C H A P T E R

Administration
34
of Parenteral Essential Terms
ampule

Medications aqueous
aspirate
bolus
cannula
Chapter Outline cartridge unit
Administration of Parenteral Immunizations cubic centimeter (cc)
Medications Contraindications and Precautions diluent
Parenteral Equipment and Supplies in Vaccine Administrations extravasation
Preparing Medications Basics of Intravenous Therapy gauge
General Guidelines for Parenteral Equipment and Supplies Employed hypodermic
Medications in Intravenous Therapy infiltration
Routes of Administration Documentation of IV Therapy intra-articular
Intradermal Injections Risks, Complications, and Adverse intradermal
Reactions of IV Therapy intramuscular (IM)
Subcutaneous Injections
Discontinuation of Intravenous Luer-Lok
Intramuscular Injections
Infusion Therapy occlusion
Parenteral Complications
Intra-articular Injections parenteral
patency
phlebitis
precipitate
primary drug
secondary drug
continues

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 836 ❖ CHAPTER 34

KEY COMPETENCIES CAAHEP ABHES

Withdraw Medication from a Vial III.C.3.b.4.g VI.A.1.a.4.m
Withdraw Medication from an Ampule III.C.3.b.4.g VI.A.1.a.4.m
Reconstitute a Powdered Base Medication with a Diluent III.C.3.b.4.g VI.A.1.a.4.m
Mix Two Medications into One Syringe III.C.3.b.4.g VI.A.1.a.4.m
Load a Cartridge or Injector Device III.C.3.b.4.g VI.A.1.a.4.m
Administer an Intradermal Injection III.C.3.b.4.g VI.A.1.a.4.m
Administer a Subcutaneous Injection III.C.3.b.4.g VI.A.1.a.4.m
Administer an Intramuscular Injection III.C.3.b.4.g VI.A.1.a.4.m
Administer a Z-Track Medication III.C.3.b.4.g VI.A.1.a.4.m

subcutaneous
Developmental Objectives
taut After completing this chapter, you should be able to:
thrombosis 1. Correctly spell and define the essential terms.
trocar 2. List six separate routes used for delivering parenteral medications.
vial
3. List four common parenteral routes by injection and list which ones are
viscosity routinely performed by the medical assistant.
wheal
4. Name and describe the components of a hypodermic needle and syringe.
5. Describe various designs of needle safety devices, and discuss the impor-
tance of using these devices.
6. Describe the importance of needle safety when administering injections.
7. Describe factors that help determine the size of the syringe, the length of
needle, and the gauge of needle to be used.
8. List complications that may occur when incorrect equipment is used or
the medication is administered using the wrong route.
9. Describe the role of the medical assistant in the administration of intrave-
nous medications.
10. List several complications that may occur when administering IV
medications.
11. List instances in which IV therapy should be discontinued.

Introduction
Medical assistants are often responsible for the administration of parenteral medi-
cations. The most common form of parenteral medication is injectables. In order
to successfully perform this task, the medical assistant must be able to select the
appropriate equipment, properly prepare the medication, select a suitable site,
and administer the medication using the correct technique. Both providers and
patients want to know that they can depend on the medical assistant to institute

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 A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
safety checks along the way to ensure that the entire
procedure is performed with absolute accuracy.
Failure to institute safety measures can result in seri-
ous consequences for the patient and possible litigation
for the office. This chapter will address the many duties
associated with parenteral drug administration and
provide useful tips that will aid in decreasing patient
discomfort and anxiety.
ADMINISTRATION OF
PARENTERAL MEDICATIONS
The term parenteral means pertaining to outside
the intestines. When referring to parenteral medica-
tion, it means to deliver medication via a route other
than through the digestive tract. The most com-
mon route used to deliver parenteral medications is
through injection; however, other parenteral routes
include intravenous (within the vein), transdermal
(through the skin), transmucosal (through the mucus
membrane), topical (on the skin), and inhalation
(through the respiratory tract). This chapter addresses
parenteral medications delivered through the injec-
tion and intravenous routes; refer to Chapter 32
for all enteral and parenteral routes.
Common parenteral routes by injection include
intradermal, subcutaneous, intramuscular, and intra-
TABLE 34-1 Advantages and Disadvantages of the Parenteral Route of Administration
ADVANTAGES
Effective route when other routes would be difficult to
use. For example, if the patient is unconscious or
unresponsive.
Medications administered by injection do not cause
irritation to the patient’s digestive system, nor are
they altered by gastric acids.
An exact dose can be administered to a direct site
by injection.
Effects of the medication take place much more
rapidly than the oral route, so a patient that is in
excessive pain would receive faster relief from a
parenteral pain reliever than an oral pain reliever.
27187_34_c34_p835-882.indd Sec1:837
❖ 837
articular. Of those routes, only three are routinely used
by the medical assistant: intradermal, subcutaneous,
and intramuscular. Some medical assistants are also
responsible for administering intravenous medications;
however, this will vary according to the state’s medical
practice act and office policy.
Parenteral medications are delivered into the blood
stream much more rapidly than oral medications, usu-
ally within minutes. The following list provides infor-
mation regarding the amount of time it takes for a
medication to enter the bloodstream through selected
parenteral routes:
❖ Intravenous: Instantly to seconds
❖ Intramuscular: 5 to 15 minutes, depending
on the drug
❖ Subcutaneous: Several minutes
Table 34-1 lists both the advantages and disadvan-
tages of parenteral administration.
Parenteral Equipment and Supplies
There is a multitude of equipment and supplies available
for the delivery of parenteral medications. Syringes and
needles come in many sizes and are selected according
to the route the medication is to be given, the patient’s
body size, the viscosity (or thickness) of the medica-
tion, and the amount of medication to be given.
DISADVANTAGES
Unsanitary equipment or mishandling of the equip-
ment could cause microorganisms to be introduced
into the patient.
An allergic reaction to a parenteral drug may occur
more rapidly and may be more severe than an allergic
reaction to an oral medication because of how
quickly it is absorbed into the bloodstream and the
amount that is given in one dose.
Improper injection procedures could cause damage to
the patient’s nerves, tissue, veins, and other vessels.
Veins could be traumatized by an intravenous
injection.
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 838 ❖ CHAPTER 34

Syringes
Syringes (Figure 34-1) used today are primarily made of
TOOL BOX
plastic and are completely disposable. Typical syringe
sizes range from 1 mL to 5 mL. Larger syringes (10 to FI E L D S M A RTS
60 mL) are used for irrigating wounds or body cavi- In order to prevent the medication from becoming
ties, drawing large amounts of blood, and for aspirat- contaminated, you must never touch the inside of
ing fluid from a patient’s joint or body cavity. Syringe the barrel of the syringe, the rubber stopper on
selection is primarily based on the amount of medica- the plunger, or the tip of the syringe that con-
tion to be administered. nects to the needle.
Syringes are packaged in hard plastic containers or
peel-apart packages and are sealed to ensure steril-
ity. If a syringe package appears to have already been
opened, the syringe should not be used and should be
disposed of properly.
The components of a syringe include the calibrated
barrel, plunger, flange, and tip (Figure 34-2). Table 34-2 FIGURE 34-2 The parts of a syringe
explains each component of a syringe.
Luer-Lok tip
Needles Tip
Barrel Rubber Rubber
Needles are available in various sizes and lengths and stopper stopper
come in disposable and nondisposable forms. Needle
selection is determined by the type of medication to be Plunger
administered, the route of administration, and the size
of the patient. Disposable needles are more commonly Plunger

used and are prepackaged in sterile plastic or paper

wrappers. Flange Flange
A needle’s gauge (G) refers to the diameter of the
needle. Gauge selection is determined by the viscosity 3 mL syringe
or thickness of the medication. Gauge sizes that are typ- separated
ically used in ambulatory care range from 20 to 27 G. 5 mL syringe separated
The larger the gauge, the smaller the diameter of the and together
needle (for example, a 22-G needle would be smaller in
diameter than a 20-G needle). Figure 34-3 shows the
different needle gauges and lengths available.

FIGURE 34-1 Syringes can range from 1 mL to 60 mL. FIGURE 34-3 Examples of different needle gauges and lengths

60 mL syringe

30 mL syringe

10 mL syringe

5 mL syringe

3 mL syringe

Tuberculin
Insulin syringe with needle

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 A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 839

TABLE 34-2 Description of the Components of a Syringe

Barrel The cylinder that holds the medication and contains calibrations for precise measuring. The barrel
is typically calibrated in milliliters (mL) or cubic centimeters (cc) but may be also be calibrated in
minims (M). Some specialty syringes contain other calibrations such as
the insulin syringe, which is calibrated in Units.
Plunger A plastic rod with a rubber stopper on one end that seals the medication
within the syringe and flared edges on the other end for maneuvering
the plunger. This apparatus either draws medication in or pushes medi-
cation out of the barrel.
FIGURE 34-4 Slip-tip
Flange The flared plastic rim on the syringe used for guiding the plunger.
Tip The part of the syringe in which the needle is attached. Different types
of syringe tips include: the Slip-tip (Figure 34-4), a smooth tip in which
the needle is attached just by slipping it onto the syringe; and the
Luer-Lok tip (Figure 34-5), which has a threaded end in which the
needle can be locked by twisting. The tip of the syringe must remain
sterile throughout the entire procedure. FIGURE 34-5 Luer-Lok tip

Table 34-3 provides specific details for selecting the
appropriate gauge based on the route and the viscos-
ity of the medication. Note: General guidelines for needle
gauges are provided later in the chapter under Routes of
Administration and should be used as guidelines for certifi-
cation and registration testing.
The length of the needle is determined by the route
of administration, the site of the injection, and the
amount of adipose tissue over the injection site. Intra-
muscular (IM) injections will require a longer needle
than a subcutaneous or intradermal injection because
muscles are deeper than the other two types of tis-
sue. The location of the injection also plays a role in
the selection of needle length. The deltoid and gluteal
muscles are two common muscles that are used for
intramuscular injections, but each muscle is a different
size and at a different depth. The deltoid is smaller and
more superficial than the gluteal muscle and, therefore,
would take a shorter needle. Finally, the amount of
adipose tissue that the patient has in the area in which

TABLE 34-3 Common Gauge Sizes Based upon the Route of Administration and Viscosity of the Medication

GAUGE OF VISCOSITY OF
NEEDLE MEDICATION ROUTE EXAMPLES
19–20 Thicker or oil-based medications IM Hormones, steroids, penicillin, and certain
vitamin preparations
21–23 Aqueous- or water-based medications IM Immunizations and other water-based
medications
23–25 Aqueous-based medications Sub-Q Immunizations, allergy medications, etc.
26–27 Aqueous-based medications ID Allergy testing extracts and PPD extract
30 Aqueous-based medications Sub-Q Used when repeated injections are given,
(usually such as insulin
ultra-fine
point)

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 840 ❖ CHAPTER 34

the injection is being administered will also play a role

in the length of the needle that is used. Patients with
larger amounts of adipose tissue will require a lon-
ger needle to penetrate through the extra layers than
patients with little adipose tissue.
Table 34-4 provides common needle lengths based
upon the route of administration, the location of the
injection, and the size of the patient. Note: General
guidelines for needle lengths are provided later in the chap-
ter under Routes of Administration and should be used as
guidelines for certification and registration testing.
TOOL BOX
FI E L D S M A RTS
Many practices stock a limited variety of needle
gauges and lengths. This can be a real problem
when the patient does not meet the parameters of
what is considered to be average. The smart med-
ical assistant will stock a wide variety of needle
gauges and lengths to accommodate patients of
all sizes and medications of all viscosities.

