ADMINISTERING INTRADERMAL INJECTION

I. Introduction

Intradermal injection is one of the routes of parenteral administration of medication.

This workbook outlines the procedure on administration of intradermal injection. Each step
of the procedure is discussed on the concepts section, to include the rationale. Practice
exercise will help you understand on how to perform the steps correctly.

II. Objectives

At the end of this activity, you should be able to:

1. Learn the concepts and principles on administration of intradermal injection.

2. Discuss the nursing roles and responsibilities in medication administration.
3. Demonstrate the steps on administration of intradermal injection safely and correctly.

III. Concept/s Explanation

Intradermal injections are commonly practiced when performing allergy test or known
as the skin testing. This route is also used for administration of vaccine, following the
recommended route of administration.
When performing allergy test, it is important to take note the site of injection. Site of
injection is usually on the inner forearm. For best interpretation of results, site is lightly
pigmented, free of lesions and good skin integrity. Medications for skin testing are to be
diluted with sterile water, using a small hypodermic syringe or tuberculin syringe. Needle is
inserted at 5 to 15 degrees, with the bevel of the needle is facing up. The diluted medication
is injected just enough to form a wheal. The skin testing is evaluated 30 minutes after
injection.Considering, medication is injected into the dermis, the slow absorption of the
medication will give time to detect if a client will develop allergic reaction to the
medication. Changes on the appearance on the injection site likely indicate allergic reaction
to the medication. Thus, allergy test is recommended and practiced to prevent anaphylactic
reactions when medication is administered directly. Also, ensuring patient safety on
medication administration.
Below are the steps on how to perform a skin test.

Figure 1.Illustration of Skin Test Figure 2. Parts of the Syringe

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A. Preparation Phase

Initially, it is necessary to prepare the materials needed.

The following materials are:
 Sterile 1 mL syringe or tuberculin syringe
 Sterile needle 25 to 27 gauge or ½ inch
 Sterile small gauze pad
 Alcohol swab
 Sterile needles – filter needle or aspirating needle
 Medication in a vial or an ampule
 Diluent (Sterile water)
 Medication Administration Record (MAR)
 Clean gloves

B. Implementation Phase

On this phase, it is important to review first the physician’s order and check the
MAR. When checking the medication, inspect the appearance and label to include the
name of the drug, route, dosage and expiration date.

Take note of the “Three Checks” on medication preparation. Check the label of
the medication against MAR when doing the following:

 When medication is taken from the cart.

 Before withdrawing the medication from a vial or an ampule.
 After withdrawing the medication from a vial or an ampule.

Prior administering the medication, identify patient correctly. Use at least two
Identifiers - Name of the patient and Birthdate. Compare the identifiers against the
MAR. Take note of any history of allergy. Administer the medication at correct time.

The next steps are the following:

a. Perform hand hygiene. Prevents transmission of microorganisms.

b. Following the steps of medication preparation, using a tuberculin syringe, draw 0.9
mL sterile water and 0.1 mL medication.
c. Identify patient correctly using two (2) identifiers. Ensures the right patient.
d. Explain the procedure to the patient. It reduces patient’s anxiety.
e. Don clean gloves. Wearing gloves reduces transmission of microorganisms.
f. Identify appropriate injection site – three to four finger widths below antecubital
space or the inner forearm. Ensure the site is free from lesions, redness, bruises and
other impaired skin conditions. Injection site with skin impairments will
interfere the absorption of medication.
g. Position patient in an appropriate comfortable position. Place forearm on a flat
surface with elbow supported.Placing in a comfortable position makes the
injection site relax.
h. Clean the injection site with alcohol swab, from the center to outward in circular
manner. Discard the swab. It removes dirt and contaminants. Prevents
transmission of microorganisms.

