Injection training

1. Vaccination Training
for Health Care Providers
Betsy Hubbard, RN, MN
Immunization Clinical Practice Supervisor
Colleen Woolsey PhD, ARNP, MSN
H1N1 Flu Training Coordinator

2. Agenda--1
 Overview & Introductions
 Flu Disease & Flu Vaccine
 Intramuscular Injection
 “Immunization Techniques” Video
 Skills practice 1: Drawing up vaccines &
using safety syringes
 Locating IM injection landmarks
 Skills Practice 2: Locating IM injection sites

3. Agenda--2
 Skills Practice 3: FluMist administration
 Giving Vaccines in a Medication Center
 Adverse Reactions
 Skills Practice 4: Positioning & comforting
restraint
 Skills Practice 5: Locating IM injection
sites on adult and child arm and leg
 Skills Practice 6: Use of Triage Algorithm
 Q&A and Evaluation

4. What is the flu?
 Highly infectious viral illness
 Characterized by abrupt
onset of fever, dry cough,
muscle aches and malaise
 Cough and malaise may
persist up to two weeks
 Transmitted by respiratory droplets
 Seasonal flu season typically occurs
late fall through spring

5. Flu can complicate underlying
medical conditions, causing….
 Bacterial infections
 Pneumonia
 Sinus and ear infections
in children
 Increased risk of stroke, MI, and heart
failure
 Increased blood sugar in diabetics
 Death

6. How is influenza transmitted?
 Large-particle
respiratory droplets
(infected person
coughs or sneezes near
a susceptible person)
 Requires close contact
(<6 feet)
 Novel A H1N1 probably
spread in ways similar
to other flu viruses

7. Transmission of Influenza
 Other possible sources of transmission:
 Contact with contaminated surfaces
 Via droplet nuclei--also called “airborne”
transmission (particles stay suspended in
the air)
 All respiratory secretions and bodily fluids
(diarrheal stool) of novel influenza A
(H1N1) cases should be considered
potentially infectious

8. Distribution by Age Group of Cases
Hospitalized with Pandemic H1N1
July 2009
0
5
10
15
20
25
30
35
40
45
50
< 6 mo 6mo-4 yrs 5-9 yrs 10-17 yrs 18-29 yrs 30-49 yrs 50-64 yrs 65+ yrs
Age group
Percent
Seasonal 2007-08 Pandemic 2009*
*April 12–June 30

11. ED Visits for ILI by Age Group
King County, WA, 2009
0
50
100
150
200
250
300
03-Jan-09
10-Jan-09
17-Jan-09
24-Jan-09
31-Jan-09
07-Feb-09
14-Feb-09
21-Feb-09
28-Feb-09
07-Mar-09
14-Mar-09
21-Mar-09
28-Mar-09
04-Apr-09
11-Apr-09
18-Apr-09
25-Apr-09
02-May-09
09-May-09
16-May-09
23-May-09
30-May-09
06-Jun-09
13-Jun-09
20-Jun-09
27-Jun-09
04-Jul-09
11-Jul-09
18-Jul-09
25-Jul-09
Week ending
NumberofEDvisitsforILI
under 2
2 to 4
5 to 17
18 to 44
45 to 64
65 and over

12. Health Care Workers: Protect
Yourself, Protect Your Clients
 Individuals are contagious for 1 to 4 days
before the onset of symptoms and about
5 days after the first symptom
 About 50% of infected people do not have
any symptoms but are still contagious
 Health care workers are frequently the
source of influenza transmission in health
care settings

13. Influenza Vaccine

14. Why immunize?
 Flu is a serious illness, the
cause of 36,000 deaths each
year in the U.S.
 Immunizations are first line
of defense:
70-90% effective in <65 yrs;
30-40% in frail elderly
 Immunizations prevent serious illness,
hospitalization and death

15. Groups at Increased Risk for
Seasonal Flu Complications
 Children less than 5 years old
 Persons aged 65 years or older
 People age <18 years who are on long-term aspirin
therapy (risk of Reye syndrome)
 Pregnant women
 Adults and children with chronic medical conditions
 Adults and children who have immunosuppression
(caused by medications or by HIV)
 Residents of nursing homes and other chronic-care
facilities

16. H1N1 vaccine—
Target groups for vaccination
 All pregnant women
 People who live with or care for children
age < 6 months
 Healthcare and emergency services
personnel
 All people ages 6 months through 24
years
 Persons ages 25 through 64 years with
chronic medical conditions

17. Who Should Not Be Immunized?
 Anyone with:
 Severe (anaphylactic) allergy
to eggs, gentamycin or a previous
dose of influenza vaccine.
 Moderate to severe illness, with or
without fever
 History of *GBS within 6 weeks
after a previous flu shot.

