The document discusses various aspects of parenteral medication administration including the four routes of parenteral administration, principles of practice, patient-centered care considerations, evidence-based guidelines, safety guidelines, needlestick prevention, equipment, preparing injections from ampules and vials, mixing medications, and administering intradermal, subcutaneous, intramuscular, and intravenous injections. Proper techniques, documentation, delegation, and special considerations are covered.

1. Chapter 22
ADMINISTRATION OF PARENTERAL MEDICATIONS
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2. Parenteral Medication
Administration
• Medications administered by the parenteral
route enter body tissues and the circulatory
system by injection
• What are the four routes of parenteral
medication administration?
• Failure to inject a medication correctly results
in complications
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3. Principles for Practice




Communicate with interprofessional team and
assess patient’s priorities of care and preferences
Use technology available when preparing and
giving medications
Educate about each medication
Minimize a patient’s discomfort when giving
injections
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4. Patient-Centered Care
• Research shows that ethnicity, genetics,
and culture influence drug response,
pharmacokinetics, pharmacodynamics,
and patient adherence and education
• Knowledge about variations in therapeutic
dose and adverse effects as well as
cultural considerations is essential in
administering medications to different
ethnic groups
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5. Evidence-Based Practice
• Select needle size based on patient gender, weight and
body mass index, condition, site, drug, and volume
• Make the ventrogluteal site the first choice wherever
possible for deep intramuscular injections as there are
reduced risks of nerve or muscle injury
• Assess the skin and the patient’s condition
• Inject at 90°, dart-like, to the hub of the needle and inject at
1 mL per second
• Wait at least 10 seconds before withdrawing the needle
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6. Safety Guidelines
1. Be vigilant; avoid distractions while preparing an
injection.
2. Verify that the medications have not expired.
3. Use at least two identifiers before administering
medications and check against the medication
administration
record (MAR).
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7. Safety Guidelines(Cont.)
4. Clarify unclear medication orders and ask for
help whenever you are uncertain about an
order or calculation.
5. Follow all policies related to use of the
technology and do not use “workarounds.”
6. Use strict aseptic technique during medication
preparation and administration.
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8. Safety Guidelines(Cont.)
7. Most of the time, you cannot delegate
medication administration.
8. No-interruption zones (NIZs) have been
recommended by the Institute for Safe
Medicine Practices.
9. Insert the needle at the proper angle,
smoothly, and quickly
10. Inject the medication slowly but smoothly.
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9. Safety Guidelines(Cont.)
11. Hold the syringe steady once the needle is in
the tissue to prevent tissue damage.
12. Withdraw the needle smoothly at the same
angle used for insertion.
13. Gently apply an antiseptic pad (e.g., alcohol)
or dry, sterile gauze pad to the site
14. Apply gentle pressure at the injection site.
15. Rotate injection sites to prevent the formation
of indurations and abscesses
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10. Needlestick Prevention
 The implementation
of safe needle
devices can
prevent needlestick
injuries
 Sharps with
engineered sharps
injury protection
(SESIP)
10
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11. Needlestick Prevention (Cont.)
 Sharps disposal
containers
 May be used
one-handed
 Colored red or
labeled with
biohazard symbol
11
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12. Equipment
 Syringes
 Single-use
 Disposable
 Luer-Lok
 Non–Luer-Lok
 Many sizes
12
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13. Equipment (Cont.)
d
 Needles
 Attached or
packaged
separately
 Disposable
 Three parts
 Vary in length an
gauge
13
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14. Equipment (Cont.)
 Disposable injection
units
 Single-dose
 Prefilled
 Disposable
14
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15. Preparing
Injections: Ampules
and Vials S
k
Aim
llp
2
u
2
le
-
s
1
 Glasstop must be
snapped off
 Require a filter
 Vials
 Rubber seal
 Single-dose or multi-
dose
15
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16. Delegation and
Collaboration
 The task of preparing injections from ampules and
vials cannot be delegated to nursing assistive
personnel (NAP)
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17. Mixing Parenteral Medications
in One Syringe
Procedural Guideline 22-1



Some medications need to be mixed from two vials or from a
vial and an ampule
Mixing compatible medicationsavoids the need to give a
patient more than one injection
Consult a compatibility chart or a pharmacist for compatible
medications
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18. Quick Quiz!
How will the nurse mix medication that has been
diluted in a vial?
A
. Shake the vial vigorously.
B.Turn the vial upside down.
C. Roll the vial in the palms.
D
. Stir the contents with the needle.
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19. Delegation and
Collaboration


The task of mixing medications in one syringe
cannot be delegated to NAP
The nurse directsthe NAP about:
 Potential side effects of medications and the need
to report their occurrence to the nurse
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20. Administering Intradermal
Injections