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 i. Remove the cap of the needle, hold the syringe with bevel facing up. Maintaining
bevel up will prevent medication to be deposited below the dermis.
j. Using non-dominant hand, taut or stretch skin over injection site. Tight skin
facilitates piercing of the needle.
k. Hold the syringe with dominant hand and insert the needle slowly, maintain at 5 to
15 degrees angle with bevel facing up. Insert needle just enough the entire bevel is
inserted. Correct angle of insertion ensures the tip of the needle is in the
dermis.
l. Inject the medication slowly until wheal or blister is formed about 6 mm. While
injecting, use non-dominant hand to stabilize the syringe. Wheal indicates that the
medication is in the dermis. Injecting it slowly minimizes discomfort.
m. Remove the needle. Do not recap needle. Discard needle and syringe into a
puncture proof container. Prevents needlestick injury.
n. If necessary, use sterile small gauze pad to blot the site. Do not massage or apply
pressure on the area.Massaging or applying pressure on the site will alter the
results. Mark circle around the perimeter of the wheal using black-ink pen.
(Optional: Check as per hospital policy.)
o. Instruct the patient not to touch or scratch the site. Wheal or blister is evaluated
after 30 minutes or depending on the prescribed time. Presence of redness or
itchiness likely indicates positive allergic reaction to the medication. Remove
gloves and do hand hygiene. Prevents transmission of microorganisms.
p. Observe patient’s response. Document necessary findings.

IV. Work/Practice Exercise

Performance Evaluation Checklist

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Procedure Title: Administering Intradermal Injection

NURSING ACTIONS YES NO REMARKS

I. Preparation
1. Prepare the necessary materials.
 Sterile 1 mL syringe or tuberculin syringe
 Sterile needle 25 to 27 gauge or ½ inch
 Sterile small gauze pad
 Alcohol swab
 Sterile needles – filter needle or aspirating
needle
 Medication in a vial or an ampule
 Diluent (Sterile Water)
o
 Clean gloves
II. Implementation
1. Review physician’s order and MAR.
2. Check the medication label against the MAR.
Inspect the appearance and check the
expiration date.
3. Perform hand hygiene.
4. Following the steps of medication preparation,
using a tuberculin syringe, draw 0.9mL sterile
water and 0.1 mL medication.
5. Identify patient correctly using two (2)
identifiers. (Name and Birthdate of the patient)
6. Explain the procedure to the patient.
7. Don clean gloves.
8. Identify appropriate injection site – three to
four finger widths below antecubitalspace or
the inner forearm. Ensure the site is free from
lesions, redness, bruises and other impaired
skin conditions.
9. Position patient in an appropriate comfortable
position. Place forearm on a flat surface with
elbow supported.
10. Clean the injection site with alcohol swab,
from the center to outward in circularmanner.
Discard the swab.
11. Remove the cap of the needle, hold the syringe
with bevel facing up.
12. Using non-dominant hand, taut or stretch skin
over injection site.
13. Hold the syringe with dominant hand and
insert the needle slowly, maintain at 5 to15
degrees angle with bevel facing up. Insert
needle just enough the entire bevel isinserted.
14. Inject the medication slowly until wheal or
blister is formed about 6 mm. Whileinjecting,
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 use non-dominant hand to stabilize the syringe.
15. Remove the needle. Do not recap needle.
Discard needle and syringe into a puncture
proof container.
16. If necessary, use sterile small gauze pad to blot
the site. Do not massage or apply pressure on
the area.
Mark circle around the perimeter of the wheal using
black-ink pen. (Optional: Check as per hospital
policy.)
17. Instruct the patient not to touch or scratch the
site.
18. Remove gloves and do hand hygiene.
19. Observe patient’s response. Document
necessary findings.
TOTAL

Total Score :_________________

Rating: _____________________

Student Signature : ____________

C.I. Signature : _________________

Date : _____________________

References:

Textbook

Potter, P., Perry, A.G., et. Al. (2017). Fundamentals of Nursing, 9th Edition. Elsevier Pte. Ltd.

