).

    -   Other sites for adults include the ventrogluteal (gluteus
        minimus and medius, which lacks major nerves or blood vessels),
        the dorsogluteal (gluteus maximus with greater risk for sciatic
        nerve damage and puncture of the superior gluteal artery) and
        the rectus femoris (mid thigh).

    -   For children, the preferred site is the vastus lateralis
        (lateral mid thigh).

5.  Fully visualize the site and palpate the correct anatomical
    landmarks to avoid harming the patient. If in doubt, choose an
    alternative site.

> **For the deltoid muscle:**

-   The patient may sit or lie down.

-   To avoid injury to the radial nerve and the deep brachial artery,
    identify upper arm landmarks by first having the patient flex the
    elbow and support the lower arm so the deltoid is relaxed.

-   Expose the arm all the way to the top of the shoulder. Find the
    lower edge of the acromium process and the lateral aspect of the
    arm. The upside down triangle between the two is the injection site.

> **For the ventrogluteal site**:

-   Ask the patient to assume a side-lying position with the top hip and
    knee flexed.

-   To locate the landmarks, place an index finger on anterior superior
    iliac crest, a middle finger on the iliac crest and a palm over the
    great trochanter.

-   Inject into center of the V formed by the hand.

> **For the dorsogluteal site**:

-   Ask the patient to lie prone with toes pointed inward.

-   Locate the posterior superior iliac spine, then the great
    trochanter. Draw an imaginary diagonal line between the two
    landmarks.

-   Administer the injection within this triangle area in the upper,
    outer quadrant of the buttocks.

> **For the vastus lateralis site**:

-   Ask the patient to sit or be supine.

-   Divide the thigh into thirds, starting at the great trochanter.

-   The injection site is the middle third area, the lateral muscle, not
    the anterior thigh.

6.  Clean the injection site.

    -   Use an alcohol swab.

    -   Use a circular motion moving outward from the site of the
        injection to a distance of about 2 inches in diameter.

    -   Allow the site to dry to avoid injecting alcohol under the skin.

7.  Administer the injection.

    -   Stretch the skin over the injection site with the nondominant
        hand.

    -   Insert the needle in a dart-like fashion at a 90-degree angle to
        about ¾ of its length.

    -   Pull back the plunger to verify that a vein has not been
        entered. If the syringe barrel starts to fill with blood, remove
        the needle, apply pressure with a 2x2 piece of gauze and start
        again.

    -   Inject the vaccine at a slow and even rate. Avoid producing
        high-pressure pain in the muscle with faster injection.

    -   Quickly and smoothly withdraw the needle at the same angle
        inserted, while applying counteraction with a dry gauze pad.

    -   Massage the area in a circular motion to distribute the vaccine,
        promote absorption and reduce pain.

    -   If there is any bleeding, apply gentle pressure with a dry
        sterile sponge. Apply a self-adhesive bandage, PRN.

8.  Discard the syringe and needle in the appropriate sharps container.

9.  Document all IM injections in accordance with the general guidelines
    (above) and practice policy.

10. Observe the patient for 15 to 30 minutes for side effects and
    adverse effects. Respond to, document and report any untoward
    effects in accordance with practice policy.

**ADMINISTRATION OF INTRADERMAL INJECTIONS**

*Administration of a substance below the epidermis for slow absorption
through the capillaries*

1.  Intradermal injections generally are performed for diagnostic
    purposes, such as to identify allergens or diagnose patients who
    have developed specific antibodies (e.g. tuberculosis).

2.  Intradermal injections have the longest absorption rate of any
    parenteral route and involve small amounts of solution, usually not
    more than 0.5 ml. The Mantoux test is given intradermally.

3.  Selecting ID syringe and needle:

    -   A 1 ml tuberculin syringe with a 1/2 to 5/8 inch, 25-27 gauge
        needle usually is used.

4.  Selecting an appropriate ID site:

    -   These sites easily are observed to facilitate the assessment of
        a local reaction.

    -   The most common site is the inner surface of the forearm, but
        the upper chest and upper back beneath the scapulae also are
        suitable.

5.  Clean the injection site.

    -   Use an alcohol swab.

    -   Use a circular motion moving outward from the site of the
        injection to a distance of about 2 inches in diameter.

    -   Allow the site to dry to avoid injecting alcohol under the skin.

6.  Administering the injection:

    -   With the non-dominant hand, spread the skin taut at the site.

    -   Place the needle almost flat against the patient\'s skin with
        the bevel up.

    -   Insert the needle at a 5 to 15 degree angle beneath the skin,
        about 1/8 inch, until the point of the needle is inserted under
        the skin.

    -   Slowly inject the solution, observing for a small well-defined
        wheal or bleb to appear. If none appear, withdraw the needle
        slightly.

    -   Withdraw the needle quickly at the same angle as inserted.

    -   Do not massage the area.

7.  Ask the patient to remain for 30 minutes to detect any untoward
    effects, including itching, rash, hives, bleeding, bruising, etc.

8.  Observe the ID site at prescribed intervals. For Mantoux, check the
    site at 48 to 72 hours. For ease of observation, consider drawing a
    circle around the injection site. Carefully explain to the patient
    the rationale, and schedule for observations.

