ARELLANO UNIVERSITY-PASIG

Andres Bonifacio Campus

Pag-asa St., Caniogan, Pasig City
COLLEGE OF NURSING

PROCEDURES CHECKLIST
GIVING INTRADERMAL INJECTIONS
PERFORMANCE
STEPS Excellent V.Good Good Fair Poor
96-100% 91-95% 86-90% 80-85% 75-79%
5 4 3 2 1
Assessment
1. Check accuracy and completeness of MAR or computer /
printout with prescriber’s original medication order. Check
patient’s name, medication name and dosage, route of
administration, and time of administration. Recopy or reprint
any portion of MAR that is difficult to read.
2. Review medication reference information about expected /
reaction when testing skin with specific allergen or medication
and appropriate time to read site.
3. Assess patient’s history of allergies: known type of allergens /
and normal allergic reaction.
4. Assess for contraindication to ID injections, such as reduced /
local tissue perfusion. Assess for history of severe adverse
reactions or necrosis that happened after previous ID injection
5. Assess patient’s knowledge of purpose and response to skin /
testing.
6. Check date of expiration for medication /
Planning
Expected outcomes following completion of procedure: /
• Patient experiences very mild burning sensation during
injection but no discomfort after injection.
• Small, light-colored bleb approximately 6 mm ( 1/4
inch) in diameter forms at site and gradually disappears.
Minimal bruising may be present.
• Patient is able to identify signs of skin reaction and
their significance.
7. Wash your hands /
8. Gather equipment needed. /
Equipment:
❏ Syringe: 1-mL TB syringe with pre-attached 25- or 27-gauge
needle, 3 8- to 5 8 -inch
❏ Small gauze pad
❏ Alcohol swab
❏ Vial or ampule of medication
❏ Clean gloves
❏ Medication administration record (MAR) or computer
printout
❏ Puncture-proof container
Implementation
9. Prepare medications for one patient at a time using aseptic /
technique and avoiding distractions. Check label of medication
carefully with MAR or computer printout 2 times
10. Check the label on the medication before picking it up. /
11. Check label again before calculating and preparing dosage. /
12. Draw up medication /
13. Check label of vial or ampule and dosage. /
14. Place MAR or identification card with medication. /
15. Carry prepared medication to bed side. /
16. Approach and identify patient using 2 identifiers /
17. Ask patient if he or she has allergies. /
18. Explain what are you going to do. /
19. Provide privacy /
20. Give the intradermal injection.
a. Put on clean gloves /
b. Select the appropriate site and clean it using /
circular motion.
c. Allow site to dry /
d. Place swab between fingers on non dominant hand. /
e. Remove needle guard. /
f. Stretch (taunt) skin at selected site. /
g. Hold syringe at 5-15 degrees angle, with needle /
bevel facing up.
h. Insert needle just until bevel is no longer visible. /
i. Inject medication slowly, withdraw needle, DO NOT /
MASSAGE
j. Encircle site (wheal or bleb) with marking skin /
pencil
k. Assess site for reaction at appropriate time. /
21. Discard syringe and needle in “sharps” container /
22. Leave patient in comfortable position. /
23. Wash your hands. /
Evaluation
24. Return to room in 15 to 30 minutes and ask if patient feels /
any acute pain, burning, numbness, or tingling at injection site.
25. Inspect bleb. /
Read TB test site at 48 to 72 hours; look for induration (hard,
dense, raised area) of skin around injection site of:
• 15 mm or more in patients with no known risk factors for
tuberculosis.
• 10 mm or more in patients who are recent immigrants;
injection drug users; residents and employees of high-risk
settings; patients with certain chronic illnesses; children less
than 4 years of age; and infants, children, and adolescents
exposed to high-risk adults
• 5 mm or more in patients who are human immunodeficiency
virus (HIV) positive, have fibrotic changes on chest x-ray film
consistent with previous tuberculosis infection, have had organ
transplants, or are immunosuppressed (CDC, 2011b).
Documentation
26. Record drug, dose, route, site, time, and date on MAR /
immediately after administration, not before.
27. Correctly sign MAR according to agency policy. /
28. Record area of ID injection and appearance of skin in your /
notes.
29. Report any undesirable effects from medication to patient’s /
health care provider and document adverse effects according to
agency policy
30. Record patient teaching, validation of understanding, and /
patient’s response to medication.
31. Teaching /
• Instruct patient not to squeeze medication out of injection site.
• Teach patients that negative skin tests may not rule out
allergies, especially when low concentrations of medication are
used.
TOTAL 210
CRITERIA FOR GRADING:

TOTAL RAW Score X 50 + 50 = 210 X 50 + 50 = 100%

Highest Score 210

Grade in Percent Description Interpretation

96-100% Performed and explained accurately, Excellent
completely and clearly.
91-95% Performed well, There are 1 or 2 points not Very Good
fully done and explained.
86-90% Performed adequately, There are 3 or 5 Good
points not explained accurately and clearly.

80-85% Performed adequately, There are more than Fair

5 points not done and explained accurately

75-79% Performance not acceptable and explanation Poor

not accurate and clear.

GRADE: 100% (EXCELLENT)

Recommendations: ______________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

Student Signature/Acknowledgement:

(Name over signature) Date:

Evaluated by:

Date:
INOCENCIA P. MARQUEZ RN, MAN