Injections

Subcutaneous (SQ)

• Review medication orders, and check for drug allergies.
  
  
• Wash hands, and put on gloves.
  
  
• Identify client by checking armband.
  
  
• Use 1 - 3 cc syringe and 23 - 25 gauge, 1/2 - 5/8 inch needle. Maximum amount of fluid to administer SQ is 1 cc.
  
  
• Choose site: abdomen, lateral and anterior aspects of upper arm or thigh, scapular area of back, or upper ventrodorsal gluteal area.
  Note: Avoid areas of bony prominence, major nerves, and blood vessels.
  
  
  Figure 10: Sites for routine subcutaneous injections. (Avoid umbilicus area.)
  Source: Smith et al., 2004, p. 556.
  
  
• Wipe with alcohol in a circular motion to cleanse. Allow to dry.
  
  
• Pinch skin between finger and thumb. Spread taut if client has substantial cutaneous tissue.
  
  
• Insert needle at 45° or 90° angle depending on body size of client: 90° if obese; 45° if average weight. If client is very thin, gather skin at area of needle insertion and administer at 90° angle.
  
  
  Figure 11: Insert needle at 45° or 90° angle into tissue for subcutaneous injection.
  Source: Smith et al., 2004, p. 554.
  
  
• Release the subcutaneous tissue, and aspirate prior to injecting medication (except insulin or heparin).
  
  
• Inject medication slowly, remove needle quickly, and gently massage site with alcohol swab. Do not massage after the administration of heparin.

Intramuscular (IM)

• Review medication orders, and check for drug allergies.
  
  
• Wash hands, and put on gloves.
  
  
• Identify client by checking armband.
  
  
• Use 3 cc syringe and 20 - 23 gauge, 1 - 2 inch needle. Maximum amount of fluid should be determined by client's muscle mass and site to be injected. Use 2 inch needle with obese client to ensure that medication is injected into a large muscle.
  
  
• If amount to be injected for adults is > 5 cc or children > 3 cc: divide dose into two syringes to administer.
  
  
• Position client, and locate site using appropriate anatomical landmarks.
  
  
• Wipe site with alcohol in a circular motion to cleanse. Allow to dry.
  
  
• Spread skin taut, and insert needle at 90° angle with quick, dartlike action.
  
  
  Figure 12: Insert needle at 90° angle for intramuscular injections.
  
  
• Aspirate, and observe for blood. (If blood appears, remove and discard needle).
  
  
• Inject medication slowly, remove needle quickly, and gently apply pressure to site with dry, sterile 2 x 2 gauze. Do not massage injection site.

Deltoid (Upper Arm)

• Use if volume is 0.5 - 1 cc, but not more than 3 cc. Use a 23 gauge, 1 inch needle.
  
  
• Client may be positioned sitting, standing, supine, or prone.
  
  
• Locate site by measuring 2–3 fingerbreadths below the acromion process on the lateral midline of the arm.
  
  
  Figure 13a: The deltoid muscle of the upper arm, used for intramuscular injections.
  Source: Kozier et al., 2004, p. 828.
  
  
  Figure 13b: The upper arm can be used for both intramuscular (IM) and subcutaneous (Sub Q) injections.
  Source: Smith et al., 2004, p. 555.
  
  
• Administer in nondominant arm when possible.

Dorsogluteal (Upper Outer Quadrant)

• Use if volume is 1 - 3 cc, but less than 5 cc. Use a 20 - 23 gauge, 1-1/2 inch needle.
  
  
• Do not use this site in children < 2 yr or emaciated clients.
  
  
• Position client in side-lying or supine position, with knee flexed on injection side, or prone with toes pointed inward to rotate femur.
  
  
• Locate site by palpating the posterior iliac spine where the spine and pelvis meet. Imagine a line from the posterior iliac spine to the greater trochanter. Administer medication above imaginary line at midpoint.
  
  
  Figure 14a: The dorsogluteal site for intramuscular injections.
  Source: Kozier et al., 2004, p. 828.
  
  
  Figure 14b: Locate greater trochanter to identify dorsogluteal site.
  Source: Smith et al., 2004, p. 565.
  