18. Flu Vaccine Formulations
 Seasonal flu vaccine
 Trivalent inactivated influenza vaccine (TIV)
 Ten-dose vial
 Prefilled syringe 0.25 ml and 0.5 ml
 Live attenuated influenza vaccine (LAIV)
 Novel H1N1 –monovalent versions of the
same formulations
 Age range for vaccines and formulations
differs by manufacturer

19. Flu Vaccine Strains
 Seasonal flu vaccine components usually
change every year
 2009-10 vaccine has: A/Brisbane (H1N1),
A/Brisbane (H3N2), and B/Brisbane
 Novel H1N1 vaccine (A/California) licensed
as “change of strain”—would have been in
seasonal flu vaccine if outbreak had started
earlier in the spring

20. Flu Vaccine Dosage
 TIV and Novel H1N1
 0.5 ml--Children 3 years through adult
 0.25 ml--Infants/toddlers age 6-35 months
 LAIV (seasonal and novel H1N1)
 0.2 ml (intranasal)
 Two doses of vaccine 4 weeks apart are needed
the first year they get it for:
 children under age 9 years for seasonal flu
 children under age 10 years for novel H1N1

21. Thimerosal Free Influenza
Vaccine--1
 Thimerosal is a preservative containing ethyl
mercury used in vaccines since 1930’s
 No conclusive scientific evidence of harm
from exposure to thimerosal
 Studies of risk were of methyl mercury
 In 1999, USPHS recommended eliminating
thimerosal in vaccines for infants, as a
precaution and to retain trust in vaccine
supply

22. Thimerosal Free Influenza
Vaccine--2
 Influenza vaccine in multi-dose vial contains
25mcg/dose
 Manufacturers make a limited amount of
thimerosal-free (<1mcg /dose) flu vaccine
 Benefits of flu vaccine outweigh any
theoretical risk from thimerosal
 Washington law requires that children <3 years
and pregnant women be given thimerosal-free
vaccine, as of 7/1/2007

23. Thimerosal Free Influenza
Vaccine--3
 Emergency suspension of thimerosal law for
H1N1 vaccine only, as of 9/24/09
 Can give thimerosal-containing vaccine to
children <3 years and pregnant women, BUT
must give notice of the suspension to:
 Everyone < 18 years
 Pregnant and breastfeeding women

24. 10 minute break
Break out Health Educators

25. Use the correct needle length
for IM injections
 1” minimum needle recommended
 1½” to 2” needle for larger arm
 Longer needles:
 Hurt less
 Cause fewer local reactions1
 Assures proper route and a valid
dose of vaccine
Diggle L, Deeks J. BMJ 2000;321(7266):931-33.

26. Needle gauge
 Determine appropriate needle gauge
 IM: 22 - 25 gauge
 Lower gauge number = bigger needle
 Use for more viscous medications
 Usual needle length/gauge for IM
vaccines is 25 G 1”

27. Syringes
 Use 3 cc syringes for vaccine
 Vanish Point safety syringes have needle
attached—various sizes and gauges
 Manufacturer-prefilled syringes—
need to attach a separate needle

28. Intramuscular (IM) injection
 Insert the needle at a 90º angle to the skin
 IM injection sites
 Deltoid (arm)
 Vastus Lateralis (thigh)

29. Intramuscular (IM) injection

30. Vaccine Administration
Video Clip from “Immunization Techniques
—Safe, Effective, Caring”

31. Skills Practice—Part 2
Measuring & administering doses
 Draw up 0.5 ml dose of sterile water
into a 3 cc safety syringe
 Show the 0.5 ml dose
 Administer 0.5 ml dose
into an orange
 Activate the syringe’s safety device
 Repeat with the Smith syringe

32. Locating injection landmarks

33. Landmarks:
2-3 finger widths
down from the
acromion process;
bottom edge is at
an imaginary line
drawn from the
axilla.
Deltoid

34.  The deltoid site may be used on a child
that is one year old and walking,
depending on the child’s muscle mass
 Assess the deltoid muscle of the child to
determine if it has sufficient mass for
the injection
 Bunching of the muscle may be needed
with smaller muscle mass
Deltoid

35. Vastus Lateralis
Landmarks:
Place one hand below
the greater
trochanter and one
hand above the lateral
femoral condyle, mid-
lateral thigh

36. The muscle of choice for IM injections in
a child less than 12 months of age
Vastus Lateralis in Infants

37. Injection Site Assessment
Do not use a site with any of the following:
 Muscle atrophy
 Inflammation
 Edema
 Scarring, tattoo, mole, or lesion
 IV port/ access
 Surgery in the limb/lymph node problems

