2.3 Drug Administration Routes, Preparation, and Administration

This section will discuss the different routes for medication administration, how to prepare for administration, and the various methods for administering drugs to the client. Both enteral and parenteral sites will be reviewed, along with the equipment needed for each type of drug administration. Techniques for drug administration will be described.

Forms and Routes of Drug Administration

There are many different forms of medication : liquid, suspensions, tablets, capsules, lotions, and ointment, to name a few. There are also many routes through which medications can be given and absorbed into the body. The routes of medication administration are broadly categorized as follows:

• Enteral administration : “Enteral” means “pertaining to the intestines.” Most enteral medications are absorbed in the intestines. The primary routes for enteral administration are oral and, to a lesser extent, rectal. Some clients have tubes placed directly into the gastrointestinal tract (e.g., nasogastric tubes or percutaneous endoscopic gastrostomy [PEG] tubes). Absorption will vary, but all will be affected by the first-pass effect.
• Parenteral administration : “Parenteral” refers to any drug that is administered outside of the GI tract; however, it most commonly refers to injectable drugs administered via the subcutaneous, intramuscular, or intravenous routes. Drugs administered via these routes have improved bioavailability because they bypass the first-pass effect, making absorption and onset of action more rapid.
  • Percutaneous administration : Some sources will define percutaneous administration as a separate category or a subcategory of parenteral routes. The percutaneous route refers to topical drugs absorbed through the skin—lotions, ointments, creams, or patches.

  The following sections describe the equipment needed for the administration of medications. The various techniques of each route are detailed, along with their pertinent advantages and disadvantages. Nursing implications are also covered in relation to each route of administration.

  Safety Alert

  Medication Safety

  The following are some tips for medication safety:

  • It is best practice to prepare medications for only one client at a time. This safety practice reduces the risk of inadvertently administering medications to the incorrect client.
  • Medications that require a focused assessment or monitoring should be kept separate from other medications. For example, if administering a medication that lowers blood pressure and heart rate, vital signs should be assessed before giving the drug. Because opioids may cause respiratory depression, respiratory rate and oxygen saturation should be assessed before and after administration of the drug.
  • All unit-dose medications should be opened at the bedside rather than in the medication room.
  • Never leave medications unattended at the bedside unless specifically ordered. Remain with the client until all medications have been administered.

  Product (Drug) Labeling

  Each prescription drug includes a package insert that provides clients with information about the drug. Many package inserts are developed by the manufacturer and approved by the FDA for use by clients and caregivers (FDA, 2023a). Some of the information contained in the inserts includes generic and trade names, routes, instructions for taking the drug, and how to store and dispose of the drug. Any side effects, especially if the drug has serious side effects, are listed, as are directions about what to do if adverse effects occur. General information about the safe use of the drug, how to report side effects, and ingredients are also listed. These package inserts are often one of the best resources for free information for the client.

  Oral Medications

  Oral administration encompasses several different drug forms. Liquids, elixirs, suspensions, tablets, capsules, and caplets may all be given orally. Oral administration is usually quick, easy, and convenient, but the onset of action is longer and unpredictable due to the first-pass effect, and not all drugs can be administered this way. Table 2.1 lists the advantages and disadvantages of oral administration.

  • More convenient for the client (it can be done at home)
  • Usually less expensive compared to parenteral forms
  • Usually safe for most clients
  • Variable absorption, with some oral drugs having poor absorption
  • Undergoes first-pass effect
  • Some drugs are destroyed in the acidic environment of the stomach; the absorption of some drugs may vary significantly in the presence or absence of food
  • Cannot be given if the client is nauseated or vomiting or has decreased GI motility
  • May be aspirated
  • Cannot be given to clients who have difficulty swallowing (stroke) or are unconscious
  • Clients must be cooperative
  Table 2.1 Advantages and Disadvantages of Oral Administration

  Steps to administering an oral medication:

  1. Assemble the appropriate equipment:
     • Drinking cup
     • Straw
     • Disposable medication cup (souffle cup or calibrated plastic medication cup for liquids)
  2. Assess the client to determine if the drug is safe and appropriate to give.
  3. Check the medication, dose, and expiration date.
  4. Check NPO status and ensure the client does not have nausea or vomiting. (NPO is a Latin term meaning nil per os, or nothing by mouth. Sometimes this will include medications.)
  5. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
     • During verification of the contents of the medication administration record and the orders
     • When preparing the medication
     • At the bedside
  6. Wait to open blister packs or oral unit doses until at the client’s bedside.
  7. Perform hand hygiene.
  8. Don gloves if you anticipate touching the pill or the client’s mouth during administration.
  9. Identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the blister pack using the protocol recommended by the institution.)
     • Perform the third medication check at the bedside. This check is completed by verifying that the medication name, dosage, route, and time match the medication administration record (this is the last opportunity to prevent an error from occurring). Most institutions now have barcode scanning at the bedside as an additional layer of security.
  10. Explain the medication to the client:
      • Name (brand and generic)
      • Dosage
      • Indication, rationale, or reason for the drug to be given
      • Frequency
      • Route
      • Adverse effects
  11. Position the client in an upright position or on side as condition allows.
  12. Assess the client’s ability to swallow and the gag reflex by offering a sip of water.
  13. Ask the client if they prefer all medications at once or one or two at a time.
  14. Give the client the medication with a cup of water (approximately 8 ounces unless the client is on a fluid restriction).
  15. Document administration within the medication administration record (MAR).
  16. Perform hand hygiene.
  17. Evaluate the client’s response to the drug(s) within the appropriate time frame.

  Nursing Implications for Oral Medications

  The nurse should do the following for clients who are taking oral medications:

  • If a tablet needs to be split, split only tablets that are scored. If a client has difficulty swallowing a tablet or capsule, consult a pharmacist for advice about the technique of administration because some capsules may be opened and emptied into a food or liquid. Timed-release capsules or tablets should not be crushed or chewed because this may affect the rate of absorption and toxicity may occur. For this reason, timed-release capsules should not be opened and emptied into food for ease of swallowing.
  • Use a hospital-approved device to split the tablet. (Some health systems split the tablets in the pharmacy and send them to the unit in unit-dosed packaging for safety purposes.)
  • Discard any unused portion according to institutional policy.
    • If the drug is a controlled substance, document the waste with another nurse in the medication room.
    • Ensure that it can be crushed.
    • Never crush sustained-release, extended-release, or enteric-coated tablets.
    • If crushing more than one tablet, keep them separate; do not combine them.

    Sublingual and Buccal Administration

    Absorption of sublingual medications occurs in the area under the tongue, whereas buccal medications are absorbed in the oral mucosa, generally between the cheek and gums. These are vascular areas, and medications administered here are absorbed rapidly because they do not undergo the first-pass effect. Table 2.2 lists the advantages and disadvantages of sublingual and buccal administration .

    Table 2.2 Advantages and Disadvantages of Sublingual/Buccal Administration

    Steps to administering a sublingual or buccal medication:

    1. Assemble the appropriate equipment:
       • Disposable medication cup (souffle cup)
       • Drinking cup
       • Straw
    2. Assess the client to determine if the drug is safe and appropriate to give.
    3. Check the medication, dose, and expiration date.
    4. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
       • During medication reconciliation
       • When preparing the medication
       • At the bedside
    5. Perform hand hygiene.
    6. Don gloves if you anticipate touching the pill or the client’s mouth during administration.
    7. Identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the blister pack, using the protocol recommended by the institution.)
    8. Perform the third medication check at the bedside.
    9. Explain the medication to the client:
       • Name (brand and generic)
       • Dosage
       • Indication, rationale, or reason for the drug to be given
       • Frequency
       • Route
       • Adverse effects
    10. Offer sips of water to moisten the oral cavity.
    11. Assist the client in placing the medication sublingually (or between the cheek and gum for buccal drugs).
    12. Instruct the client to allow the medication to dissolve completely. Discuss the importance of not swallowing or chewing the pill.
    13. Educate the client about the importance of abstaining from food, drinking, or smoking until after the medication has dissolved.
    14. Document administration within the MAR.
    15. Perform hand hygiene.
    16. Evaluate the client’s response to the drug(s) within the appropriate time frame.