  
  Figure 14c: Locate posterosuperior spine of iliac crest.
  Source: Smith et al., 2004, p. 565.
  
  
  Figure 14d: Draw imaginary line between trochanter and iliac spine.
  Source: Smith et al., 2004, p. 566.
  
  
  Figure 14e: Inject medication directly into dorsogluteal site at 90° angle.
  Source: Smith et al., 2004, p. 566
  
  

Ventrogluteal

• Use if volume is 1 - 3 cc. Use a 20 - 23 gauge, 1-1/2 inch needle.
  
  
• This is the preferred site for adults and children < 7 mo.
  
  
• Position client in supine lateral position.
  
  
• Locate site by placing the hand with heel on the greater trochanter and thumb toward umbilicus. Point to the anterior iliac spine with the index finger (forming a "V"). Injection of medication is given within the "V" area.
  
  
  Figure 15a: The ventrogluteal site for intramuscular injections.
  Source: Kozier et al., 2004, p. 826.
  
  
  Figure 15b: Identify greater trochanter, and place palm at site.
  Source: Smith et al., 2004, p. 564
  
  
  Figure 15c: Place palm on greater trochanter, and point to anterior iliac spine.
  Source: Smith et al., 2004, p. 565.
  
  
  Figure 15d: Inject medication at 90° angle within "V" area.
  Source: Smith et al., 2004, p. 565.
  
  

Anterolateral Thigh (Vastus Lateralis)

• Use 22–25 gauge, 5/8–1 inch needle.
  
  
• This is the preferred site for infants and children < 7 mo.
  
  
• Position client in supine or sitting position.
  
  
• Locate by identifying the greater trochanter and lateral femoral condyle. Injection site is the middle third and anterior lateral aspect of the thigh.
  
  
  Figure 16a: The vastus lateralis site of the right thigh, used for intramuscular injections.
  Source: Kozier et al., 2004, p. 827.
  
  
  Figure 16b: The vastus lateralis muscle of the upper thigh.
  Source: Kozier et al., 2004, p. 827.
  
  
  Figure 16c: Identify greater trochanter and lateral femoral condyle.
  Source: Smith et al., 2004, p. 566.
  
  
  Figure 16d: Select site using middle third and anterior lateral aspect of thigh.
  Source: Smith et al., 2004, p. 566.
  
  
  Figure 16e: Inject medication at 90° angle directly into muscle.
  Source: Smith et al., 2004, p. 566.
  
  

Z-Track Method

• Discard needle after medication is drawn up, and use new needle for injection to minimize tissue staining or irritation.
  
  
• Use this method when administering injection in ventrogluteal or dorsogluteal sites.
  
  
• Displace skin to one side (laterally) before inserting needle.
  
  
  Figure 17: Z-track is used to prevent backflow of medication into subcutaneous tissue.
  Source: Smith et al., 2004, p. 568.
  
  
• Insert needle at 90° angle, aspirate, and administer if no blood is present.
  
  
• Withdraw needle before releasing skin.

Intradermal

• Review medication orders, and check for drug allergies.
  
  
• Wash hands, and put on gloves.
  
  
• Identify client by checking armband.
  
  
• Use a tuberculin or 1 cc syringe and 25–27 gauge, 3/8–5/8 inch needle. Amount to be injected is usually 0.01–0.1 cc.
  
  
• Choose site: dorsal forearm, upper back or upper chest.
  
  
  Figure 18: Body sites commonly used for intradermal injections.
  Source: Kozier et al., 2004, p. 820.
  
  
• Wipe site with alcohol in a circular motion to cleanse. Allow to dry.
  
  
• Insert needle, with bevel facing upward, at angle of 10–15°.
  
  
• Advance needle until entire bevel is under skin.
  
  
• Slowly inject medication to form small bleb.
  
  
  Figure 19: Inject solution to form wheal on skin.
  Source: Smith et al., 2004, p. 555.
  
  
• Withdraw needle quickly, and pat site gently with sterile 2 × 2 gauze pad. Do not massage area.