38. Skills Practice—Part 3
Locating Injection Sites
Locate the appropriate
site for a deltoid
injection on your partner.

39. Intranasal Vaccine (LAIV)

40. Skills Practice—Part 4
FluMist Administration
 Dispense the first half of the FluMist dose
into the air (NOT INTO YOUR NOSE!)
 Remove the dose-divider clip
 Dispense the second half of the FluMist
dose

41. Getting ready to give vaccines
in a Medication Center
 Assessment and client education is done by
others in Step 1:
 Registration/Consent form
 Risk vs. benefit of vaccine (Vaccine
Information Statement)
 Thimerosol Information Sheet
 After care instructions
 Emergency Situations call 911 and use PH
CHS Emergency Response Procedures (see
Handouts for Vaso-vagul and Emergency Response)

42. Getting Ready--2
 Identify antigen/formulation to be
administered
 Patient documentation
 Wash/sanitize hands
 Draw up/prepare
the vaccine
 Have bandage and supplies ready

43. Giving the injection
 Ensure client is seated
 Gloves are not required, unless there is a
break in the skin on the nurse’s hand(s)
 Clean the injection site with alcohol and
let it dry before injecting
 Suggest client take slow deep breath,
relax arm muscle during injection
 Aspiration not necessary

44. After the immunization--1
 Engage syringe’s safety device
 Have the patient hold the cotton on their
injection site
 No need to massage the injection site
 Used needles and syringes go into sharps
container
 Place empty vials into biohazard bags

45. After the immunizaton--2
 Partial vials and unused manufacturer
pre-filled syringes go back into the
cooler or refrigerator (35-46° F)
 If you attach a needle to a
manufacturer pre-filled syringe, you
must use it in the same clinic day or
discard it

46. Immediate Adverse Reactions:
Be Prepared!
 Monitor, if possible, for 15-20 minutes
 Anaphylaxis rare but may be life-threatening
 Symptoms:
 Dyspnea, rapid breathing, wheezing
 Flushed face, perspiration, anxiety
 Hives, itching, swelling at injection site
 Itchy/puffy eyes, swelling of mouth or
throat
 Hypotension, cold/clammy skin, syncope
 Summon help from paramedics!

47. Additional Considerations
 Bloodborne Pathogen Exposure
 Vaccine Adverse Event Reporting
System (VAERS)

48. Positioning the Patient
 Adults and adolescents should sit down!
 Parents should use “comforting restraint”
technique
 Parent embraces the child and controls
all four limbs
 Avoids “holding down” or overpowering
the child, but helps you steady and
control the limb of the injection site

49. Comforting Restraint for
Infants & Toddlers
Hold the child on parent’s lap
1. One of child’s arms embraces
parent’s back and is held under
parent’s arm
2. Other arm controlled by parent’s
arm and hand--for infants,
parents can control
both arms with one hand
3. Both legs anchored with the
child’s feet held firmly between
parent’s thighs, and controlled by
parent’s other arm.

50. Comforting Restraint for
Kindergarten & Older Kids
 Hold the child on
parent’s lap or have the
child stand in front of
the seated parent
1. Parent’s arms embrace
the child
2. Both legs are firmly
between parent’s legs

51. Skills Practice—Part 5
 Positioning an infant and child to
receive vaccine

52. Skills Practice
Locating landmarks and giving IM injections
 Locate IM injection sites on adult arm
 Locate IM injection sites on baby leg
 Practice giving IM injections

53. Triage
 Why?
●Assure safe disposition of patients
●Present patient information consistently
● Expansion of skill set for potential public
health response

54. Triage: A piece of the pie
 Screening clients
assists in:
● determining those
who may need
vaccination
● prophylaxis or
● urgent medical
attention