    Nursing Implications for Sublingual or Buccal Medications

    The nurse should do the following for clients who are taking sublingual or buccal medications:

    • Always remain with the client until all medications are taken; do not leave drugs at the bedside unattended unless the provider has ordered the medication to be left at the bedside.
      • Exception: Sublingual nitroglycerin tablets or sprays are often ordered to be left at the bedside so that a client may take them as needed in the event of chest pain.

      Nasal Spray Administration

      Nasal sprays can be rapidly absorbed into the mucous membranes of the nasal cavity. Table 2.3 lists the advantages and disadvantages of nasal sprays.

      • Convenient
      • Rapidly absorbed
      • Very rapid onset of action
      • Avoids first-pass effect
      • May affect taste
      • Few drugs are available in this form
      • May be irritating to the nasal mucosa
      • Aseptic technique should be used due to the connection between the nasal cavity and sinuses
      • Some nasal sprays, such as oxymetazoline for congestion, should be used for only 3–5 days; rebound congestion may occur if used beyond that time
      Table 2.3 Advantages and Disadvantages of Nasal Sprays

      Steps to administering a nasal spray:

      1. Assemble the appropriate equipment:
         • Clean gloves
         • Tissue
         • Medication
      2. Assess the client to determine if the drug is safe and appropriate to give.
      3. Check medication, dose, and expiration date.
      4. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
         • During medication reconciliation
         • When preparing the medication
         • At the bedside
      5. Educate the client.
         • Explain the method for administering the medication. (This route may be self-administered in the future; however, the nurse should observe this in order to provide appropriate documentation in the MAR.)
         • Inform the client that they may experience a burning or stinging sensation with administration.
      6. Instruct the client to gently blow their nose (unless it is contraindicated for the client).
      7. Assess the nostrils for erythema, edema, drainage, or tenderness.
      8. Client should be upright in a sitting position with their head tilted back.
      9. Block one nostril.
      10. Hold the medication bottle upright and shake.
      11. Immediately insert the tip of the applicator into the nostril.
      12. Ask the client to inhale while simultaneously squeezing a spray into the nostril.
      13. Once the bottle has been squeezed to deliver the medication, do not release the squeeze until the spray bottle has been removed from the nares. Ensure that the nozzle of the nasal spray does not touch the nasal turbinates or septum because pain or injury could occur.
      14. Repeat the process in the other nostril if indicated.
      15. Have tissue available if needed to blot the nostril. The client should avoid blowing their nose immediately.
      16. Wipe the spray applicator with a clean, dry cloth or tissue.
      17. Remove gloves and perform hand hygiene.
      18. Document administration within the MAR.
      19. Evaluate the client’s response to the drug(s) within the appropriate time frame.

      Be aware that some nasal medications may vary from this procedure; it is important to consult the product labeling to confirm the appropriate administration technique.

      Nursing Implications for Nasal Sprays

      The nurse should do the following for clients who are taking nasal sprays:

      • Do not readminister the drug if the client sneezes following the administration of the nasal spray because there is no way to assess how much of the drug has been absorbed.

      Removing Parenteral Medication from a Vial

      When administering a parenteral medication , such as a subcutaneous or intramuscular injection, it is important to remember that this is an invasive procedure (a needle is inserted into the client). The medication may come in a prefilled syringe; however, it is usually drawn up by the nurse from a vial of medication. The nurse should be very alert during the process of drawing up and administering the medication to keep the needle and contents sterile.