Sk
Ty
ip
ll
ica
2
lly
2
g
-
iv
2
en for skin testing



Use a tuberculin (TB) or small syringe with a short, ⅜-to ⅝-inch,
fine-gauge (25 to 27) needle
Insertion angle is5 to 15 degrees
Inject only small amounts of medication (0.01 to 0.1 mL)
intradermally
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21. Quick Quiz!
The nurse performing an intradermal (ID) injection
feels resistance when inserting the medication. What
should the nurse do next?
A.Remove the needle.
B.Dilute the medication.
C.Advance the needle.
D.Inject the medication.
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22. Delegation and
Collaboration


The task of administering ID injections cannot be
delegated to NAP
The nurse directsNAP about:
 Potential medication side effects and the need to
report their occurrence to the nurse
 Reporting to the nurse any change in the patient’s
condition
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23. Recording and Reporting
• Record drug, dose, route, site, time, and
date on MAR immediately after
administration, not before
• Record in your notes area of ID injection
and appearance of skin
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24. Recording and Reporting
(Cont.)
• Report to patient’s health care provider any
undesirable effects from medication and
document adverse effects according to
institutional policy
• Record patient teaching, validation of
understanding, and patient’s response to
medication
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25. Special Considerations
 Teaching
 Do not squeeze medication from site
 Negative skin tests may not rule out allergies
 Wear identification band listing all allergies
 Do not wash off markings around site
 Observe forskin reactions
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26. Special Considerations
(Cont.)


Pediatric
 Test immediately if exposed to people with
confirmed orsuspected TB
 If ongoing exposure suspected, test for TBevery
2 to 3 years
Gerontological
 Hold skin taut to ensure that ID injection is
administered correctly
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27. Administering Subcutaneous
Injections
Skill 22-3
 Inject in small doses
 Base needle length
and angle on
patient weight and
estimate of
subcutaneous tissue
 What sitesare used
for subcutaneous
injections?
27
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28. Administering Subcutaneous
Injections
Skill 22-3 (Cont.)
 Injection pen
 Needlelessinjection
system
 Subcutaneous
injection device
28
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29. Special Considerations for
Administration of Insulin



Patients choose one anatomic area and rotate
siteswithin that region
Absorption ratesof insulin vary on the basisof the
injection site
Timing of injections is critical for correct insulin
administration
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30. Special Considerations for
A
dP
m
atiein
n
tsia
s
re
tr
aa
t ris
t
kif
o
orn
blee
o
din
fgHeparin



Assess for contraindications and medication
interactions
Administer subcutaneously or intravenously
Low-molecular-weight heparins
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31. Delegation and
Collaboration


The task of administering subcutaneous injections
cannot be delegated to NAP
The nurse directsNAP about:
 Potential medication side effects and the need to
report their occurrence to the nurse
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32. Recording and Reporting
• Immediately after administration, record on
MAR the medication, dose, route, site, time, and
date given. Correctly sign MAR according to
institutional policy
• Record in nurses’ notes patient teaching,
validation of understanding, and patient’s
response to medication
• Report to patient’s health care provider any
undesirable effects from medication and
document adverse effects in record
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33. Special Considerations


Teaching
 Wear identification band
 Techniques for self-administration
Pediatric
 Administer to small children only amounts up to 0.5
mL subcutaneously
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34. Special Considerations
(Cont.)


Gerontological
 Use upper abdominal site when the patient has little
subcutaneous tissue
Home care
 Safe disposal of sharps
 Reuse of syringes
 Injection techniques that minimize patient
discomfort
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35. Administering Intramuscular
Injections
Skill 22-4
 Requires a longer
and larger-gauge
needle
 Injection sites
 Ventrogluteal
 Vastus lateralis
 Deltoid
35
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36. Injection Sites:Ventrogluteal
 Safe for adults and
children
 Use landmarks to
identify injection site
36
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37. Injection Sites:VastusLateralis
 Used in adults
 Preferred site for
administration of
biologics to infants,
toddlers, and
children
37
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38. Injection Sites:Deltoid
 Easily accessible
 Use for small
medication volumes
(2 mL or less)
38
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39. Delegation and
Collaboration


The task of administering intramuscularinjections
cannot be delegated to NAP
The nurse directsNAP about:
 Potential medication side effects and the need to
report their occurrence to the nurse
 Reporting to the nurse any change in the patient’s
condition
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40. Recording and Reporting
• Immediately after administration, record on
MAR the medication, dose, route, site, time,
and date given. Correctly sign MAR
according to institutional policy
• Record in nurses’ notes patient teaching,
validation of understanding, and patient’s
response to medication
• Report to patient’s health care provider any
undesirable effects from medication and
document adverse effects in record
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41. Special Considerations


Teaching
 Self-injection techniques
 Observation of injection sites
Pediatric
 Assistance holding and distracting children
 Pain-management techniques
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42. Special Considerations
(Cont.)