Parts of the Needle Even though needles come in

disposable and nondisposable forms, they all have
similar components. Figure 34-6 shows different nee-
dles that are used for various routes and Figure 34-7
shows the different parts of a needle.
The parts of a needle include the following:
❖ Point: The sharpened end of the needle, cut in a
slanted edge called the bevel

TABLE 34-4 Common Needle Lengths Based upon the Route of Administration,
Location of the Injection, and Size of the Patient (Adult Chart)

INTRADERMAL INJECTIONS
Patients of all sizes 3 ⁄8⬙ to 1⁄2⬙

SUBCUTANEOUS INJECTIONS
Patients with little adipose tissue (muscular patients) 3 ⁄8⬙ to 1⁄2⬙
Patients with an average to large amount of adipose tissue 1 ⁄2⬙ to 5⁄8⬙

INTRAMUSCULAR INJECTIONS
Deltoid: Adult with an underdeveloped or atrophied deltoid muscle and very little adipose
tissue (i.e., frail adult) 5 ⁄8⬙
Deltoid: Adult with a well-developed deltoid muscle and an average amount of adipose tissue 1⬙
Deltoid: Adult with a well-developed deltoid and a large amount of adipose tissue 11⁄4⬙
Gluteal: Adult with very little adipose tissue 11⁄4⬙ to 11⁄2⬙
Gluteal: Adult with an average amount of adipose tissue 11⁄2⬙
Gluteal: Adult with a large amount of adipose tissue 2⬙ to 3⬙
Vastus lateralis (thigh): Adult with very little adipose tissue 1⬙
Vastus lateralis (thigh): Adult with an average amount of adipose tissue 11⁄4⬙
Vastus lateralis (thigh): Adult with a large amount of adipose tissue 11⁄2⬙ to 2⬙

Little adipose tissue: Can only pull up very little adipose tissue when lightly pinching the skin in the area
in which you are administering the injection (females or males less than 130 lb).
Average amount of adipose tissue: Can pull up an average amount of adipose tissue when lightly pinching the
skin in the area in which you are administering the injection (females 130 to 200 lb or males 130 to 260 lb).
Large amount of adipose tissue: Can pull up a large amount of adipose tissue when lightly pinching the skin in
the area in which you are administering the injection (females 200+ lb or males 260+ lb).

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 A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 841

TOOL BOX Intramuscular Subcutaneous

C R I T I C A L TH I N K I N G Intradermal

C H A LL E N G E
An elderly, frail patient comes into the practice
to obtain a flu vaccine, which is an aqueous or
water-based solution. The patient’s deltoid mus-
cle is not very prominent and the patient has very
little fat over the deltoid. The needles available
are 23 G 5⁄8⬙, 22 G 1⬙, and 20 G 11⁄2⬙.
Intracatheters
1. What needle would work best for this for intravenous
particular medication and patient? Give use Butterfly needle and tubing for
infusions of medications i.v.
the reason for your selection. over a period of time

FIGURE 34-6 Different needles used for various routes of

administration

TOOL BOX
Lumen Shaft

C R I T I C A L TH I N K I N G
C H A LL E N G E Point Bevel
Mrs. Sims in room 2 is waiting for an ACTH injec-
tion. ACTH is a very thick, oily hormone. Mrs.
Plastic sheath
Sims has a large amount of adipose tissue around
her hips and buttocks region and weighs 253
pounds. The needle sizes available include 27 G
3⁄ ⬙, 25 G 5⁄ ⬙, 22 G 1⬙, 21 G 11⁄ ⬙, and 20 G 2⬙.
8 8 2 Point Shaft Hub
1. Which needle would work best under Lumen Hilt
these conditions? List your reasons.

❖ Lumen: The bore of a hollow needle
❖ Bevel: The flat, slanted edge of the needle that
helps to ease the insertion of the needle into the
tissue; there are finer cuts and different lengths of
bevels, such as a fine tip bevel, which is used for
insulin syringe needles. The finer the cut of the
bevel, the less pain felt by the patient and the less
trauma to the patient’s tissue.
❖ Shaft: The hollow steel tube of the needle through
which the medication passes into the patient
❖ Hub: The component that facilitates the attach-
ment of the needle to the syringe; the hub is
color-coded for easy recognition of the size and
must remain sterile when assembling the needle
and syringe.
❖ Safety device: A mechanism to shield the needle
after use (see Figure 34-8)
FIGURE 34-7 The parts of a needle
TOOL BOX
FI E L D S M A RTS
Even though most injection equipment looks very
similar, you should refrain from mixing one man-
ufacturer’s equipment with another manufactur-
er’s equipment. There may be slight variations in
the equipment’s locking mechanisms, preventing
the needle from firmly attaching to the syringe.
This may cause leakage of medication from the
syringe and detachment of the needle during the
procedure.

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 842 ❖ CHAPTER 34

Needle Safety when Using Parenteral Equipment

Needle safety is very important when working with
parenteral equipment. Each office should use safety
devices to help prevent accidental needlesticks from
contaminated needles. There are a variety of different
types of safety devices, including retractable needles
and plastic sheaths that slide down over the needle.
Figure 34-8 shows a couple of different types of safety
devices.
If a dirty needlestick occurs while performing an
injection, the medical assistant should wash the area
immediately with soap and water and report the inci-
dent to a supervisor. An incident report should be
completed and the employee should receive counsel-
ing regarding what lab testing should be performed
and possible treatment options. Refer to Chapter 10
for a review of needle safety guidelines and procedures (a) (b) (c)
to follow in the event of a needlestick.
FIGURE 34-9 Various medication containers: (a) ampule;
(b) cartridge unit; (c) vial
Preparing Medications
Medications for parenteral administration are stored in
a variety of different containers. Medications may be Measuring Medication in a Syringe
stored in a(n):
The type of syringe used will be based on the amount
❖ Ampule (Figure 34-9a): A glass container with a of medication to be administered and sometimes on
stem that holds a single dose of medication the type of medication (for example, insulin). Syringe
❖ Cartridge unit (Figure 34-9b): A disposable, sizes 3 cc and below are normally calibrated using two
prefilled, single-dose cartridge of medication that scales: minims and milliliters (mL). Larger syringes are
slips into a nondisposable injection device normally calibrated in mL only. To draw up the cor-
❖ Vial (Figure 34-9c): A glass or plastic container rect amount of medication, the medical assistant must
that may contain either a single dose or multiple be able to properly read the calibrations on the outside
doses of medication of the syringe. The shorter lines on a 1-cc tuberculin

FIGURE 34-8 Examples of safety needles that assist in preventing accidental needlesticks (Courtesy and © Becton,
Dickinson, and Company.)

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 A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S
syringe are measured in increments of hundredths.
Each small line represents 0.01 cc, or 1⁄100 of a cubic
centimeter. The longer lines are measured in tenths—
each line represents 0.1 cc, or 1⁄10 of a cc, and range
from 0.1 to 1.0 cc. On a 3-cc syringe, the smaller cali-
brations are measured in tenths and represent 0.1, or
1 ❖ When removing the medication vial from the shelf
⁄10 of a cc. The larger lines represent increments of 1⁄2,
1, 11⁄2, 2, 21⁄2, and 3 cc. On a 5-cc syringe, the smaller
calibrations are measured on a scale of 0.2, or 2⁄10 of a
cc, with the longer calibration lines representing 1, 2,
3, 4, and 5 cc.
Some specialty syringes are measured in units. A
unit is the amount of a substance necessary to stimu-
late a biological effect. The biological effect that one
unit of medication has upon body tissue is decided
upon by the International Conference for the Unifica-
tion of Formulas. Unit increments are commonly used
for substances such as insulin and particular vitamins
and are specific to the individual substance or medi-
cation being administered; therefore, insulin syringes
may not be interchanged with other types of syringes.
To correctly fill a syringe, the plunger should be
pulled back so that the top of the rubber stopper is
even with the calibration line on the outside of the
syringe, matching the amount of medication ordered
by the physician (Figure 34-10).
Withdrawing Medication from a Vial
When medication is stored in a vial, it may be in a single-
dose vial (containing an individual dose of medication)
or a multiple-dose vial (containing several doses). The
FIGURE 34-10 Examples of syringes containing specific
amounts of medication: (a) 3 mL syringe filled to 1.5 mL;
(b) standard U-100 insulin syringe filled with 70 U of U-100
insulin; (c) 1 mL syringe filled to 0.3 mL
(a)
(b)
(c)
27187_34_c34_p835-882.indd Sec1:843
❖ 843
name and strength of the drug should be checked on
the medication label a minimum of three times and
verified with the physician’s order. Always check the
expiration date on the vial as well. This information is
usually checked:
❖ Right before preparing the medication
❖ Right after preparing the medication
A vial is packaged with a sterile cap that protects the
rubber stopper. The sterile cap will need to be removed
in a manner that prevents the stopper from becoming
contaminated prior to removal of the medication. Care
must also be taken not to contaminate or damage the
vial when preparing the medication.
Medication in a vial must be aspirated, or pulled
into the syringe through a needle, by pulling back on
the plunger of the syringe.
To prepare the syringe for use, remove it from the
wrapper and assemble the needle. Pull the plunger
TOOL BOX
FI E L D S M A RTS
Always inspect the rubber stopper of the vial to
make certain that the rubber is completely intact.
Check the medication in the vial to make sure
the there is no precipitate (pieces of solid mate-
rial or crystals) or unusual cloudiness. If anything
unusual does appear, do not use the medication
and check with a supervisor to see if it should be
discarded. Always check to see how the medi-
cation should be stored, both before and after
opening.
TOOL BOX
FI E L D S M A RTS
There is no need to clean the stopper on a medi-
cation vial immediately after removing the seal.
The stopper is sterile at this point unless you con-
taminate it when removing the seal. Once the first
dose of medication has been removed, the stop-
per is no longer considered sterile and will need
to be cleansed with an alcohol wipe with each
subsequent use.
9/4/08 6:50:51 PM
 844 ❖ CHAPTER 34
within the barrel back to the calibration line that
matches the amount of medication to be removed. For
example, if removing 11⁄2 mL of medication from the
vial, 11⁄2 mL of air must be inserted into the vial before
withdrawing the medication.
There is an air pressure vacuum inside the vial that
makes it easier to pull up the medication. The purpose
of forcing air into the vial is to equalize the pressure
within the vial after the medication has been removed.
If the proper amount of air is not inserted within the
vial, the pressure within the vial will drop, making it
very difficult to pull back on the plunger when filling
subsequent syringes. On the other hand, if too much
air is inserted within the vial, the pressure within the
vial will become very powerful, causing the medication
to be involuntarily forced out through the stopper and
out into the syringe.
Once the vial is prepared and the plunger is
pulled back to the amount of medication being with-
drawn, insert the needle into the vial. With the vial
still in an upright position, push the plunger for-
ward to expel the air within the syringe into the vial
(Figure 34-11). Pick up the vial and invert it with the
needle in it. Make certain that the needle is below
the liquid line before pulling back on the plunger
(Figure 34-12).
FIGURE 34-11 Expel an amount of air into the vial that is equal
to amount of medication to be withdrawn.
27187_34_c34_p835-882.indd Sec1:844
TOOL BOX
C R I T I C A L T H I N K ING
C H A L L E N GE
When withdrawing medication from a vial, you
notice that it is very difficult to pull back on the
plunger.
1. What may be the cause of this problem?
2. What can you do to correct the problem?
Carefully pull back on the plunger until reaching the
desired amount of medication to be withdrawn. Gently
pull the needle out of the vial and carefully place the
cap on the needle following institutional policy. (Tiny
air bubbles in the syringe may need to be removed by
gently flicking the syringe prior to withdrawing the
needle from the vial.) Procedure 34-1 lists the proper
steps for performing this procedure.
Withdrawing Medication from an Ampule
An ampule is made of sterile glass and contains one
single dose of medication premeasured to the exact
volume or amount needed. Examples of single-dose
medications contained in an ampule include heparin
FIGURE 34-12 The needle must be below the liquid line in
the vial before withdrawing the medication.
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 A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 845

paring the medication. The neck of the ampule should

TOOL BOX be placed in a sharps container.
A special needle that contains a small filter
F IEL D S M A R T S within the lumen can be used to remove any glass par-
It is not against OSHA policy to recap a sterile ticles that may have mixed with the medication when
needle. The Needle Stick Safety and Prevention the top was snapped from the body of the ampule. A
Act is in reference to contaminated needles, not membrane filter (Figure 34-15) may also be attached
sterile needles. to the syringe before attaching the needle to keep glass
out of the syringe. The filter needle is then removed
and replaced with a hypodermic needle before inject-
ing the patient. Refer to Procedure 34-2 for the proper
and morphine. The neck of the ampule is constricted steps to follow when withdrawing medication from an
and may cause medication to become trapped at the ampule.
top of the ampule (Figure 34-13). By flicking the
ampule with your wrist and hand, any trapped medi-
cation in the top will be forced down into the body of FIGURE 34-14 Cover the neck of the ampule with gauze and
snap the neck off away from you.
the ampule. The outer surface of the ampule should be
cleaned with an alcohol pad or other antiseptic prior
to opening.
The glass ampule is hermetically sealed, mean-
ing the dose is completely enclosed in glass, and the
neck is scored (indented), so it will break easily when
opened. The medical assistant should practice safety
procedures when separating the neck of the ampule
from the body of the ampule by covering the neck with
a gauze square and breaking it away from the body
(Figure 34-14). This will help prevent tiny particles of
glass from flying into the face or eyes of the person pre-

FIGURE 34-13 Force medication from the neck of the ampule

by a quick snap of the wrist.