      Steps to withdrawing medication from a vial:

      1. Perform hand hygiene and don clean gloves (not sterile).
      2. Inspect and verify the medication, dose, volume, and expiration date.
      3. Verify the dosage calculation.
      4. Remove the plastic cap from the top of the unused vial with a flick of the thumb.
      5. Wipe the rubber stopper or port with an alcohol swab and allow it to air dry for approximately 10 seconds.
         • The cap does not keep the top of the port sterile. Dust and microbial contaminants can collect under the cap, so it is important to cleanse with alcohol.
      6. Insulin and tuberculin syringes have preattached needles. If drawing up insulin, insulin syringes have preattached needles with orange caps (see Figure 2.6). Insulin syringes are marked in unit measures rather than in milliliters (mL). The needles on these syringes are fragile and bend very easily, so it is important to be careful when inserting and withdrawing the needles from the vial.
      7. When drawing up medications into syringes that are not insulin or tuberculin syringes:
         1. Attach a blunt-tipped needle to the syringe of choice. The syringe choice should be large enough to hold the dose of medication, but the smallest syringe closest to that measurement (i.e., if administering 4 mL, draw it up in a 5 mL syringe rather than a 10 mL, 20 mL, etc.).
         2. Remove the needle cap and draw air into the empty syringe to the volume of medication to be given (e.g., if giving 2 mL of medication, then draw up 2 mL of air).
         3. Insert the air into the vial of medication through the center of the rubber port at the top of the vial.
            • Ensuring that the tip of the needle is above the fluid level of the vial will help avoid the presence of bubbles. (It prevents agitation of the drug.)
            • Be sure to maintain the sterility of the needle.
            • Do not touch the needle.
            • Be careful not to bend the needle.
         4. Inject the air into the vial.
         5. Invert the vial and hold it at eye level to slowly withdraw the desired volume of medication.
            • If the medication is withdrawn too quickly, air bubbles may enter the syringe.
            • Important tip: Ensure that the tip of the needle is below the fluid level in the vial so that no air is drawn into the syringe.
            • Withdraw slightly more of the medication than needed.
            • Express any air bubbles and the excess medication back into the vial until the desired amount of medication is in the syringe.
            • Withdraw the needle from the vial, being careful not to bend the needle.
            • Exchange the blunt needle for a regular needle prior to administration.

         

         Figure 2.6 An insulin syringe has a pre-attached needle and an orange cap. (credit: modification of work “Standard insulin syringe” by Matanya/Wikimedia Commons, Public Domain)

         Removing Medication from Ampules

         Steps to withdrawing medication from an ampule:

         1. Wash hands and don clean gloves.
         2. Medication may be seen in both the bottom and top portion of the ampule (see Figure 2.7). Thump or flick the top of the ampule to bring the medication to the bottom portion of the ampule.

         

         Figure 2.7 An example of what an ampule looks like; note the top and bottom portion. (credit: “Group of modern plastic ampules on blue background” by Marco Verch/Flickr, CC BY 2.0)

         1. Place an unopened alcohol swab packet or gauze pad between the thumb and fingers and wrap around the neck of the glass ampule. Snap the neck quickly and firmly away from you (and anyone around you).
         2. Dispose of the top of the ampule in a sharps container.
         3. Attach a blunt filter needle to the appropriate syringe.
         4. Remove the cap of the filter needle and insert the needle into the center of the opened ampule, being careful to avoid touching the rim of the ampule with the needle.
         5. Do not inject air into the ampule.
         6. Gently pull back on the plunger to draw the medication into the syringe, keeping the needle tip in the fluid. The ampule can be tipped to the side to aid in the process of drawing the medication into the syringe.
         7. If bubbles are aspirated into the syringe, do not expel the bubbles back into the ampule. Simply remove all of the fluid, withdraw the needle, and hold the syringe in a vertical position (at a 90-degree angle). Tap the side of the syringe to move the air bubbles to the top of the syringe and expel the excess air without wasting the medication.
         8. Scoop the needle cap onto the needle, twist and remove the filter needle from the syringe, and dispose of the filter needle in a sharps container.
         9. If the volume in the syringe is greater than needed, discard according to institutional policy.
         10. Place a sterile tip or the appropriate needle for parenteral administration onto the syringe.
         11. Do not administer the medication using the filter needle used to draw up the medication.
         12. Proceed with labeling and administering the medication according to the administration technique needed.