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 Images
Figure 1:http://www.bccdc.ca/resource-gallery/Documents/Communicable-Disease
Manual/Chapter%204%20-%20TB/TST%20Quick%20Reference%20Guide.pdf

Figure 2: https://www.slideshare.net/lopao1024/injection-technique-zabat-31619695

Website
International Nosocomial Infection Control Consortium (INICC). (2017). Care Bundles to
Prevent Central and Peripheral Line-Related Bloodstream Infections.
http://www.inicc.org/media/docs/2017-INICCBSIPreventionGuidelines.pdf

ADMINISTERING A SUBCUTANEOUS INJECTION

NURSING ACTIONS YES NO REMARKS

1. Assemble equipment/ supplies.

▪ Medication Administration Record (MAR)

▪ Medication in a vial or ampule

▪ Sterile syringe

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 ▪ Aspirating needle

▪ Antiseptic swab

▪ Dry, sterile gauze (optional)

▪ Clean gloves

2. Check each medication against the original order in the medical

record.

3. Clarify any inconsistencies in the order.

4. Check for allergies to medication

5. Know the actions, special nursing considerations, safe dose

ranges.

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6. Perform hand hygiene

7. Prepare medication in the medication area or bring the cart at

patient’s bedside.

8. Prepare medication for one patient at a time.

9. Read the MAR and select the proper medication from the
patient’s drawer.

10. Compare the medication label with the MAR: name of the drug,
expiration date, preparation and perform calculations (first check
takes place at this point.)

Follow the 3 Checks:

▪ When drug is taken from the patient’s drawer.

▪ Before withdrawing the medication.
▪ After withdrawing the medication.

11. Ensure patient receives the medication on the correct time.

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12. Perform hand hygiene and observe hospital’s policy on infection
control.

13. Recheck medication label against the MAR. (second check takes
place at this time.)

14. Prepare the medication (follow the steps in preparing

medication.)

15. Recheck medication label against the MAR

( 3rd check takes place at this time.)

Transport medication at patient’s bedside.

16. Identify the patient. Compare information with the MAR.

Identify the patient in 2 methods:

▪ Check the Name and the Birthdate on the

identification band.
▪ Ask patient to state his/her name and birthdate.

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17. Prepare the patient and provide privacy by drawing the bedside
curtain.

18. Introduce yourself.

19. Complete necessary assessment before administering the

medication.

▪ Assess status and appearance of subcutaneous site

(lesions, swelling, scarring, redness, tissue damage,
tenderness and site that has not been used frequently.)

20. Explain the purpose of the medication: How it will help and
Effects of the medication.

21. Put on clean gloves

22. Assist the patient to appropriate position for the site.

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23. Identify the appropriate landmark for the site chosen.

24. Cleanse the area around the injection site with antimicrobial
swab. Use a firm, circular motion inward and outward from the
site.

25. Allow to dry thoroughly

26. Remove the needle cap with your nondominant hand, pulling it
straight off.

27.Grasp and bunch the area surrounding the injection site or spread
the skin taut at the site.

28. Hold the syringe in the dominant hand between the thumb and
forefinger.

29. Inject the needle, bevel up quickly at 45 degree angle.

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30. After the needle is in place, release the tissue, ensure that the
needle stays in place as the skin is released.

31. Immediately move your nondominant hand to steady the lower

end of the syringe.

32. Slide your dominant hand to the end of the plunger. Avoid
moving the syringe.

33. Inject the medication slowly at a rate of 10 sec/ml.

34. Withdraw the needle quickly, pulling along at the line of

insertion.

35. Using a gauze square/ alcohol swab, apply gentle pressure to site
after the needle is withdrawn. DO NOT MASSAGE THE SITE.

36. DO NOT RECAP the used needle. Dispose syringe and needle
in appropriate receptacle.

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 37. Assist the patient to position of comfort.

38. Remove gloves. Perform hand hygiene.

39. Document after the administration of the medication: drug,

dosage, time, route, assessment.