FIGURE 34-15 Various membrane filters that can be attached to

syringes of all sizes, in place of using a standard filter needle

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 846 ❖ CHAPTER 34
Reconstituting Medications for Injection
Certain medications are packaged in powdered (dry)
form and must be reconstituted with a liquid in order
to be injected. Powder forms of medication have a lon-
ger shelf life than liquid forms. A diluent (liquid) is
used to reconstitute the powder. Normally this solu-
tion is sterile saline (NaCl), sterile water (H2O), or
lidocaine. The diluent may be supplied with the medi-
cation or may need to be drawn up separately. The
medical assistant must always follow the manufactur-
er’s instructions when reconstituting a medication.
Once the diluent is removed from its original con-
tainer, it is injected into the powdered drug vial and
gently mixed by rolling the solution between both hands
until the all of the powder particles are dissolved.
Once the particles are completely dissolved, the
medical assistant will draw up the freshly made dilu-
tion (medication) following the physician’s orders.
Procedure 34-3 provides detailed instructions on the
steps required for reconstituting powdered drugs.
Mixing Two Medications in a Single Syringe
When a physician orders two medications, it is some-
times possible to combine the two drugs into one
syringe, thus making it possible to give one injection
instead of two separate injections. It is most important
to check with the physician or pharmacist to clarify if
the two medications can be combined. Some medica-
tions are not compatible and may cause problems if
combined.
When combining two medications, the medical
assistant must determine which medication is the
TOOL BOX
F IEL D S M A R T S
Changing the needle between the vial and patient
reduces complications during and following the
injection. Each time the needle is pushed through
the stopper of a vial, it becomes dulled, making it
difficult to puncture the skin and creating more
pain for the patient. In addition, irritating sub-
stances such as allergy extracts may adhere to
the needle upon aspiration from the vial. As the
needle penetrates the skin, a small amount of the
medication may adhere to the outside of the skin,
promoting a painful local reaction at the site of
the injection.
27187_34_c34_p835-882.indd Sec1:846
primary drug and which is the secondary drug. The
primary drug is the first drug to be drawn up into the
syringe. When administering insulin, the primary drug
is the clear insulin and the secondary drug is the cloud-
ier insulin. Always check with the physician when in
doubt. Procedure 34-4 lists step-by-step instructions
for mixing two medications in a single syringe.
Using a Medication Cartridge or an Injector Device
Some medications come in sealed, prefilled glass car-
tridges that hold a single dose of medication. Depo-
Provera, penicillin G benzathine, Phenergan, and
interferon are examples of medications that are avail-
able in cartridges. The prefilled cartridge–needle units
require no mixing, no special calculations, and are eas-
ily administered to the patient.
The cartridge–needle units are designed to fit into a
cartridge unit syringe, referred to as an injector device
(Figure 34-16). Injector devices, such as Tubex® and
Carpuject® syringes, are usually nondisposable, made of
nonchrome-plated brass or plastic, and are interchange-
able with many brands of cartridges. Procedure 34-5
lists steps that are performed when using a cartridge
injector device.
General Guidelines for Parenteral
Medications
In most medical facilities, the medication is prepared
in a different room than the examination room and
transferred to the exam room prior to injecting. Below
are guidelines to follow when preparing and adminis-
tering all types of injections:
FIGURE 34-16 A cartridge–needle unit and a reusable injec-
tor device
Plunger rod Plunger
Rubber collar
Disposable sterile
cartridge-needle
unit
9/4/08 6:50:55 PM
 A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 847

❖ Prepare only one order of medication at a time
and for one patient at a time. If the patient is to
be given multiple injections, prepare each one
separately and label syringes or syringe wrappers
with a marking pen so that you can identify which
syringe holds what medication.
❖ Follow standard safety precautions when dealing
with needles and syringes.
❖ Ensure that contamination does not occur to the
equipment during preparation or transport.
❖ Never allow another health care worker to
prepare a medication that you will administer,
nor should you prepare a medication for someone
else. The responsibility for a medication error
falls on the person who administers the
medication.
❖ Follow the seven rights (from Chapter 32) when
administering all medications.
❖ Use two patient identifiers before administering
any medications (part of the Patient Safety Act).
❖ Check the patient’s drug allergy status, latex
allergy status, and adhesive allergy status prior to
administering any medication.
❖ Wash your hands and wear gloves just prior to
administering any parenteral medications. The
gloves are to protect you against possible bleeding
from the site.
❖ Never allow a patient to stand while receiving an
injection. The patient’s blood pressure may drop
and the patient may faint.
❖ Sites should be free of scar tissue, wounds, lesions,
rashes, moles, or any other disturbance in tissue
growth.
❖ Cleanse all sites with an approved skin antiseptic
using a circular motion prior to the injection.
❖ Stabilize your hand when holding the needle and
syringe. Hand movement may cause the needle to
move, nicking a blood vessel or nearby nerve.
❖ Follow the same track coming out of a site that
you use going in. This will decrease injury to the
surrounding tissue.
❖ Engage the needle sheath or safety device on the
syringe immediately following the injection and
dispose of the unit in the sharps container.
❖ Patients should wait a minimum of 20 to
30 minutes following the injection to monitor
for anaphylaxis.
Guidelines for Aspiration
When administering intramuscular and subcutane-
ous injections, the medical assistant should aspirate
to make certain that the needle is not in a blood ves-
sel. Depositing drugs directly into the bloodstream that
are meant for slower absorption may result in serious
complications to the patient. To aspirate, pull back
slightly on the plunger and look for blood in the tip
of the syringe. If this occurs, the needle–syringe unit
must be removed and disposed of according to OSHA
guidelines.
Some drug manufacturers discourage aspiration
when administering certain types of medications. Med-
ical assistants should check the drug package insert
when in doubt. Table 34-5 lists general guidelines for
aspiration.
Guidelines for Massaging the
Site Following the Injection
At the conclusion of subcutaneous and intramuscular
injections, gently massage the site with a cotton ball
or gauze pad to assist with the disbursement of the
medication. Massaging is contraindicated with particu-
lar types of medications, especially those that may be
irritating to the tissue or those that can stain the skin.
Examples of medications in which massage is contra-
indicated include heparin, imferon, insulin, Fragmin,
and Lovenox. Massaging after these injections can
damage tissue at the site or cause the medication to be
absorbed incorrectly.
Massaging is contraindicated when performing all
intradermal injections due to the disbursement of the
extract into deeper tissue and when administering all
Z-track injections.

TABLE 34-5 General Guidelines for Aspiration

Intradermal Do not aspirate on any intradermal injections.

Subcutaneous General guidelines call for aspiration during subcutaneous injections; however, some
medications given through this route discourage aspiration, including Heparin, Lovo-
nox, and insulin. Always check the manufacturer’s insert for clarification.
Intramuscular (IM) General guidelines call for aspiration for IM injections; however, always check the drug
package insert for clarification.

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 848 ❖ CHAPTER 34
Following the Procedure
Patients should be monitored for anaphylaxis (life-
threatening allergic reaction) for 20 to 30 minutes fol-
lowing the injection. Most anaphylactic reactions will
occur during this time period. Check the patient at the
end of the monitoring period to make certain there are
no concerns. Observe the site where the injection was
administered and look for any local reactions including
redness, wheals, or swelling. Ask if the patient is expe-
riencing any breathing difficulties or any other unusual
symptoms. If the patient experiences anything out of
the ordinary, check with the provider before dismiss-
ing the patient. Provide the patient with education on
how to manage the injection site and what to expect
FIGURE 34-17 An example of
a hospital medication log used to
document all medications for a
specific patient
27187_34_c34_p835-882.indd Sec1:848
over the next few days. Document the procedure and
the follow-up observations in the patient’s chart. Refer
to Chapter 4 for a complete procedure on document-
ing medications. Medications such as immunizations
and narcotics should also be documented in designated
log. Figure 34-17 shows a hospital medication log.
ROUTES OF ADMINISTRATION
The route that is selected for parenteral delivery will be
primarily based on the manufacturer’s recommenda-
tion and the intended use of the drug. Routes selected
by the manufacturer are based on absorption properties
of the drug and possible irritants or dyes in the drug
9/4/08 6:50:59 PM
 A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 849

TOOL BOX
F IEL D S M A R T S
Patients will often tell you that they do not have
to wait following an injection because they are
not allergic to the medication. Remind patients
that they can develop an allergy at any time and
that office protocol requires the patient to wait.
Patients refusing to wait should sign a refusal
form that states the possible consequences of not
waiting. Place the refusal form in the patient’s
chart and document the refusal on the progress
note. Know your office’s protocol in the event a
patient does have a reaction. EpiPens or epineph-
rine should be stocked in any room where injec-
tions are administered.
FIGURE 34-18 The needle is inserted at a 10° to 15° angle for
an intradermal injection.

that may make it harmful to surrounding tissue. Alter-
ing any drug routes could cause harmful side effects for
the patient, such as tissue abscess and degeneration,
tissue staining, and shock.
Intradermal Injections
The term intradermal means pertaining to within the
skin. The epidermis (outer layer of the skin) is the layer
of skin that is used for intradermal injections. In order
for the needle to stay within this layer, the needle should
be positioned at a 10° to 15° angle (Figure 34-18).
When the medication is slowly injected at this angle, a
bubble of fluid called a wheal (Figure 34-19) should
appear on the outer surface of the skin.
The standard sites used for intradermal injections
are the inner lower forearm and the middle of the back
(Figure 34-20). These sites are used due to the lack of
hair found in these areas and the thinness of the skin.
Because of the location of the injection, aspiration is not
necessary when performing intradermal injections.
Common types of injections administered through
this route include allergy extract for testing purposes
and the PPD or tuberculin skin test. Intradermal injec-

FIGURE 34-19 A wheal should appear on the surface of the arm

following an intradermal injection.
TOOL BOX
E M R A P P L I C AT I O N
Many EMR software applications have a “Logs”
section integrated within the software. Medica-
tion logs can be easily accessed by clicking on
the “Logs” icon or equivalent name and clicking
on the appropriate medication log. Often, the
manufacturer’s name, lot number, and expiration
date will automatically appear from the previous
entry. Make certain that these items match the
current medication label. If they do not, change
these items to match the current label.

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 850 ❖ CHAPTER 34

FIGURE 34-20 Sites for

an intradermal injection
include the inner forearm
and the upper portion of
the back.

tions should never be massaged because it will force Subcutaneous Injections

the liquid to be dispersed in deeper tissues, causing the
wheal to disappear.
Patients receiving intradermal injections will need
to have the site evaluated within a prescribed time
frame. The provider will measure the site where the
wheal was induced. If the wheal extends over a specific
parameter, it means that the test is positive. Table 34-6
is a summary chart for key information regarding
intradermal injections. Refer to Procedure 34-6 for
a complete procedure on administering intradermal
injections. Chapter 16 provides additional information
on TB skin testing.
The term subcutaneous is a medical term that means
pertaining to under the dermis (or true layer of the
skin). Subcutaneous tissue is made up of fatty and con-
nective tissue. When administering a subcutaneous
injection, the adipose tissue should be slightly pinched
between the finger and thumb to help differentiate the
adipose tissue from the muscle. The injection is placed
in the fatty tissue of the body, not the muscle. In order
to reach this tissue, the medical assistant should posi-
tion the needle at a 45° angle (Figure 34-21); however,
a 90° angle may be appropriate for patients with lots of
adipose tissue or when using a shorter needle.