55. Triage
 How?
Using the algorithms
● Pediatric Algorithm
● Adult Algorithm
● Home Care Instructions
● Triage Note

56. Pediatric Triage Algorithm
Patient Presents With Influenza Like Illness (ILI)
· Fast breathing or trouble breathing
· Bluish skin color
· Not drinking enough fluids
· Severe or persistent vomiting
· Not waking up or not interacting
· Infants with no wet diapers for 6 hours and not taking fluids,
irritable or screaming with pain
· Flu-like symptoms improve, then return with fever and
worse cough
· Irritability where the child doesn’t want to be held
Answers yes to
one or more of the
indicators of severe illness
Elevated Risk
Advise to seek medical care
immediately
Assess for Co-morbid Conditions
· Fever:
Newborns with fever over 100.4 F
3 months – 2 year with fever > 102 F
Any age – fever > 100.5 F x 3 days
Any age – fever > 105 F
· Fever with rash
· Not drinking enough fluids
· Asthma, Cystic Fibrosis or Chronic Obstructive Pulmonary Disease
· Coronary Vascular Disease or Congestive Heart Failure
· Diabetes
· Pregnancy* If PHSKC patient, refer triage to provider for treatment
· Morbidly obese (BMI >40%)
· Organ transplant recipient or immune compromised
· AIDS
· Renal Dialysis
· Sickle cell or other hemolytic anemias
· Receiving or completed chemotherapy in the past 30 days
· Neurocognitive and/or Neuromuscular Disease
· On chronic aspirin therapy
· Live with someone 65 years or older
Other household contacts with an underlying condition (listed above)
who are at risk?
Does the patient have one
or more co-morbid factors?
Low Risk
Okay for self-care at home. Repeat
self assessment if condition
worsens.
Any positive answer
No positive answers
Yes
No positive answers
Pediatrics < 18 years
Sick with a fever >100F,
and a cough or sore throat
Intermediate Risk Conditions
Recommend person contact at their
primary care provider or seek care in
clinic.

57. Adult Triage Algorithm
Patient Presents With Influenza Like Illness (ILI)
· Difficulty breathing or shortness of breath
· Constant pain or pressure in the chest or abdomen
· Less responsive than normal or becoming confused
· Severe or persistent vomiting
· Unable to keep liquids down
· Exhibiting signs of dehydration such as dizziness when
standing or absence of urination
· Seizures
· Flu-like symptoms improve but then return with fever and
worse cough
Answers yes to
one or more of the
indicators of severe illness
Elevated Risk
Advise to seek medical care
immediately
Assess for Co-morbid Conditions
· 65 years or older
· Asthma, Cystic Fibrosis or Chronic Obstructive Pulmonary Disease
(COPD)
· Coronary Vascular Disease (CVD) or Congestive Heart Failure (CHF)
· Diabetes
· Pregnancy* If PHSKC patient, refer triage to provider for treatment
· Morbidly Obese (BMI >40%)
· Organ transplant recipient or immune compromised
· AIDS
· Renal Dialysis
· Receiving or completed chemotherapy in the past 30 days
· Neurocognitive and /or Neuromuscular Disease
· Sickle Cell or other hemolytic anemias
· Live with a child less than 19 years old on chronic aspirin therapy
Check in with caller to see if there is any other close household contact that
is showing possible “flu” like symptoms that may affect patient with above
conditions.
Other household contacts with an underlying condition
who are at risk?
Does the patient have one
or more co-morbid factors?
Low Risk
Okay for self-care at home. Repeat
self assessment if condition
worsens.
Any positive answer
No positive answers
Yes
No positive answers
Adults >18 years
Sick with a fever
>100.0 F with a
cough or sore throat
Intermediate Risk Conditions
Recommend person contact at their
primary care provider or seek care in
clinic.

58. Home Care
 Home Care Recommendations for ILI
 Keep away from others as much as possible. This is to keep from making others sick.
 Get plenty of rest.
 Drink clear fluids (such as water, broth, sports drinks, and electrolyte beverages for infants) to keep from being dehydrated. You will probably be
sick for several days with fever, cough and stuffy nose.
 Cover your cough and sneezes.
 Frequent hand washing.
 Don’t share drinking glasses or eating utensils. Dishes can be done in dishwasher or with hot soapy water.
 Throw away tissues and other disposable items used by the sick person in the trash. Wash your hands after touching used tissues and similar waste.
 Have everyone in the household wash hands often with soap and water, especially after coughing or sneezing. Alcohol-based hand cleansers are also
effective.
 Avoid touching your eyes, nose and mouth.
 Take medications for symptom relief as needed for fever and pain such as acetaminophen (Tylenol®) and ibuprofen (Advil®, Motrin®, Nuprin®) and
cough medicine. These medicines do not need to be taken regularly if your symptoms improve.
 Stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without
the use of fever-reducing medicine.)
 Do not give aspirin (acetylsalicylic acid) or products that contain aspirin (e.g. bismuth subsalicylate – Pepto Bismol) to children or teenagers 18 years
old or younger.
 Children younger than 4 years of age should not be given over-the-counter cold medications without first speaking with a health care provider.
 􀂾 If you develop any of the following, seek medical care immediately:
 o Difficulty breathing
 o Purple or blue discoloration of lips
 o vomiting or unable to keep liquids down
 o Dizziness, no urination, lack of tears in infants (signs of dehydration)
 o Seizures, uncontrolled convulsions
 o Confusion, less responsive than normal

59. Triage Note

60. Skills Practice- Part 6
Using the tools
 Use pediatric and adult algorithms
 Demonstrate when to advise home care
vs. office visit
 Preview triage note and use in
conjunction with the home care sheet

61. Questions?

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