Gerontological
 Age-related considerations
Home care
 Administration techniques
 Pain-management techniques
 Safe sharpsdisposal
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43. Administering Medications by
Intravenous (IV) Bolus
Skill 22-5




An IV bolus introduces a concentrated dose of a medication
directly into a vein by way of an existing IV access
Usually requiresa small fluid volume
Common in emergenciesto delivera
fast-acting medication quickly
Patients must be monitored closely for adverse reactions
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44. Administering Medicationsby
IV Bolus
Skill 22-5 (Cont.)
Fourstrategiesto reduce harm
1.Use commercially available or pharmacy prepared
IV push medication whenever possible.
2.Do not dilute IV push medicationsunless
recommended by the manufacturer, agency policy,
or reference literature.
3
.
IV push medicationsshould be administered at the
rate recommended by the manufacturer, agency
policy, or reference literature.
4.Appropriately label of clinical prepared syringes.
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45. Delegation and
Collaboration


The task of administering medications by IV bolus
cannot be delegated to NAP
The nurse directsNAP about:
 Potential actions and side effects of the
medications and to report occurrence
 Reporting patient complaints of moisture or
discomfort around insertion site
 Obtaining required vital signs and reporting them to
nurse
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46. Recording and Reporting
• Immediately record on the MAR the medication
administration, including drug, dose, route, time
instilled, and date and time administered. Include
initials or signature
• Report to patient’s health care provider any
adverse reactions. Patient’s response sometimes
indicates need for additional medical therapy
• Record in nurses’ notes patient’s medication
response
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47. Special Considerations


Teaching
 Explain IV medication purpose and signs of adverse
effects
Pediatric
 Infuse IV push medications slowly and in small
volumes
 Follow institutional policies when administering
medications via IV bolus
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48. Special Considerations
(Cont.)


Gerontological
 Reduced function of renal and metabolical systems
Home care
 Medication administration technique
 Safe medication storage
 Emergency contact information
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49. Administering Intravenous
Medications by Piggyback,
Intermittent Infusion Sets, and
Mini-Infusion Pumps
Skill 22-6
 Use small volumes of
compatible IV fluids
infused over a
desired time
49
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50. Administering Intravenous
Medications by Piggyback,
Intermittent Infusion Sets, and
Mini-Infusion Pumps
Skill 22-6 (Cont.)
 Needle safety
 Safe needle systems
 Needleless systems
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51. Delegation and
Collaboration


The task of administering IV medications by
piggyback, intermittent infusion sets, and mini-
infusion pumpscannot be delegated to NAP
The nurse directsNAP about:
 Potential medication actions and side effects and
the need to report their occurrence to the nurse
 Reporting any patient complaints of moisture or
discomfort around IV insertion site
 Reporting to the nurse any change in patient’s
condition orvital signs
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52. Recording and Reporting
• Immediately record on the MAR or computer
printout the medication, dose, route, infusion
rate, and date and time administered. Include
initials of signature
• Record on intake and output (I&O) form
volume of fluid in medication bag or Volutrol
• Report to patient’s health care provider any
adverse reactions
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53. Special Considerations


Teaching
 Explain medication purpose, administration rate,
and adverse effects
Pediatric
 To assess fluid balance, monitor I&O carefully when
infusing IV medications
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54. Special Considerations
(Cont.)


Gerontological
 Risk of medication toxicity
 Risk for fluid volume overload
Home care
 Explain steps of medication administration,
signs of complications, and management of
complications
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55. Administering Continuous
Subcutaneous Medications
S
k
Fe
ill
w2
er
2
ri
-
s
7
ksand less
expense than IV
administration
 Easy to operate in
the home care
setting
55
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56. Administering Continuous
Subcutaneous Medications
Skill 22-7 (Cont.)



Use a small-gauge (25 to 27) winged butterfly IV needle or a
special commercially prepared Teflon cannula
Use the same anatomic sites for subcutaneous injections and
the upper chest
Requiresa computerized pump with safety features
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57. Delegation and
Collaboration


The task of administering continuous
subcutaneous infusion (CSQI) medications
cannot be delegated to NAP
The nurse directsNAP about:
 Potential medication side effects or reactions;
reporting occurrence to nurse
 Reporting to the nurse complications at the CSQI
needle insertion site
 Obtaining any required vital signs and reporting
them to the nurse
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58. Recording and Reporting
• After initiating CSQI, immediately document
medication administration details in patient’s
medical record. Use initials or signature
• For opioids, follow policy to document waste
• Record patient response to medication and
appearance of site every 4 hours or per policy
• Report to patient’s provider any adverse effects
from medication or infection at insertion site and
document according to agency policy
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59. Special Considerations


Teaching
 Wear medical alert identification, carry backup
batteries and medication, and explain diabetes
management and pump care
Pediatric
 Improves glycemic control and offersgreater
flexibility for adolescents
 Clean/change sites every 48 to 72 hours
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60. Special Considerations
(Cont.)


Gerontological
 Hypodermoclysistherapy
Home care
 Explain desired effect of medication, side effects,
adverse effects, pump operation, medication
administration, supply disposal, and site-cleansing
procedures
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