TABLE 34-6 Intradermal Injection Summary Chart

NEEDLE SIZE 26–27 G, 3⁄8⬙–5⁄8⬙

SYRINGE SIZE 1 mL
ANGLE OF INSERTION 10°–15°
ASPIRATE No
COMMON MEDICATIONS OR Allergy extract, TB extract
EXTRACTS GIVEN THIS ROUTE
MAXIMUM AMOUNT OF ML 0.1 mL
PER LOCATION
MASSAGE No

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 A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 851

Intramuscular Subcutaneous Intravenous Intradermal

90-degree 45-degree 25-degree 10- to 15-

angle angle angle degree angle
Epidermis
Dermis
Subcutaneous
tissue
Muscle

FIGURE 34-21 Angles

for injection into the
Intramuscular Subcutaneous Intravenous Intradermal correct layer of skin or
(IM) (SC) (IV) (ID) muscle

Aspiration is recommended for many medications Intramuscular Injections

given subcutaneously, but is contraindicated in a select
few. Sites commonly used for this route include the
fatty outer portion of the upper arms, the lower abdo-
men, the middle and lower back, and the thigh region
(Figure 34-22). Table 34-7 lists important facts about
subcutaneous injections. Refer to Procedure 34-7
for instructions on how to administer subcutaneous
injections.
The term intramuscular (IM) means within the mus-
cle. Intramuscular injections are given with a longer
needle and at a steeper angle of 90°. The needle must
be long enough to penetrate through the skin and sub-
cutaneous tissues and deep into the muscular tissue;
otherwise, the medication will seep into the subcuta-
neous tissue and may cause a sterile abscess or malab-
sorption of the medication.

FIGURE 34-22 Common sites for

a subcutaneous injection

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 852 ❖ CHAPTER 34

TABLE 34-7 Subcutaneous Injection Summary Chart

NEEDLE SIZE 23–25 G, 1⁄2⬙–5⁄8⬙

SYRINGE SIZE 1–3 mL (use an insulin syringe when giving insulin)
ANGLE OF INSERTION 45°–90°
ASPIRATE The majority of drugs given through this route should be aspirated, but
aspiration is contraindicated in a select few drugs (refer to Table 34-5).
COMMON MEDICATIONS OR Allergy injections, insulin injections, heparin, Lovonox, MMR vaccine,
EXTRACTS GIVEN THIS ROUTE small pox vaccine, IPV vaccine, VAR vaccine
MAXIMUM AMOUNT OF ML 1 mL
PER LOCATION
MASSAGE Yes, except in a select few medications (read manufacturer’s instructions)

Body areas normally used for intramuscular injec-

tion sites are the musculature of the dorsogluteal and TOOL BOX
ventrogluteal regions, vastus lateralis, and the deltoid.
When administering an intramuscular injection, the FI E L D S M A RTS
tissue overlying the muscle should be held taut (a term Ask the patient to relax the muscle when giving
that means to pull or draw tight) to ascertain that the an IM injection. The relaxed muscle will help
medicine is deposited into the muscle and not the sub- with absorption of the medication and cause less
cutaneous tissue. Table 34-8 provides facts regarding pain for the patient.
IM injections. Procedure 34-8 lists specific steps for
administering IM injections.

Dorsogluteal when administering injections in this area to ensure

The dorsogluteal site is used to administer injections that damage does not occur to underlying structures,
in adults and older children. Viscid or thicker medi- bones, vessels, or nerves.
cations or medications greater than 1 mL are usually When locating the correct site for this injection,
injected into this muscle. Extreme caution is to be used first locate the greater trochanter of the femur. Next,

TABLE 34-8 Intramuscular Injection Summary Chart

NEEDLE SIZE 20–23 G, 1⬙–3⬙

SYRINGE SIZE 3–6 mL
ANGLE OF INSERTION 90°
ASPIRATE Yes
COMMON MEDICATIONS OR Most vaccines, analgesics, antibiotics, steroids, hormones
EXTRACTS GIVEN THIS ROUTE
MAXIMUM AMOUNT OF ML Deltoid: l mL; large muscles such as the dorsogluteal and vastus lateralis:
PER LOCATION 3 mL
MASSAGE Generally: yes; Z-Track: no

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TOOL BOX TOOL BOX

F IEL D S M A R T S FI E L D S M A RTS
When a physician orders a medication that To assist with relaxation of the dorsogluteal mus-
exceeds the maximum number of mL that the site cle, place the patient in a prone position with the
can hold, inquire about dividing the dose into toes turned inward.
two even doses and giving it in two different loca-
tions. Always check with physician for approval
prior to dividing.
emaciated, thin, or elderly patients due to a lack of suf-
ficient muscle tissue.

locate the posterior iliac spine. Draw an imaginary line Ventrogluteal

between these two landmarks. Any place above and The ventrogluteal muscle can accommodate many of
outside of the imaginary line (Figure 34-23) is consid- the same medications injected into the dorsogluteal
ered acceptable for this site. muscle and may be used for patients of all ages. The
The danger involved with using this site is the acci- ventrogluteal area is free of major nerves and vessels so
dental penetration of or damage to the sciatic nerve, it is considered safer than the dorsogluteal site.
the superior gluteal artery or vein, or the iliac crest To locate the ventrogluteal site, the medical assis-
of the hip. Do not use the dorsogluteal site on infants tant should be positioned to face the lateral side of the
and use careful consideration with small children and patient’s hip. Center the top of the hand or fingers over
the patient’s gluteal medial muscle, just below the iliac
crest. If facing the patient’s right side, place the left
FIGURE 34-23a The dorsogluteal site palm over the greater trochanter of the femur, place the
Iliac crest
index finger of the left hand on the anterior superior
Gluteus medius
iliac spine, and spread the middle finger posteriorly
muscle as far as it will reach along the iliac crest. This should
Posterior superior create a “V.” Within the “V” is where the injection will
iliac spine
be administered (Figure 34-24).
Gluteus minimus
muscle
Vastus Lateralis
The vastus lateralis is part of the quadriceps group
Greater trochanter of the thigh and is the preferred site for administer-
of femur ing injections on infants and young children. This is
Sciatic nerve because it is larger and more developed than any of the
Gluteus maximus
muscle other large muscle groups at birth. The vastus lateralis
Iliotibial tract can also be used to administer IM injections to adults
and is relatively free of large vessels and major nerves.
Some adults may find it more painful to use this site
FIGURE 34-23b The landmark for dorsogluteal injections than the dorsogluteal or ventrogluteal sites. To find
the correct location of the vastus lateralis in adults, the

TOOL BOX
FI E L D S M A RTS
To assist with relaxing the vastus lateralis, have
the patient sit at the edge of the table with legs
dangling over the edge of the table.

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 854 ❖ CHAPTER 34

Tubercle of Femoral
iliac crest nerve
Gluteus medius
muscle Anterior
Anterior superior superior
iliac spine iliac spine
Gluteus minimus Tensor
muscle fasciae
latae muscle
Tensor fasciae latae
muscle Femoral
artery and
Gluteus vein
maximus Greater trochanter
muscle of femur Sartorius
muscle

Vastus
lateralis
FIGURE 34-24a The ventrogluteal site muscle

Patella

FIGURE 34-25a The adult vastus lateralis site

FIGURE 34-24b The landmark for ventrogluteal injections

medical assistant should position the hand so that it is

at least one hand’s width below the proximal end of the
greater trochanter of the femur. Place the other hand so
that it is at least one hand’s width above the kneecap.
The injection may be placed anywhere between those
two landmarks along the lateral or outer portion of
the thigh (Figure 34-25). Sites for infant and pediatric
injections are found in Chapter 19.

Deltoid FIGURE 34-25b The landmark for vastus lateralis injections

The deltoid is a smaller muscle than the other intra-
muscular sites, but can be used for thinner, less viscid
medications with a limited volume, such as immuniza-
tions. No more than 1 mL of medication should be TOOL BOX
given in this location. The deltoid is not recommended
for infants and small children because the muscle is not FI E L D S M A RTS
yet fully developed. The deltoid can be located by plac- To assist with relaxation of the deltoid muscle,
ing two fingers on the acromion process and measur- have the patient drop the arm against the side of
ing 1 to 2 inches below it (Figure 34-26). The injection the body.
should be administered in the most prominent portion
of the muscle.

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 A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 855

Acromion cutaneous tissue over the dorsogluteal tissue are dis-

Clavicle
placed or pulled laterally before the needle is inserted
by placing the palm of the nondominant hand on the
surface of skin, and pulling it several inches to the
Deltoid muscle side. This hand should not move until the end of the
Brachial artery procedure. The needle is inserted and the syringe is
and vein aspirated (one-handed technique) to make certain that
the needle is not in a blood vessel. Following aspira-
Cephalic vein tion, medication is slowly injected into the tissue. Wait
10 seconds before removing the needle to give the
Humerus
medication time to be absorbed. Immediately remove
the hand, holding the tissue to help create a seal
(Figure 34-27). The displaced tissue will return to its
FIGURE 34-26a The deltoid site original shape or location and stop the medication from
leaking out into the subcutaneous tissue. The pathway
of the needle is interrupted when using this technique
and is quite effective in preventing the loss of medica-
tion or discoloration of the skin from occurring. Do not
massage Z-track injections. Procedure 34-9 provides fur-
ther details on how to perform this procedure. Com-
mon medications given by the Z-track method include
iron preparations and medications that are irritating to
superficial tissue, such as Vistaril®.

FIGURE 34-27 Remove the hand holding the Z-track immedi-

ately after withdrawing the needle.

FIGURE 34-26b The landmark for deltoid injections

TOOL BOX
F IEL D S M A R T S
When administering an immunization in the
deltoid muscle, use the patient’s dominant arm.
Increased muscle use will promote better circula-
tion and will help to work out the soreness from
the injection much faster.

Skin pulled taut Skin released

Z-Track Method of Injection
The Z-track method is used when the medication may
cause irritation to the skin or cause discoloration of
the tissues. This method seals the medication deeply
within the muscle and allows no exit path back into
the subcutaneous tissue and skin. The skin and sub-

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 856 ❖ CHAPTER 34

PARENTERAL COMPLICATIONS adults receive their fair share of immunizations as well.

To reduce the risks of parenteral complications, follow
the guidelines listed throughout the chapter. Table 34-9
lists potential ramifications of performing injections
using incorrect techniques.
IMMUNIZATIONS
When most people think about immunizations, often
they just think about children (refer to Chapter 19 for
information about immunizations in children), but
Immunizations such as the hepatitis B series, DT immu-
nizations, and flu and pneumonia vaccinations are just
a few of the common immunizations that are listed on
the adult immunization schedule. There have been a
few new immunizations introduced in recent years,
including the shingles vaccine and the HPV vaccine.
It is important to help patients stay up to date with
immunizations and provide patients with education
about the newest immunizations available and their
benefits. Figure 34-28 lists the standard immuniza-
tions for adults.

TABLE 34-9 Possible Parenteral Complications

INCORRECT TECHNIQUE CONSEQUENCES EFFECTS

Failure to change the needle
between the vial and patient
Using a needle that is too
short
Using a needle that is too
long
Failing to aspirate on
medications that should
be aspirated
Break in sterile technique
Choosing a muscle that is
underdeveloped
Injecting a patient with a
small-gauge needle when
administering a viscid
solution
Tissue irritation or discoloration
Excess pain to the patient
Medication will be deposited
into incorrect tissue
Medication will be deposited
into incorrect tissue
Deposition of medication
directly into a vein or artery
The introduction of micro-
organisms into the muscle,
subcutaneous tissue, or blood
stream
May cause injury to the nearby
nerves
May cause injury to the
surrounding tissue
Local reaction to the skin or muscle
Discoloration of the skin
Increased amount of pain because of the
needle’s dullness
Medication will not be absorbed the
way the manufacturer intended it to be
absorbed, thus changing the desired
effects of the medication
Abscess
Tissue degeneration
Medication will not be absorbed the
way the manufacturer intended it to be
absorbed, thus changing the desired
effects of the medication
Could cause damage to the periosteum
resulting in infection and bone retardation
Needle could break off into the bone
Shock: Medication was not intended
to go directly into the bloodstream.
May cause patient’s heart to beat faster,
respiration rate to increase, blood pres-
sure to drop. Patient may become
unconscious.
Blood infection
An abscess in the subcutaneous tissue,
muscle tissue, or surrounding tissue
Tissue degeneration
Tingling
Excruciating pain
Paralysis
Burning
Tissue degeneration
Increased pain to the patient

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 A D M I N I S T R AT IO N OF PA R E N T E R A L M E D I C AT IO N S ❖ 857

Recommended Adult Immunization Schedule

Note: Thes ons must be read with the footnotes that follow.