**References**\
IM and SC injections. *Patient Care* 1990 Oct 15; 24(16): 147, 150,
153-4 passim.

Hahn K. Brush up on your injection technique. *Nursing* 1990 Sep; 20(9):
54-58.

Newtown M, Newton D, and Fudin J. Reviewing the \"big three\" injection
routes. *Nursing* 1992 Feb; 22(2): 34-41.

Timby B and Lewis L. Administering parenteral medications. Chapter 24 in
*Fundamental skills* *and concepts in patient care*. Fifth edition.
Philadelphia: J.B. Lippincott Co., 1992.

**THE TRAVEL CLINIC REFRIGERATOR\
**

**Policy**: Guidelines for choosing and maintaining the travel clinic
refrigerator.

**Purpose**: To ensure proper storage of vaccines in the travel clinic
refrigerator.

**Procedure**

1.  Be sure all personnel know the importance of maintaining the cold
    chain and the value of the vaccine inventory. They need to
    understand that vaccine shipments must be placed in the refrigerator
    or freezer as soon as they are delivered to the clinic so vaccine
    potency is maintained in accordance with the manufacturers\'
    temperature requirements.

2.  Purchase a refrigerator with a separate freezer door for your
    vaccine storage.

3.  Locate the refrigerator in a place convenient for the staff. Do not
    locate it in a patient exam room.

4.  Have a padlock on the refrigerator door and lock it nightly to
    prevent access by unauthorized personnel.

5.  Set the refrigerator thermostat to the proper storage temperature.
    The CDC recommends a refrigerator temperature of 36-46°F (2-8°C) and
    a freezer temperature at 5°F (0°C). If you stock varicella vaccine,
    the freezer will need to maintain a temperature of -15°F. *See the
    vaccine manufacturers\' recommendations for the range of optimum
    temperatures for specific vaccines*.

6.  Place \"kitchenware-type\" thermometers in both the refrigerator and
    freezer units. Designate one staff member to check the thermometers
    every morning and document the readings on a temperature log affixed
    to the front of the units. Direct all staff to report temperature or
    other refrigerator problems promptly.

7.  To help stabilize unit temperatures, store containers of water in
    open refrigerator space and ice or ice packs in open freezer space.
    Also limit refrigerator access to travel clinic staff to prevent
    frequent door openings that can affect unit temperature.

8.  Prohibit food storage in the travel clinic refrigerator to limit
    door openings and possible overheating of the vaccines. Place a
    label on the unit door that states \"Vaccine Refrigerator: Not For
    Food Storage.\"

9.  Make sure refrigerator remains plugged in at all times. To help
    prevent a power failure:

    -   Place a safety lock on the refrigerator plug: one that makes it
        difficult to remove the plug from the socket.

    -   Post warning signs so electricians, janitors, or other personnel
        don\'t unknowingly damage the stock by unplugging the
        refrigerator or turning off the circuit or electricity. Place a
        \"Warning: Do Not Unplug\" sign on the plug, wall outlet,
        refrigerator door and the circuit breaker box door.

10. Stock vaccines to maintain potency:

    -   Do not place vaccines in a refrigerator until the proper
        temperatures have been reached and logged.

    -   Place new vaccine shipments in the refrigerator or freezer as
        soon as they arrive at the clinic. Oral polio and varicella will
        go into the freezer compartment. If a shipment arrives warm,
        mark the batch, place it separately in the unit, and contact the
        drug manufacturer for recommendations.

    -   Keep vaccines in their original containers to permit checking of
        expiration dates.

    -   Rotate vaccines on refrigerator shelves to avoid expiration.
        Place the newest vaccines toward the back of the shelf, and move
        older vaccines forward.

    -   Do not store vaccines on the refrigerator door, as temperatures
        vary from the rest of the unit.

11. When storing and using vaccines, carefully follow the
    manufacturer\'s guidelines to maintain the cold chain. For easy
    reference, keep vaccine inserts and a list of vaccine lot numbers on
    file near the refrigerator. If vaccines are inadvertently left out
    of the refrigerator, inappropriately frozen, or in any other way not
    maintained in a manner consistent with the manufacturer\'s
    guidelines, mark the batch, place it separately in the unit and
    contact the vendor for recommendations.

12. Follow manufacturer\'s guidelines for regular refrigerator
    maintenance. If the unit requires defrosting, temporarily store
    vaccines safely to maintain the cold chain.

13. If vaccines will be transported from the refrigerator, contact the
    drug manufacturer for detailed guidelines.

**References**\
Centers for Disease Control and Prevention. Epidemiology and Prevention
of Vaccine-Preventable Diseases. Atlanta, GA: U.S. Department of Health
and Human Services.

Centers for Disease Control and Prevention. Ice, Champagne, and Roses
\[videorecording (00-6526)\]. CDC, National Immunization Program. (call
404-639-8828 for more information)

Other resources include the the CDC manual *Vaccine Management:
Recommendations for Handling and Storage of Selected Biologicals*
(available at www.cdc.gov/nip/publications/vac_mgt_book.pdf); \"General
Recommendations on Immunizations\" (CDC, AAFP: *MMWR* 55, No. RR-15,
12/1/06); \"Guidelines for Maintaining and Managing the Vaccine Cold
Chain\" (CDC: *MMWR* 52, No. 42, 10/24/03); and the AAP *Red Book 2006*,
pp. 12-18. See also the EnCompass article: \"Storage and Handling.\"