Parenteral Medications – Four Injection Routes

It is an ESSENTIAL SKILL that separates nurses from other profession. Professional nursing life is considered INCOMPLETE if this skill has never been tried or has never been practiced. The skill is the ability to INJECT parenteral medications.

Nurses must remember by HEART the various injection routes, as well as, the injection sites, injection equipments, injection techniques, and steps.

So let us review and go back to the BASICS!

The four injection routes

Intradermal injection

  • Commonly used for tuberculin and systemic allergy testing.Intradermal injection Parenteral Medications   Four Injection Routes
  • Common sites are the inner aspect of the forearm. Upper arm, upper chest or upper back beneath the  scapulae are also sites for intradermal injections. 
  • Choose sites that are not heavily pigmented, not hairy, and free from blemishes to detect adverse reactions easily.
  • Use a tuberculin syringe, a 1-mL syringe with 0.01mL increment calibration.
  • In the absence of a tuberculin syringe, gauge 26-27 needles(5/8” to 3/8” long) paired with a 1mL- 3mL syringes can be used

Steps and Injection technique:

  1. With gloves on your hands, locate the injection site and sterilize site with an alcohol pad.
  2. Hold and secure patients’ forearm in your nondominant hand, and stretch the skin taut.
  3. Needle must approach the skin almost parallel (10-15 degree angle) and its bevel up.
  4. Insert the needle into the skin or in between the layers of the skin.
  5. Inject just a small amount of antigen/ substance into the skin to form a wheal.
  6. Remove the needle and mark the test site along the contours of the wheal with a black or blue-colored-pen to track response of each substance.
  7. Check response after 15- 30 minutes. Usually 30 minutes is the safest and best time.
  8. The redder and bigger the induration is, the stronger the allergic reaction.

Subcutaneous injection 

  • Commonly used for heparin and insulin administration. Subcuntaneos injection Parenteral Medications   Four Injection Routes
  • Common sites are the fat pads of the lateral upper arms, upper back, on the abdomen, upper hips, and lateral thighs.
  • Rotate injection sites according to schedule when administering repeatedly, especially with insulin.
  • Insulin syringes and insulin pens can be used for accurate unit dosage.
  •  In the absence of insulin syringes and insulin pens, gauge 25-27 needles (5/8” to ½” long) paired with a 1mL syringe can be used.

Steps and Injection technique:

  1. With gloves on your hands, select an injection site and sterilize site with an alcohol pad.
  2. Grasp the site with your nondominant hand firmly to lift the subcutaneous tissue
  3. Insert needle at a 45-90 degree angle and release the patient’s skin to avoid injecting the drug into compressed tissue that may irritate nerve fibers.
  4. Pull back plunger to check for blood return. Don’t check for blood return in heparin as it can cause hematoma. This is also not necessary for insulin. Usually prefilled syringes don’t need to check for aspiration of blood.
  5. Inject the drug
  6. After injecting the drug,  gently but quickly remove the needle at the same angle it was inserted.
  7. Cover the site with an alcohol pad.
  8. Remove the pad and check the site for bleeding or bruises.

INTRAMUSCULAR INJECTION 300x218 Parenteral Medications   Four Injection RoutesINTRAMUSCULAR INJECTION

  • Commonly used for administering medications deep into the muscle tissue.
  • Common sites are:
    • Ventrogluteal- buttocks with landmark greater trochanter and anterior superior iliac spine
    • Dorsogluteal- buttocks with landmarks greater trochanter and posterior iliac spine
    • Vastus Lateralis- lateral and middle third of the thigh with landmark lateral femoral
    • Deltoid- arms with landmark acromion process
    • Rectus Femoris- easiest to locate at the center of the thigh because it has no landmark
  • Z-track injection is a type of intramuscular injection of irritating drug such as Iron Dextran.  This method promotes absorption of the drug by preventing drug leakage into the subcutaneous layer.
  • Use needles with sizes appropriate to age and muscle size. Use 25G-27G for infants, 23G-24G for children, and 20G- 23G for adults. Needle length is more than 5/8” long.  An inch and a half long needle is for those with more fat tissues.
  • A 16G needle can be used into the gluteal muscle for drugs like Magnesium Sulfate and the like.

Steps and Injection technique:

  1. With gloves on your hands, locate the injection site and sterilize site with an alcohol pad.
  2. Tap the site gently to stimulate the nerve endings and minimize pain when needle is inserted.
  3. Grasp the site with your non dominant hand firmly to lift the muscular tissue. Prepare and insert an alcohol pad in between your non dominant fingers.
  4. Insert needle deep into the muscle at a 90 degree angle using the dominant hand.
  5. Non dominant hand releases the patient’s skin to support the syringe when the dominant hand pulls back the plunger to check for blood return. An aspirated blood in the syringe means the needle has hit a blood vessel.
  6. If no blood appears, inject the drug gently into the muscle.
  7. After injecting the drug,  gently but quickly remove the needle at the same angle it was inserted.
  8. Cover the site with an alcohol pad.
  9. Remove the pad and check the site for bleeding or bruises.

INTRAVENOUS INJECTION

  • Commonly used for  IV drug bolus and IV drug incorporation.
  • Create an access by inserting a cannula directly into the vein. When you have an access, connect Luer connector to an IV tubing for IV infusion of different types of solution and drugs.

Steps and Injection technique:

-Let’s say there is already a venous access attached to a mainline IV bag.

      IV med Incorporation

    1. Wipe the port (where the spike will go through) with an alcohol pad.
    2. Stop the flow of the mainline IV bag by rolling the clamp downwards.
    3. Hold the IV bag with your nondominant hand, while the dominant hand inserts the needle into the port.
    4. Inject drug into the IV bag and then mix by tipping the IV bag downwards and upwards.
    5. Open clamp and regulate the drug solutions’ drops.

        IV med bolus

    1. Sterilize injection port of the IV tubing with an alcohol pad.
    2. Make sure the prepared drug in the syringe has no bubbles or air.
    3. Insert the needle into the injection port gently so as not to puncture the IV tubing.
    4. Fold the IV tubing above the injection port with your nondominant hand, while the dominant hand injects the drug IV tubing. This makes sure that the drug goes towards the patient and not up the IV, towards the drip chamber.

Photo credits: (1) (2) (3)

References:

Fundamentals of Nursing: Made Incredibly Easy! by Lippincott Williams and Wilkins Lippincott’s Nursing Procedures 5th edition by Lippincott Williams and Wilkins

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About J.Mag, RN, USRN

J.Mag is a registered nurse from the Philippines. J.Mag has worked and volunteered in different hospitals. J.Mag even passed a couple of foreign nursing board exams including Prometric for the Kingdom of Saudi Arabia and NCLEX for the state of Vermont, USA. When not busy working for the Department of Health as a community health team supervisor, and studying for other foreign exams, J.Mag is most likely writing articles.