Figure 1. Recommended adult immunization schedule, by vaccine and age group

United States, October 2007 – September 2008
VACCINE AGE GROUP 19–49 years 50–64 years > 65 years

Tetanus, diphtheria, 1 dose Td booster every 10 yrs

pertussis (Td/Tdap)1,* Substitute
Substitute 11dose
doseofofTdap
Tdapforfor
TdTd
3 doses
Human papillomavirus (HPV)2,* females
(0, 2, 6 mos)

Measles, mumps, rubella (MMR) 3,* 1 or 2 doses 1 dose

Varicella 4,* 2 doses (0, 4– 8 wks)

In uenza 5,* 1 dose annually

Pneumococcal (polysaccharide) 6,7 1–2 doses 1 dose

Hepatitis A 8,* 2 doses (0, 6–12 mos or 0, 6–18 mos)

Hepatitis B 9,* 3 doses (0, 1–2, 4– 6 mos)

Meningococcal 10,* 1 or more doses

Zoster 11 1 dose

*Covered by the Vaccine Injury Compensation Program.

For all persons in this category who meet the age Recommended if some other risk factor is
requirements and who lack evidence of immunity present (e.g., on the basis of medical,
(e.g., lack documentation of vaccination or have occupational, lifestyle, or other indications)
no evidence of prior infection)

Report all clinically signi cant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on ling a VAERS report are available
www.vaers.hhs.gov
at or by
telephone, 800-822-7967.
Information on how to le a Vaccine Injury Compensation Program claim is availablewww.hrsa.gov/vaccinecompensation
at or by telephone, 800-338-2382. To le a claim for vaccine injury, contact the U.S. Court of
Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400.
Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available at
www.cdc.gov/vaccines or from the CDC-INFO Contact Center at
CS115143

800-CDC-INFO (800-232-4636) in English and Spanish, 24 hours a day, 7 days a week.

Use of trade names and commercial sources is for identi cation only and does not imply endorsement by the U.S. Department of Health and Human Services.

FIGURE 34-28 Recommended adult immunization schedule by vaccine and age group, updated annually and posted on the CDC’s Web
site, http://www.cdc.gov.

Contraindications and Precautions

TOOL BOX in Vaccine Administrations
There are many misconceptions regarding immuniza-
C R I T I C A L TH I N K I N G tions among the general population. It is important for
C H A LL E N G E medical offices to stock brochures that will assist in
You are performing a flu vaccine on a very frail answering these questions and in helping to calm the
senior adult. Upon insertion of the needle, the fears of patients and parents of pediatric patients about
needle suddenly comes to a stop and you feel like risks involved with immunizing.
you hit a brick wall. Some of the more common misconceptions are that
1. What probably just occurred? immunizations should not be given to women who
2. How can you correct this? are pregnant or breastfeeding. The only two vaccines
3. Should you tell the patient what just known to actually cause harm to a developing fetus are
happened? How about the provider? the MMR and Varicella due to the fact that they are live
4. How could this have been prevented? vaccines. Some of the newer vaccines, such as the HPV
vaccine, are still being experimented with to determine
if there are risks to the developing fetus.

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 858 ❖ CHAPTER 34

Immune-compromised patients should explore the ply with federal and state laws regarding safe work
benefits and risks of immunizing and make an informed practices and for patient comfort. Containers for
decision on what is best for their particular situation. IV fluids have changed from glass containers to pli-
Some contraindications to vaccines include the able plastic bags (Figure 34-29) that are lightweight
addition of preservatives or stabilizers that may be and not at risk of becoming broken or damaged.
the cause of allergy sensitivity such as gelatin, eggs, IV fluid bags range in size from 50 to 2000 mL,
or other types of plant derivatives used in processing with the smaller bags often referred to as “piggyback”
the vaccines. Read the package inserts very carefully bags. When prescribed, the pharmacy will open the bag
and screen the patient before administering the immu- to add additional medications to the fluids and label
nizing agents to verify prior history of sensitivity or the bag with the specific prescription the physician has
allergic reaction. The CDC has a great deal more infor- ordered. If a bag is found with the opaque outer bag
mation regarding immunization contraindications on removed, do not use the solution because sterility and
their Web site at http://www.cdc.gov. viability of the product may be compromised.
The tamper-proof additive caps are removed when
additive drugs are mixed within the IV bag. Piggyback
BASICS OF INTRAVENOUS containers are used for reduced volume of fluid infu-
THERAPY sion and are filled with ready-to-use medications at the
Intravenous (IV) therapy is the administration of flu- time of manufacturing. The pharmacy will add addi-
ids or medications directly into a vein. The purpose of tional medications if prescribed, such as antibiotics.
administering fluids intravenously may be to replace Commonly used fluids contained within an IV bag
lost fluids or to introduce medication, solutions, or for infusion are normal saline (NaCl) or dextrose in
nutrients to a patient. IV injections are usually admin- water. Infusions are given to replace lost body fluids,
istered directly into the vein (bolus) or injected into restore fluid balance of cellular tonicity, or to provide
an access port on the IV line. Intravenous therapy is medications or nutrients to the body. Homeostasis of
preferred when the patient requires fast absorption and
can bring quick results because fluids enter the blood- FIGURE 34-29 Flexible IV solution containers (Courtesy of
stream immediately. IV therapy is drug specific, mean- Baxter Healthcare Corp.)
ing only certain drugs are administered by this route.
It is important to understand the difference between
intravenous injections and intravenous infusion. IV
injections consist of a relatively small amount of fluid
being introduced into the veins, while IV infusion is the
process of infusing fluid volumes of 50 mL to 500 mL
or more into the body.
Laws vary from state to state as to whether medi-
cal assistants can perform procedures directly related
to intravenous therapy. Health care facilities such as
ambulatory care clinics and urgent care centers have
started to delegate specific job duties to the medical
assistant including gathering the supplies, starting the
IV, monitoring the patient for adverse reactions, and
discontinuing the IV. A licensed physician is the one
who prescribes IV therapy. Whether or not the medical
assistant will be able to start IVs will be determined by
state law and office policy. The medical assistant must
be aware of the laws in the state in which she practices
so that the medical assitant does not go beyond the
scope of duty.

Equipment and Supplies Employed

in Intravenous Therapy
Equipment and supplies available for use in IV
therapy are continually being updated to com-

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TABLE 34-10 Common Fluids Used for IV Therapy

INFUSION
5% Dextrose in water (D5W)
Normal saline (0.9% NaCl)
Dextrose in saline solutions
Ringer’s Solution
Na 147 mEq/L, K 4 mEq/L,
Cl 155 mEq/L
INDICATIONS
Fluid replacement for rehydration
Used to replace sodium losses
Fluid replacement for burns, rehydration, maintenance infusion, circulatory
insufficiency, and in cases of shock
Restores fluid and electrolyte balance, used when patients have lactose
intolerance, may be used as a blood replacement for a short time

the body and its functions is the primary reason for
infusion of fluids. The fluid choice is based on the
electrolyte balance and the patient’s needs at the time.
While there are numerous types of fluids used dur-
ing IV administration, some common products are
included in Table 34-10.
Infused fluids are introduced to the body through
administration sets, which is tubing that connects the
IV bags to the IV cannula in the patient. Administra-
tion sets come in a variety of styles, from the very basic
solution set to multiple administration tubing. All
IV tubing sets have common components including
clamps, a piercing pin, a drip chamber, and a cannula
adapter.
Basic IV Administration Sets
Each IV administration set has similar components,
including:
❖ Piercing pin (Figure 34-30): A hollow spike that is
inserted into the administration port of the IV bag.
It is important this remains sterile when inserted.
❖ Drip chamber (Figure 34-30): This is where the
solution flows prior to its entry into the tubing; it
acts as a pressurizing chamber for non-vented bags.
❖ Roller clamp (Figure 34-31): This is used to regu-
late the flow of fluids through the IV tubing.
❖ IV cannula or catheter (Figure 34-32): A flex-
ible tube that is used to insert medication within

FIGURE 34-30 An IV administration tubing set FIGURE 34-31 Tubing clamps

Piercing pin
Open
Flange
Open
Drip chamber Drop orifice
Close Open Close

Luer
slip Close

Close Open
Slide clamp
FIGURE 34-32 A catheter and needle

Injection port
Flow control
clamp Protective
Catheter cap
hub
Flashback
area
Catheter

Needle

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 860 ❖ CHAPTER 34
a body cavity or blood vessel. It has a trocar (a
sharp-pointed needle) attached to it that punc-
tures the skin to get the catheter within the vein.
❖ Slide clamp: This is used to restrict fluid flow and
act as a quick on/off control of the IV tubing. The
tubing ends in a sterile-capped adapter, which is
attached to the cannula.
Because of the legal issues involved with IV admin-
istration, the medical assistant’s responsibilities for
IV therapy are usually to collect the equipment and
supplies and to assist with taping the IV in place (Fig-
ure 34-33). The provider or nurse will usually be
responsible for starting the IV.
The infusion of fluids can be achieved by either an
infusion pump (Figure 34-34) or by gravity flow. The
gravity method is controlled by the roller clamps on
the IV tubing. The tighter the clamp, the less fluid that
flows through the tube. The drip chamber is used in
calculating the drops per minute that flow into the IV
tubing.
The IV pumps are more concise in delivery and more
practical and safe for the patient. Constant monitoring
FIGURE 34-33 Proper taping of an IV site: (a) Place a foam pad under the cannula; (b) apply the dressing; (c) pinch to secure the dress-
ing to tubing; (d) secure with tape; (e) when removing, use alcohol to loosen tape. (Courtesy of ConMed Corp.)
(a)
(d)
27187_34_c34_p835-882.indd Sec1:860
of the IV set for occlusions is not necessary with the IV
pumps. The pump will sound an alarm if an occlusion
(blockage or closure) is detected or if the timing of the
flow rate indicates the bag is almost empty. With the
pump, the fluid is forced with light pressure into the
veins and lessens reflux, which is the backing up of
fluids into the veins and tissues. The pump can be set
for different lengths of time and rates of infusion. Some
pumps can run multiple IV lines on the same patient.
Documentation of IV Therapy
The health care professional that inserts and starts the
IV will be responsible for documenting the procedure.
Documentation in the patient’s chart should include
the IV site location, number of attempts of insertion,
any complications of the procedure, the date and time
of insertions, the needle gauge and length, and the
person’s initials that inserted the catheter. Any adverse
reactions to the procedure such as redness, pain, swell-
ing, bruising, and other essential findings that are not
problematic at this point but could lead to complications
at a later date and time should also be documented.
(b) (c)
(e)
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Large Backlit Center Dual-Channel RS-232 Data Port

Pressure History
Graphically displays
pressure trend for
last two hours.
Rapid Rate, On-Line
Titration
Facilitates rapid rate
adjustments without
interrupting flow.
Programmable
Start Time
Can automatically start
multiple infusions at
specified times.
Display Delivery Enables communication
(Scratch Pad) Permits simultaneous with a variety of
Facilitates programming. delivery of two separate information and
infusions at independent remote monitoring
rates. systems. Micro/Macro Infusion
Capability
Delivers precise infusions
at rates from 0.1 to
99.9 mL/hr in 0.1 mL/hr
increments and from 1 to
999 mL/hr in 1 mL/hr
increments.
Pump/Controller
Modes
Eliminates time-
consuming instrument
exchanges (based on
hospital infusion
protocols). Can switch
between pump and
controller modes with
the press of a single
key.

All Fluids Air-In-Line

Detector
Significantly reduces Flo-Stop® Device
the chance of Provides disposable-
accidental administration based protection
of air. against accidental IV
free-flow.