         Safety Alert

         Filter Needles

         Never inject a medication into a client using a filter needle. A filter needle is used to remove any microscopic glass particles that might occur as a result of ampule breakage. This has the potential of administering these glass fragments into the client.

         Subcutaneous Administration

         Subcutaneous injections are administered “under the skin” into the adipose tissue between the dermis and muscular layer (see Figure 2.8). Clients can be instructed to self-administer injections subcutaneously. Common medications administered within this layer are enoxaparin, heparin, and insulin. Medication administered here is often absorbed slowly due to the reduced number of blood vessels in this area. There are many potential sites for subcutaneous injections: upper arms, thighs, abdomen, back, and buttocks. The specific sites for each drug are usually detailed in the drug’s package insert or labeling. Routine injections should be rotated regularly among the different sites. Do not inject into sites that are hard when palpated. Do not rub the injection site, though gentle pressure may be applied to the area after the drug has been administered.

         

         Figure 2.8 Different types of injections require different angles of injection. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

         Table 2.4 lists the advantages and disadvantages of subcutaneous administration.

         Table 2.4 Advantages and Disadvantages of Subcutaneous Administration

         Steps to administering a subcutaneous medication:

         1. Assemble the appropriate equipment:
            • Medication
            • Sterile syringe (1–3 mL)
            • Small-gauge needles (3/8–5/8 inch) (tuberculin and insulin syringes have preattached needles)
            • Alcohol swabs
            • Gloves (clean gloves, not sterile)
         2. Assess the client to determine if the drug is safe and appropriate to give.
         3. Check the medication, dose, volume, and expiration date.
         4. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
            • During medication reconciliation
            • When drawing up the medication
            • At the bedside
         5. Perform hand hygiene.
         6. Don gloves.
         7. Identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the vial or unit dose, using the protocol recommended by the institution.)
         8. Perform the third medication check at the bedside.
         9. Explain the medication to the client:
            • Name (brand and generic)
            • Dosage
            • Indication, rationale, or reason for the drug to be given
            • Frequency
            • Route
            • Adverse effects
         10. Prepare medication using the correct needle length (3/8–5/8 inches), gauge (25–29 gauge), and syringe (usually no more than 1.5 mL can be given via this route). For clients with little adipose tissue, use the smaller needle.
         11. Select an injection site with an adequate fat pad.
             • Avoid bruises, rashes, inflammation, or areas of injury.
             • Ensure that the injection site is a minimum of 2 inches away from the umbilicus, a stoma, or an incision.
             • Preferred sites include the abdomen, upper arms, and anterior thighs.
         12. Assist the client into a position in which the site or extremity can be relaxed.
         13. Cleanse the area with an alcohol swab using a circular motion by starting at the center and working outward in a widening circle to about 2–3 inches. Allow to air dry.
         14. Grasp the skinfold between your thumb and index or third finger of the nondominant hand. (A new alcohol swab or gauze can be placed between the fourth and fifth fingers of this hand to use after injection.)
         15. Remove the needle cap carefully and dispose.
         16. Instruct the client that they will feel a “pinch.”
         17. Quickly and smoothly insert the needle into the skin and adipose tissue at a 45- to 90-degree angle. The anticoagulant enoxaparin is a subcutaneous injection that should be given at a 90-degree angle.
         18. Inject the medication with the dominant hand depressing the plunger with slow and even pressure, while holding the barrel of the syringe steady with the nondominant hand.
         19. Do not aspirate for subcutaneous injections.
         20. Withdraw the needle smoothly at the same angle that it was inserted to prevent trauma at the injection site.
         21. Apply gentle pressure with the alcohol swab, but do not massage the site, especially if the medication given was an anticoagulant such as heparin or enoxaparin, because this may cause extensive bruising.
         22. Activate the safety device on the syringe and dispose of the syringe in the sharps container or a puncture-resistant needle disposal container according to institutional policy. Never throw it into the trash.
         23. Do not recap the needle! This is a safety hazard for the nurse. Recapping needles may lead to needle sticks and exposure to pathogens.
         24. Remove gloves and perform hand hygiene.
         25. Document in the MAR. When documenting a subcutaneous injection, be sure to document the site the medication was administered to allow for the rotation of sites.
         26. Evaluate the client’s response to the drug(s) within the appropriate time frame.