40. Evaluate the patient’s response to medication within the

appropriate time frame for the particular medication.

Total:

Total Score :_________________

Rating: _____________________

Student Signature : ____________

C.I. Signature : _________________

Date : _____________________

ADMINISTERING AN INTRAMUSCULAR INJECTION

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NURSING ACTIONS YES NO REMARKS
1. Assess for:

 Client allergies to medications

 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 cooperate.

2. Determine :

 Whether the size of the muscle is appropriate to

the amount of medication to be injected.
3. Assemble equipment and supplies ;

 MAR or computer printout

 Sterile medication (usually provided in an ampule or

vial)

 Syringe and needle of size appropriate for the

amount of solution to be administered

 Antiseptic swabs

 Clean glove
4. Check the MAR
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 the medication

and dose . Read the label on the medication:

 When it is taken from the medication cart

 Before withdrawing the medication ; and

 After withdrawing the medication

Confirm that the dose is correct

5. Organize the equipment

Procedure:

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 1. Perform hand hygiene, and observe other
appropriate infection control procedures.

2. Prepare the medication from the ampule or vial

drug withdrawal.

Whenever feasible , change the needed on the syringe before

the injection.

Invert the syringe needle uppermost, and expel all excess air.
3. Provide for client’s privacy.

4. Prepare the client

Check the client’s identification band

Assist the client to supine, lateral , prone , or sitting position ,

depending on the chosen site.

Obtain assistance in holding an uncooperative client.

5. Explain the purpose of the medication and how it
will help, using language that the client can
understand . includes relevant information about
effects of the medication.
6. Select , locate and clean the site

Select a site free of skin lesions, tenderness, swelling,

hardness, or localized inflammation , and one that has not
been used frequently.
If injections are to be frequent , alternate sites. Avoid using
the same site twice in a row.
Locate the exact site for the injection

Put on clean gloves.

Clean the site with an antiseptic swab. Using a circular
motion, start at the center and move outward about 5 cm (2
inches).

Transfer and hold the swab between the third and fourth
fingers of your non-dominant hand in readiness for needle
withdrawal ,or position the swab on the client’s skin above
the intended site allow the skin to dry prior to injecting
medication.
7. Prepare - the syringe for injection

Remove the needle cover and discard without contaminating

the needle

If using a prefilled unit-dose medication, take caution to

avoid dripping medication on the needle prior to injection.
If dripping occurs, wipe the medication off the needle with
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sterile gauze.
8. Inject the medication using a Z-track technique .

Use the ulnar side of the non-dominant hand to pull the

skin approximately 2.5 cm (1 inch) to the side.

Holding the syringe between the thumb and forefinger,

pierce the skin quickly and smoothly at a 90 degree angle, and
insert the needle into the muscle.
Hold the barrel of the syringe steady with your non-
dominant hand and aspirate by pulling back on the plunger
with your dominant hand. Aspirate for 5-10 seconds. If blood
appears in the syringe, withdraw the needle, discard the
syringe, and prepare a new injection .

If blood does not appear, inject the medication steadily and

slowly (approximately 10 seconds per milliliter) while holding
the syringe steady.
After injection, wait for 10 seconds.

9. Withdraw the needle

Withdraw the needle smoothly at the same angle of
insertion . Release the skin.
Apply gentle pressure at the site with a dry sponge.

If bleeding occurs, apply pressure with a dry, sterile gauze

until it stops.

10. Activate the needle device , or discard the

uncapped needle and attached syringe into the
proper receptacle. Remove gloves. Perform hand
hygiene.

11. Document all relevant information.

Include the time of administration, drug name, dose, route,
and the client’s reactions.
12. Assess effectiveness of the medication at the time it
is expected to act.

Total Score :_________________

Rating: _____________________

Student Signature : ____________

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C.I. Signature : _________________

Date : _____________________
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