Multi-Dosing Dual-Rate Volume/Time Automatic Drug

Enables the automatic
delivery of a series of
infusions, from the
same IV container, at
specified times.
Piggybacking
Automatically switches
to primary parameters
upon completion of
secondary (piggyback)
infusion.
Dosing Calculation
Automatic calculation Calculates drug dose or
of rate by programming rate automatically for all
volume and time. standard units of measure.

FIGURE 34-34 An IV infusion pump (Courtesy of Alaris Medical Systems.)

Risks, Complications, and Adverse
Reactions of IV Therapy
Intravenous therapy can have numerous inherent risks
and complications associated with this type of medica-
tion administration procedure. The medical assistant
must be knowledgeable in recognizing the complica-
tions, signs, and symptoms that may arise from the IV
infusion. The different complications can be classified
as local, systemic, or be a combination of the two.
Local complications may consist of pain and irrita-
tion at the insertion site, cannula dislodgement, cathe-
ter or needle occlusion, and phlebitis (inflammation of
the vein). Other complications may involve hematoma
formation, venous spasm, vessel collapse, thrombosis
(blood clot), and nerve, tendon, or ligament damage.
It is essential to communicate with the patient to
assess complications of IV therapy or patient intoler-
ance of the IV catheter. The medical assistant may be
the health care professional that monitors the patient
for complications and should know when the provider
or nurse should be alerted. Table 34-11 explains some
questions to ask a patient to clearly define the effective-
ness of the therapy and patient tolerance.
Once the medical assistant has assessed the patient’s
pain, it is important to relay this information to the
provider so a determination can be made for the most

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 862 ❖ CHAPTER 34

TABLE 34-11 Guideline Questions for Patient
Pain Assessment
1. Tell me about the pain you are having.
2. Where does it hurt?
3. When did it start?
4. Is the pain in one spot, or does it radiate to
other places?
5. What kind of pain is it? Aching? Gnawing?
Burning? Stabbing or piercing? Dull?
Throbbing?
6. Are there any other symptoms of discomfort?
7. Rate the pain on a scale of 1 to 10, with 10
being the worst pain.
appropriate intervention. Depending on the findings,
the actions may include discontinuation of the therapy,
changing position of the extremity, adjusting the flow
rate of infusion, re-taping the site, or applying a warm
or cool compress. Table 34-12 explains in further detail
more of the complications and risks of IV therapy.
Systemic complications are much more danger-
ous and can be life threatening. The medical assistant
should become familiar with symptoms that may indi-
cate a systemic reaction. Table 34-13 provides details
of systemic complications that may occur during IV
infusion therapy. If the medical assistant notices any of
the signs below, immediately alert the provider.
Discontinuation of Intravenous
Infusion Therapy
When the physician determines the patient no lon-
ger needs IV infusion, the IV must be discontinued.
The first step in discontinuing IV infusion is proper
aseptic technique and the application of gloves. Then
the IV tubing is clamped off and removed from the
adapter or extension set. Take care to not remove the

TABLE 34-12 Complications and Risks of Intravenous Therapy

COMPLICATIONS
AND RISKS DESCRIPTION SYMPTOMS
Infiltration or Medication fluid leaks from the Redness, severe swelling, hardness at the
extravasation cannula or from the vein into the site, pain, and edema
tissues surrounding the site.
Catheter and needle Redness
displacement
Occlusion The cannula becomes blocked and Blood in IV tubing
allows blood to back up into the
IV tubing.
Loss of patency Occurs when the vein wall has Blood in IV tubing
(the openness of been damaged
the vein)
Phlebitis Bacteria can form as a normal Vein may be hard, red streak along vein,
(inflammation of immune response due to the death inflammation, and swelling
the vein wall) of leukocytes and other tissue cells.
Thrombosis Blood clots form, causing slow or Slow or stopped infusion
stopped infusion. Fever and malaise may be present.
Hematoma Blood infiltrates into the tissues. Discoloration of the skin, discomfort, and
swelling
Cellulitis A bacterial infection that can spread Redness, red streak at the site of the needle
to surrounding tissues or nearby

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TABLE 34-13 Signs and Symptoms of Systemic Complications

SYSTEMS AFFECTED BY
SYSTEMIC COMPLICATIONS
Cardiovascular system
Gastrointestinal system
Integumentary system
Nervous system
Respiratory system
Special senses
SIGNS AND SYMPTOMS
Facial edema, generalized edema, erythema along veins, palpitations,
hypotension, cardiac arrest
Dysphagia, gastric cramping, intestinal cramping, nausea, vomiting
Flushing, red flare, rash, IV site edema, pruritus (itching), urticaria (hives)
Agitation, anxiety, confusion, disorientation, headache, loss of sensation or
numbness, vertigo
Nasal congestion, runny nose, cough, sensation of tightness in throat,
mucous membrane edema, bronchospasm, respiratory arrest
Pruritus, watery eyes, scratchy throat, tinnitus (ringing in ears), buzzing
sound in ears, tingling or numbness in fingers or toes, vertigo

adapter—this will cause blood to leak profusely out of

the cannula hub. Remove the transparent dressing by FIGURE 34-35 Inspect the cannula following withdrawal from
the patient’s vein.
rubbing the patient’s skin with an alcohol pad, which
will loosen the adhesive in the dressing. This helps
patients who have a lot of hair on their arm or in cases
in which the adhesive dressing has adhered to skin and
is difficult to remove.
Once the transparent dressing is removed, the tape
securing the cannula hub should be removed. Take
care not to accidentally dislodge the hub from the
site during this process. When the tape is completely
removed, prepare a gauze pad and place above the
cannula site. Inform the patient to take a deep breath
and when the patient breathes in, remove the cannula
in one smooth continuous movement without press-
ing down on the cannula. Place the gauze over the site
and apply pressure for five minutes. Be sure to inspect
the cannula (Figure 34-35) to make sure it is in one
piece and has not broken off within the vein. Docu-
ment in the patient’s chart the state of the cannula for
its “intact” form (for example, “Cannula removed from
right anterior forearm. Cannula intact. Patient toler-
ated procedure well. No swelling, no bruising, or other
complications noted.”).
Intravenous therapy is a concise procedure and
should be performed only by specially trained individu-
als. If medical assistants are asked to perform duties that
exceed their training, life-threatening incidences may
occur to the patient. If unsure of what exactly is detailed
in the procedure, verify with the ordering physician to
ensure complete understanding of the expectations of
performance and completion of the administration of

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 864 ❖ CHAPTER 34
intravenous therapy. If medical assistants are allowed
to perform IVs in their state but feel uncomfortable
performing the procedure, they should get assistance
from their superior or the provider.
INTRA-ARTICULAR
INJECTIONS
The term intra-articular means within a joint. Some
injections are given within a joint to help reduce inflam-
mation and pain. Patients that suffer with osteoarthritis
are usually good candidates for these types of injections.
The knee is the most common joint in which these
injections are given but other joints can be injected as
well. Steroids to reduce inflammation are the common
drug category used to treat osteoarthritis.
The medical assistant’s duty for these injections
would be to prepare the patient for the injection and
to have all of the equipment ready for the physician.
The medical assistant may need to help hold the joint
still during the injection procedure.
PROCEDURE 34-1 Withdraw Medication from a Vial
Objective:
To prepare medication from a vial for administration.
Equipment/Supplies:
❖ Vial of medication
❖ Antiseptic wipe
❖ Needle and syringe appropriate for
procedure
PROCEDURAL STEPS
1. Wash your hands and apply gloves.
2. Assemble the equipment.
3. Work in a quiet and well-lit area.
4. Select the correct medication from the storage
area and check the drug label (Medication
Check #1).
5. Check the expiration date.
27187_34_c34_p835-882.indd Sec1:864
TOOL BOX
C R I T I C A L T H I N K ING
C H A L L E N GE
You work in an urgent care center and the phy-
sician instructs you to start an IV on a specified
patient. You know that the Medical Practice Act
in the state in which you work requires a licensed
health care provider or registered nurse to per-
form this procedure. All of the rest of the medi-
cal assistants in the facility start IVs. One of the
medical assistants tells you that she will assist you
with your first IV.
1. How will you respond to the physician?
❖ Gauze 2x2 sponges
❖ Sharps container
❖ Medication tray
RATIONALE
This prevents the spread of infection and contamina-
tion during the procedure.
Distractions and poor lighting may lead to medication
errors.
This assists in making certain you have the correct
medication.
Using a medication beyond the expiration date may
decrease the effectiveness of the drug.
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PROCEDURAL STEPS RATIONALE

6. Compare the medication with the physician’s This alleviates the possibility of
order (Medication Check #2). mistakes and wasting of valu-
able medication.
7. Calculate the correct dose to be given, if needed. Giving the correct dose helps to
Verify the correct calculations with the physician obtain the desired effects and
if necessary. avoid complications.
8. Open the syringe and attach the needle to the
syringe. FIGURE 34-36
Cleanse the stopper
9. Open the antiseptic wipe and clean the vial This prevents contamination of of the vial.
stopper (Figure 34-36). the vial and the needle when
preparing the injection.
10. Holding the syringe at eye level, pull back on the This keeps the pressure in the
plunger of syringe to draw an amount of air into vial at atmospheric pressure.
the syringe equal to the amount of medication to
be withdrawn from the vial.
11. Check to make sure the needle is firmly attached If the needle is not firmly
to the syringe and remove the cap from the needle. attached to the syringe, it may
become disconnected and cause
FIGURE 34-37
an injury to the person prepar- Insert the needle
ing the medication or to the through the rubber
patient during the procedure. stopper.
12. Insert the needle through the rubber stopper
(Figure 34-37) until it reaches the empty space
between the stopper and the fluid level.
13. Push forward on the plunger to inject air into the Forcing air into the medication
vial. Keep the needle above the fluid level. can cause the fluid to break
down or bubble, thus creating
more bubbles in the medication
vial.
14. Invert the vial while holding onto the syringe and This helps prevent microorgan- FIGURE 34-38
plunger. Hold the vial and syringe without con- isms from entering the vial and Hold the vial at
taminating the needle or hub of the syringe. These the patient from obtaining an eye level during
parts of the syringe must remain sterile. infection. withdrawal of the
medication.
15. Hold the syringe at eye level and withdraw the This ensures that you are
proper amount of medication (Figure 34-38). reading the calibration lines
correctly.
16. Keep the tip of needle below the fluid level. This prevents air microorgan-
isms from entering the vial
and from being drawn into the
syringe.
17. Remove any air bubbles in the syringe by tap- If there are air bubbles in the
ping or flicking the side of the syringe where the syringe, you may not have the
bubbles are located (Figure 34-39). correct amount of medication. FIGURE 34-39
Air bubbles can take up extra Flick the syringe
space. Air bubbles may also to remove any air
bubbles.
cause pain to the patient.
continues

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 866 ❖ CHAPTER 34

continued

PROCEDURAL STEPS RATIONALE

18. Remove any air remaining in the tip of the syringe. Removing air bubbles and expelling any air could
Check to make certain that you still have the cor- change the volume of medication in the syringe.
rect amount of medication. If you do not, make
the appropriate adjustments to ascertain you have
the correct amount before removing the needle
from the vial.
19. Remove the needle from the rubber stopper of
the vial.
20. Replace the needle cap on the syringe Replacing the nee-
(Figure 34-40) or replace with a new needle dle unit reduces the
and cap setup. risk of a local reac-
tion if the needle
used to withdraw
the medication is
changed between
the vial and patient.
Pushing the needle
through the rub-
FIGURE 34-40 Replace the
ber stopper dulls needle cap.
the needle; a new
needle pierces the
skin much easier.
21. Read the medication label and replace the Three checks help to ensure you have the correct medi-
medication vial in the correct storage cabinet cation and prevents errors from occurring.
(Medication Check #3).
22. Place the syringe onto a clean tray with other items
necessary for the injection, including an alcohol
wipe, a cotton ball, and an adhesive bandage.

PROCEDURE 34-2 Withdraw Medication from an Ampule

Objective:
To prepare medication from an ampule for administration.