         Nursing Implications for Subcutaneous Administration

         The nurse should do the following for clients receiving a subcutaneous injection:

         • For heparins and insulins: Both are high-alert medications. A second nurse will need to verify the dose. Do not draw up the dose until a witness is available to verify.
         • Never draw heparin up into an insulin syringe. (Fortunately, many heparins come in prefilled syringes for safety reasons.)
           • Insulin, and only insulin, should be drawn up into an insulin syringe. Never draw up insulin into a regular syringe with milliliter (mL) markings because this will cause an overdose of insulin.

           Link to Learning

           ISMP Guidelines for Safe Subcutaneous Insulin Use

           Review the ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults. According to the Institute for Safe Medication Practices (ISMP), insulin is associated with more medication errors than any other type or class of drugs.

           Intramuscular Injections

           Intramuscular injections (IM) are administered deep into the muscular tissue beneath the dermis and subcutaneous layers (see Figure 2.9). The most common sites for IM injections are the ventrogluteal and deltoid areas. Vastus lateralis landmarks are preferred for infants and children under age 2. Table 2.5 lists the advantages and disadvantages of intramuscular administration.

           • Absorption is more rapid than with subcutaneous injections.
           • Rapid onset of action
           • Avoids first-pass effect
           • Maximum volume of medication via ventrogluteal route is 3 mL (If more than 3 mL is required, separate into two injections.)
           • Incorrect placement of the needle may cause harm to the client (nerve or blood vessel injury)
           • Some drugs are very irritating to the tissues, which causes pain
           • Drug absorption is variable (depends on the muscle group)
           • Painful
           Table 2.5 Advantages and Disadvantages of Intramuscular Administration

           Steps to administering an intramuscular medication:

           1. Assemble the appropriate equipment:
              • Medication
              • Syringe (3 mL)
              • Needles (unless preattached)
              • Alcohol swabs
              • Gloves (clean gloves, not sterile)
           2. Assess the client to determine if the drug is safe and appropriate to give.
           3. Check the medication, dose, volume, and expiration date.
           4. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
              • During medication reconciliation
              • When drawing up the medication
              • At the bedside
           5. Perform hand hygiene.
           6. Don gloves.
           7. Identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the vial or package, using the protocol recommended by the institution.)
           8. Perform the third medication check at the bedside.
           9. Explain the medication to the client.
              • Name (brand and generic)
              • Dosage
              • Indication, rationale, or reason for the drug to be given
              • Frequency
              • Route
              • Adverse effects
           10. Prepare medication using the correct needle length (1–1.5 inches), gauge (18–27 gauge), and syringe (no more than 3 mL can be given via the ventrogluteal route, and no more than 1 mL can be given in the deltoid). (See Figure 2.9.)
           11. Select an injection site.
               • Avoid areas of hardness, bruising, rashes, inflammation, injury, or infection.
               • Assess muscle size and integrity.
           12. Assist the client into a position in which the site or extremity can be relaxed.
           13. Cleanse the area with an alcohol swab using a circular motion by starting at the center and working outward in a widening circle to about 2 inches. Allow to air dry for 10 seconds.
           14. Remove the needle cap carefully.
           15. Instruct the client that they will feel a “stick.”
           16. Grasp the syringe like a dart with the dominant hand.
           17. Quickly and smoothly insert the needle through the skin and adipose tissue to the muscular layer at a 90-degree angle.
           18. Inject the medication with the dominant hand depressing the plunger with slow and even pressure, while holding the barrel of the syringe near the hub steady with the nondominant hand.
           19. Withdraw the needle smoothly at the same angle that it was inserted.
           20. Apply gentle pressure with the alcohol swab, but do not massage the site.
           21. Activate the safety device on the syringe and dispose of the syringe in the sharps container or in a puncture-resistant needle disposal container according to institutional policy. Never throw it into the trash.
           22. Do not recapthe needle! This is a safety hazard for the nurse. Recapping needles may lead to needle sticks and exposure to pathogens.
           23. Remove gloves and perform hand hygiene.
           24. Document in the MAR. When documenting an IM injection, be sure to document the site the medication was administered to allow for the rotation of sites if other doses are necessary.
           25. Evaluate the client’s response to the drug(s) within the appropriate time frame.

           

           Figure 2.9 Needles come in a variety of gauges and lengths. The larger the number of the gauge, the smaller the needle. The number designating the length of the needle will be the actual length of the needle in inches. (credit: “Needles of various gauge and length” by Sean/Rx-wiki, CC BY 3.0)

           Follow institutional policy about aspiration with IM injections. The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) no longer recommend the practice of aspiration for vaccinations because no large blood vessels lie close to the area of injection (CDC, 2023). It is thought that it may cause pain at the site if the syringe is not stable and may actually cause damage to the tissue. At this point in time, there is not enough evidence-based information to support or abort the process of aspiration. Most studies look at the potential discomfort felt with aspiration rather than the safety of intramuscular administration. If the institution recommends aspiration, follow these steps:

           1. Quickly and smoothly insert the needle through the skin and adipose tissue into the muscular layer at a 90-degree angle.
           2. With the dominant hand, pull back on the plunger to aspirate for blood return for 5 seconds. If blood enters the hub of the needle/syringe, stop. Pull the needle out and begin again using a new needle and a different site.
           3. If no blood return is seen with aspiration, inject the medication with the dominant hand depressing the plunger with slow and even pressure, while holding the barrel of the syringe near the hub steady with the nondominant hand.
           4. Continue, using the instructions above.

           Z-Track Method

           Some institutions require all IM injections to be given with the Z-track method . It is particularly helpful with medications that stain the skin or are irritating, such as iron preparations. The Z-track method is never wrong, but it isn’t always necessary. For this reason, know the institutional policy and proceed accordingly.

           1. Use the nondominant hand to displace the skin tissue laterally approximately 1 inch.
           2. Hold the tissue laterally and insert the needle.
           3. Gently inject the medication into the muscle and wait 10 seconds.
           4. Remove the needle and then release the skin and allow it to return to its normal position after withdrawing the needle.

           Deltoid Injections

           To give a deltoid injection, remove clothing to expose the upper arm and shoulder area. Discuss the preferred arm with the client. They may prefer the nondominant arm to be used due to potential soreness; however, many individuals prefer the dominant arm because the increased movement with that arm may work the soreness out earlier. The client may bend the elbow to assist with relaxation of the muscle. To determine landmarks, find the acromion process, which will be the base of an upside-down triangle. Locate the lateral midpoint on the arm in line with the axilla. The injection site will be located in the center of the triangle, approximately 1.5 inches below the acromion process. (See Figure 2.10.)

           

           Figure 2.10 The deltoid injection site is located within the triangle shown here. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)