Equipment/Supplies:
❖ Ampule of medication ❖ Gauze 2x2 sponges
❖ Antiseptic wipes (2) ❖ Sharps container
❖ Needle and syringe appropriate for ❖ Medication tray
procedure
❖ Filter needle

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PROCEDURAL STEPS RATIONALE

1. Wash your hands and apply gloves. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area. Distractions and poor lighting may lead to medication
errors.
4. Select the correct medication from the storage This helps to ascertain you have the correct medication
area and check the drug label (Medication and prevents error from occurring.
Check #1).
5. Check the expiration date. No medication should be given if the drug has reached
the expiration date, as it may not be effective.
6. Compare the medication with the physician’s order This alleviates the possibility of mistakes and wasting
(Medication Check #2). of valuable medication.
7. Calculate the correct dose to be given, if needed. An incorrect dose could cause great harm to the
patient.
8. Open the syringe and filter needle and assemble, A filter needle filters out possible glass fragments that
if necessary. may be present from snapping the stem from the body
of the ampule.
9. Tap the stem of the ampule lightly, or snap the This forces the medication into the base of the ampule
wrist of the arm holding the ampule, to remove container.
any medication in the neck of the ampule.
10. Open the antiseptic wipe and clean the ampule This prevents contamination of the needle when pre-
container. Allow the ampule to dry completely. paring the injection.
11. Place a piece of gauze around the neck of the This protects the fingers when breaking open the neck
ampule. Hold the ampule firmly between the of the vial.
fingers and the thumbs of both hands.
12. Break off the stem by snapping it quickly and This keeps glass fragments from flying into the medical
firmly away from the body. Discard the top in assistant’s eyes or face.
a sharps container and carefully set the ampule
down on a flat, firm surface.
13. Check to make sure the filter needle is firmly If the needle is not firmly attached it may cause injury
attached to the syringe and remove the cap from to the person preparing the medication.
the needle.
14. Insert the needle into the ampule below the fluid Tilting the ampule facilitates
level. Hold the ampule at a slight angle while emptying the entire ampule.
advancing the needle within the glass body. Com-
pletely draw up all the medication into the syringe
(Figure 34-41).
15. Remove the needle from the ampule without This prevents contamination of
allowing the needle to touch the edges of the the needle.
ampule.
FIGURE 34-41
16. Dispose of the ampule into the sharps container. Hold the ampule
Immediately disposing of the at a slight angle
Check the medication label before discarding the ampule prevents injury to the when withdrawing
ampule (Medication Check #3). person preparing the medica- medication.
tion for injection.
continues

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 868 ❖ CHAPTER 34

continued

PROCEDURAL STEPS RATIONALE

17. Remove any bubbles in the syringe. This helps to prevent little air bubbles from entering the
patient.
18. Pull back slightly on the plunger to draw the med- This removes any medication that remains within the
ication from the needle into the syringe, engage filter needle. Medication cannot be administered to the
the safety device, and remove the filter needle. patient with the filter needle.
19. Open a new needle for administering medication The filter needle may have glass fragments inside, so it
to the patient and attach it correctly to the syringe. is not used.
20. Remove the cap from the needle and push slightly This expels any air that is within the syringe tip and
forward on the plunger to remove air that is within shaft of the new needle to ensure that air is not being
the tip of the syringe and shaft of the needle. injected into the patient’s tissues.
21. Replace the needle cap on the syringe following
institutional policy.
22. Prepare the medication tray. Place a bandage, a
gauze pad or cotton ball, an antiseptic wipe, and
the syringe on a medication tray for transporting
to the exam room to administer the injection to
the patient.

PROCEDURE 34-3 Reconstitute a Powdered-Base Medication

with a Diluent
Objective:
To reconstitute a powdered-base medication for preparation of administering
an injection to a patient.

Equipment/Supplies:
❖ Vial of powdered medication ❖ Gauze 2x2 sponges
❖ Vial of diluent ❖ Sharps container
❖ Antiseptic wipe ❖ Medication tray
❖ Two needles and a syringe appropriate
for procedure
PROCEDURAL STEPS RATIONALE
1. Wash your hands and apply gloves. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area. Distractions and poor lighting may lead to medication
errors.
4. Select the correct medication and diluent from Having the wrong medication or diluent could cause
the storage area, and check both drug labels harm to the patient.
(Medication Check #1).

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PROCEDURAL STEPS RATIONALE

5. Check the expiration date on both labels. Medication should not be given if the drug has reached
the expiration date, because it may not be effective.
6. Compare the medication with the physician’s order This alleviates the possibility of mistakes and wasting
(Medication Check #2). of valuable medication.
7. Calculate the correct dose to be given, if needed. Giving the wrong dose could cause great harm to the
Verify the correct calculations with the provider if patient.
necessary.
8. Open the syringe and needle and assemble, if
necessary.
9. Clean both the powder vial and the reconstituting This prevents possible contami-
fluid vial stopper with alcohol before use nation to the medication vials
(Figure 34-42). or the patient.
10. Pull back on the plunger to fill the syringe with This equalizes the pressure
the amount of air equal to the amount of diluting within the vial.
liquid required for reconstitution from the vial
containing the diluent.
11. Check to make sure the needle is firmly attached If the needle is not firmly
to the syringe and remove the needle cap. attached to the syringe, it may FIGURE 34-42
become disconnected and cause Cleanse the rubber
an injury to the person prepar- stopper of both vials.
ing the medication.
12. Insert the needle into the diluent vial.
13. Push in the plunger, forcing the air from the This equalizes the amount of air
syringe into the vial of diluent (Figure 34-43). in the vial.
14. Invert the vial in the dominant hand, holding it
between the thumb and index finger.
15. Keep the needle immersed in the solution while If the needle tip is not inserted
drawing the solution into the barrel of the syringe. in the fluid, air will be drawn
into the syringe. FIGURE 34-43
Inject air into the
16. Check for air bubbles and determine that the exact diluent vial.
amount of diluent is withdrawn from the vial
before removing the needle from the vial.
17. Carefully remove the needle from the vial.
18. Insert the needle into the vial containing the
powdered medication (Figure 34-44).
19. Add the appropriate amount of reconstituting This allows the powder to be
liquid to the powdered drug, slowly rotating vial flushed with the fluids and
while injecting fluid into it. helps to minimize the forma-
tion of clumps within the
powder. FIGURE 34-44
Inject the diluent into
20. Replace the needle cap on the syringe following powdered medication
institutional policy. vial.

continues

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 870 ❖ CHAPTER 34

continued

PROCEDURAL STEPS RATIONALE

21. Roll the vial between the hands to thoroughly mix This allows all of the
the medication (Figure 34-45). particles to be sus-
pended appropriately.
22. Record the new date of expiration on the label of Once the medication
the medication vial. has been prepared, it is
only good for a certain
amount of time.
23. Recheck the medication label before returning A third check helps in
the vial to the proper storage area (Medication ascertaining you have FIGURE 34-45 Gently roll
Check #3). the correct medication. the vial between the hands to
mix well.
24. Prepare to administer the medication to the
patient. Place a bandage, a gauze pad or cotton
ball, an antiseptic wipe, and the syringe on a
medication tray for transporting to the exam room
to administer the injection to the patient.

PROCEDURE 34-4 Mix Two Medications into One Syringe

Objective:
To draw two medications into one single syringe for injection administration
to a patient.

Equipment/Supplies:
❖ Two vials of medication ❖ Gauze 2x2 sponges
❖ Antiseptic wipe ❖ Medication tray
❖ Two needles and a syringe appropriate ❖ Sharps container
for procedure

PROCEDURAL STEPS RATIONALE

1. Wash your hands and apply gloves.
2. Assemble the equipment.
3. Work in a quiet and well-lit area.
4. Select the correct medications from the storage
area and check their drug labels (Medication
Check #1).
5. Check the expiration dates on both vials.
This prevents the spread of infection and contamina-
tion during the procedure.
Distractions and poor lighting may lead to medication
errors.
Reading the label helps to acertain you have the correct
medication.
No medication should be given if the drug has reached
the expiration date, as the medication may not be as
effective.

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PROCEDURAL STEPS RATIONALE

6. Compare the medications with the physician’s This alleviates the possibility of mistakes and wasting of
order (Medication Check #2). valuable medication.
7. Calculate the correct doses to be given, if needed. Giving an incorrect dose could cause great harm to the
Verify the correct calculations with the provider if patient.
necessary.
8. Open the syringe and needle and remove them
from their packaging. Attach the needle to the
syringe.
9. Clean the rubber stopper of both vials with an This removes microbes that may be on the stoppers.
alcohol wipe.
10. Determine which medication is the primary medi- The primary medication is the first medication to be
cation vial. Do not do anything with the primary drawn up.
medicine at this point.
11. Draw up an amount of air into the syringe that is Air is injected into the second vial at this point because
equal to the amount of medication required from once the syringe is filled with medication from the first
the second vial. vial, it will no longer be possible to inject air into the vial.
12. Check to make sure the needle is firmly attached If the needle is not firmly attached it may become
to the syringe and remove the needle cap. detached from the syringe, causing harm to the preparer.
13. Insert the needle into the second vial and push Pushing the needle into the medication will contaminate
the air from the syringe into the vial to replace the needle, affecting the next vial.
the medication that will be taken out later. Do not
allow the needle to touch the liquid.
14. Carefully remove the needle from the vial.
15. Draw up an amount of air into the syringe that is This equalizes the pressure due to the fluid being
equal to the amount of medication required to be removed from the vial.
taken from the primary vial.
16. Insert the needle into the primary vial. Push Pushing air into the liquid could create bubbles in the
forward on the plunger, forcing air from the syringe and vial.
syringe into the primary vial without contacting
the medication.
17. Invert the vial in the dominant hand, holding it
between the thumb and index finger.
18. Keep the needle immersed in the solution while If the needle tip is not inserted in fluid, air will be drawn
drawing the solution into the barrel of the syringe. into the syringe.
19. Remove any air remaining in the tip of the syringe. This expels any remaining air within the syringe and the
If there is medication lacking in the syringe, pull needle and ascertains you have the correct amount of
back on the plunger so that the correct amount of medication.
medication is drawn into the syringe.
20. Remove the needle from the stopper of the first This reduces the risk of medication from the first vial
vial, engage the safety device, and discard into a carrying over to the second vial.
sharps container. Replace the needle with a new
needle.

continues

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 872 ❖ CHAPTER 34

continued

PROCEDURAL STEPS RATIONALE

21. Smoothly insert the needle into the secondary vial.

22. Invert the vial and slowly withdraw the medica- If medication from the primary vial mixes with the
tion required from the vial. Do not allow any secondary vial it will contaminate the contents of the
medication from the first vial to be inadvertently second vial.
injected into the second vial. Pulling slowly to
avoid creating air bubbles, pull the plunger back
to the correct calibration mark on the syringe.
23. Remove the needle from the second vial.
24. Check for air bubbles and remove them from the
syringe.
25. Check again that the total amount of medication If the incorrect dosage is in the syringe, the patient may
in the syringe is the correct total to be adminis- not obtain the full effects of the medication.
tered.
26. Replace the needle cap on the syringe following Some facilities will allow recapping of clean needles,
institutional policy. while other facilities prefer the scoop method.
27. Recheck the medication labels of both vials before Checking the label three times helps to ascertain you
returning the vials to the proper storage area have the correct medication and prevents errors from
(Medication Check #3). occurring.
28. Prepare to administer the medication to the
patient. Place a bandage, a gauze pad or cotton
ball, an antiseptic wipe, and the syringe on a
medication tray for transporting to the exam
room to administer the injection to the patient.

PROCEDURE 34-5 Load a Cartridge or Injector Device

Objective:
To prepare medication from a prefilled cartridge for administration.

Equipment/Supplies:
❖ Prefilled cartridge of medication ❖ Gauze 2x2 sponges
❖ Cartridge holder ❖ Sharps container
❖ Antiseptic wipe ❖ Injection tray

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PROCEDURAL STEPS RATIONALE

1. Wash your hands and apply gloves. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment.
3. Work in a quiet and well-lit area. Distractions and poor lighting may lead to medication
errors.
4. Select the correct medication from the storage This ascertains that you have the correct medication.
area and check the drug label (Medication
Check #1).
5. Check the expiration date. No medication should be given
if the drug has reached the
expiration date, as it may not
be effective.
6. Compare the medication with the physician’s This alleviates the possibility of
instructions (Medication Check #2). mistakes and wasting of valu-
able medication.
7. Calculate the correct dose to be given, if needed. There may be instances in
which a patient does not need FIGURE 34-46
the entire dose within the Turn the ribbed collar
cartridge. to the open position.

8. Pick up the cartridge unit holder (the injector).

9. Turn the ribbed collar toward the open position This allows for the insertion of
until it stops (Figure 34-46). the cartridge into the holder.
10. Hold the injector with the open end up and fully
insert the sterile cartridge–needle unit.
11. Firmly tighten the ribbed collar of the unit at the
syringe base by turning the ribbed collar toward
the “close” arrow. (Hold the cartridge to prevent it
from swiveling inside the holder while tightening.) FIGURE 34-47
Thread the plunger
12. Thread the rod of the plunger into the cartridge If the cartridge is not tightened
onto the cartridge
unit until a slight resistance is felt (Figure 34-47). securely onto the holder, the unit.
needle unit may move during
the injection procedure.
13. Prepare the medication for injection into the Checking the label three times
patient at this time. Place a bandage, a gauze pad ascertains you have the correct
or cotton ball, an antiseptic wipe, and the syringe medication and prevents errors
on a medication tray for transporting to the exam from occurring.
room. Check the medication label one last time
(Medication Check #3).
14. After use, do not recap the needle.
15. Disengage the plunger rod from the cartridge This prevents the fingers from FIGURE 34-48
unit holder while holding the needle down and being in front of the needle. After the injection
away from the fingers or hands over a sharps unit is given, disengage
the plunger from the
(Figure 34-48).
cartridge unit.

continues

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 874 ❖ CHAPTER 34

continued

PROCEDURAL STEPS RATIONALE

16. Unscrew the ribbed collar of the cartridge unit
holder.
17. Allow the needle cartridge unit to drop into the This helps to prevent an acci-
sharps container (Figure 34-49). dental needlestick.
18. Cleanse the cartridge holder with an antiseptic This prevents cross-
cleanser and allow to dry. contamination from occurring
to the next patient receiving
medication from a prefilled
cartridge. FIGURE 34-49
Allow the cartridge
19. Cleanse the work area and remove gloves and to drop freely into the
wash your hands. sharps container.

PROCEDURE 34-6 Administer an Intradermal Injection

Objective:
To administer an intradermal injection into a patient.

Equipment/Supplies:
❖ Appropriate sized needle and syringe ❖ Sharps container
unit with correct medication ❖ Disposable gloves
❖ Antiseptic wipe ❖ Medication tray
❖ Gauze 2x2 sponges

PROCEDURAL STEPS RATIONALE

1. Wash your hands.
2. Assemble the equipment. Institute the Seven
Rights of Drug Administration.
3. Identify the patient using two identifiers, identify
yourself, and explain the procedure
4. Ask patient about drug allergies or latex allergies.
5. Select the proper injection site (anterior forearm or
middle of back).
6. Cleanse the site with antiseptic and allow to air
dry completely. (Cleanse in a circular motion
working outward to an area of 2 to 3 inches.)
This prevents the spread of infection and contamina-
tion during the procedure.
Instituting the seven rights helps to alleviate errors.
Giving the medication to the wrong patient can cause
serious problems for the patient.
Giving the patient a drug or using products that the
patient is allergic to can cause an anaphylactic reaction.
This prevents the possible contamination of the injec-
tion site and ensures the removal of microorganisms
from the injection site area. Wet alcohol may cause the
site to burn when you inject the medication.

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PROCEDURAL STEPS RATIONALE

7. Prepare the equipment and apply gloves. Wearing gloves prevents contamination of bloodborne
pathogens during the procedure.
8. Remove the needle cap. Pull the cap straight off, Twisting may loosen the needle attached to the syringe.
never twist.
9. Stretch the skin taut at the site of administration. This allows the needle to be inserted easier and keeps
the tissue from moving during insertion.
10. Insert the needle at a 10° to 15° angle
with the bevel upward just under the skin
(Figure 34-50).
11. Inject the medication slowly and steadily. A wheal This allows the tissue
should form (Figure 34-51). to slowly displace and
provides space for the
fluid. If the needle is
too deep, a wheal will FIGURE 34-50 Insert the
not form and the injec- needle bevel up just below the
surface of the skin.
tion will have to be
repeated.
12. Remove the needle quickly at the same angle of This prevents injury to
insertion. the tissue.
13. Do not press on or massage the injection site. The medication will be
Do not apply a bandage to the site. dispersed into deeper
tissue if pressure is
applied to the area. A
bandage will absorb FIGURE 34-51 A wheal will
the medication. form if the procedure was
performed correctly.
14. Properly engage the safety device on the needle Engaging the safety
and dispose of the needle–syringe unit in the device will help to
sharps container. prevent an accidental needlestick.
15. Remove gloves and wash your hands. This prevents contamination and the spread of
infection.
16. Give proper patient education for caring for The 20 to 30 minute wait is to observe the patient for
the site and inform the patient to wait 20 to anaphylaxis.
30 minutes.
17. Perform post-injection observation and document Documentation illustrates that the procedure was
the procedure in the patient’s chart and the appro- performed.
priate logs.

DOCUMENTATION EXAMPLE:
05-22-XX Tubersol, 0.1 mL, ID , right lower forearm, per Dr. Jones. Manf – Kline Beecham, Lot number—K449, exp.
3:15 p.m. date – 12/XX. Pt. tolerated well, instructions given to return to clinic 48–72 hours for PPD reading.
– complications during post-injection observation. Sherri Jones, CMA (AAMA)

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 876 ❖ CHAPTER 34

PROCEDURE 34-7 Administer a Subcutaneous Injection

Objective:
To administer an injection through the subcutaneous tissue.

Equipment/Supplies:
❖ Appropriate sized needle and ❖ Sharps container
syringe unit with correct medication ❖ Disposable gloves
❖ Antiseptic wipe ❖ Medication tray
❖ Gauze 2x2 sponges ❖ Adhesive bandage
PROCEDURAL STEPS RATIONALE
1. Wash your hands. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment. Institute the Seven Instituting the seven rights will help prevent errors
Rights of Drug Administration. from occurring.
3. Identify the patient using two identifiers, identify Giving the medication to the wrong patient can cause
yourself, and explain the procedure. serious problems for the patient.
4. Ask the patient about drug allergies, latex allergies, Giving the patient a drug or using products that the
or adhesive allergies. patient is allergic to can cause an anaphylactic reaction.
5. Select the proper injection site (fatty tissue of the
arms, thighs, or stomach).
6. Cleanse the site with antiseptic and allow to air This prevents the possible contamination of the injec-
dry completely. (Cleanse in a circular motion tion site and ensures the removal of microorganisms
working outward to an area of 2 to 3 inches.) from the injection site area. Wet alcohol may cause the
site to burn when you inject the medication.
7. Prepare the equipment and apply gloves. This prevents contamination by bloodborne pathogens
during the procedure.
8. Remove the needle cap. Pull the cap straight off, Twisting may loosen the needle attached to the syringe.
never twist.
9. Grasp or pinch the tissue lightly with one hand. This helps to determine
the subcutaneous layer of
tissue and helps with the
needle insertion.
10. Insert the needle at a 45° angle with the other
hand, using a quick and smooth motion
(Figure 34-52).
Unnecessary movement of FIGURE 34-52 The
11. Stabilize the needle within the tissue. proper angle of inser-
the syringe can cause tissue tion for a subcutaneous
damage and pain to the injection
patient.

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PROCEDURAL STEPS RATIONALE

12. Aspirate to ensure the needle is not in a blood
vessel.
13. Inject the medication slowly and steadily.
14. Remove the needle quickly at the same angle of
insertion.
15. Place a cotton ball or gauze sponge over the injec-
tion site and gently massage the area, if applicable.
16. Properly engage the needle’s safety device and
dispose of the needle and syringe into the sharps
container. Apply a bandage to the site to prevent
the patient’s clothes from becoming contaminated
with blood.
17. Remove gloves and wash your hands.
18. Give proper patient educational materials and
waiting instructions.
19. Perform post-check of the patient and site 20 to
30 minutes following the procedure.
20. Chart the procedure correctly on the progress note
and appropriate logs.
If the needle has inadvertently been inserted into a
vessel, there will be a bloody return into the syringe.
Do not inject, but remove the needle immediately.
Depositing medication into a blood vessel could cause
harm to the patient.
Injecting the medication too quickly can cause discom-
fort to the patient and not allow the medication to be
absorbed properly.
This helps to prevent trauma to the tissue.
This helps ease the discomfort caused from the injec-
tion and accelerates absorption of the medication
(unless massaging is contraindicated).
Engaging the safety device helps to reduce the possibil-
ity of a needlestick.
This prevents contamination and the spread of
infection.
Allergic reactions usually occur within 20 to 30 min-
utes of the procedure.
Documentation illustrates that the procedure was
performed.

DOCUMENTATION EXAMPLE:
05-22-XX Varivax #1, 0.5 mL, sub-q, right arm per Dr. Sullivan. Manf.–Kline Beecham, Lot number–K449, exp. date
3:15 p.m. – 12/XX. Pt. tolerated well, instructions given to pt. for site care and VIS sheet provided—consent form
signed and filed in chart.. Post injection follow-up, –complications. Sherri Jones, CMA (AAMA)

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 878 ❖ CHAPTER 34

PROCEDURE 34-8 Administer an Intramuscular Injection

Objective:
To administer an injection within the muscular tissue.

Equipment/Supplies:
❖ Appropriate sized needle and ❖ Medication tray
syringe unit with correct medication ❖ Sharps container
❖ Antiseptic wipe ❖ Disposable gloves
❖ Gauze 2x2 sponges ❖ Adhesive bandage
PROCEDURAL STEPS RATIONALE
1. Wash your hands. This prevents the spread of infection and contamina-
tion during the procedure.
2. Assemble the equipment. Institute the Seven Instituting the seven rights will help prevent errors
Rights of Drug Administration. from occurring.
3. Identify the patient using two identifiers, identify This prevents the wrong patient from receiving the
yourself, and explain the procedure. medication.
4. Ask the patient about drug allergies, latex allergies, Giving the patient a drug or using products that the
or adhesive allergies. patient is allergic to can cause an anaphylactic reaction.
5. Locate the proper injection site (deltoid, dorsoglu- The right site must be selected in order for the drug to
teal, ventrogluteal, or vastus lateralis). be absorbed properly.
6. Cleanse the site with antiseptic and allow to air This prevents the possible contamination of the injec-
dry completely. (Cleanse in a circular motion tion site and ensures the removal of microorganisms
working outward to an area of 2 to 3 inches.) from the injection site area. Wet alcohol may cause the
site to burn when you inject the medication.
7. Prepare the equipment and apply gloves. This prevents contamination by bloodborne pathogens
during the procedure.
8. Remove the needle cap. Pull the cap straight off, Twisting may loosen the needle attached to the syringe.
never twist.
9. Stretch the tissue to hold the skin taut with your
nondominant hand.
10. Using your dominant hand, insert the needle at This helps with the needle
a 90° angle using a quick and smooth motion insertion.
(Figure 34-53).
11. Stabilize the needle within the tissue. Unnecessary movement
of the hand holding the
syringe can cause tissue
damage and pain to the
patient.
12. Aspirate to ensure the needle is not in a blood Depositing the medication FIGURE 34-53 The
vessel. If blood enters the syringe, do not inject, into the bloodstream could proper angle of inser-
but remove the needle immediately. If there is no cause great harm to the tion for an intramuscular
bloody return into the needle, proceed with the patient. injection
injection process.

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PROCEDURAL STEPS RATIONALE

13. Inject the medication slowly and steadily.
14. Remove the needle quickly at the same angle of
insertion.
15. Place a cotton ball or gauze sponge over the injec-
tion site and gently massage the area, if applicable.
16. Engage the safety device on the needle, and
dispose of the needle–syringe unit in the sharps
container.
17. Place an adhesive bandage over the site and
remove gloves and wash your hands.
18. Give related patient educational materials and
proper waiting instructions.
19. Perform post-check of the patient and site 20 to
30 minutes following the procedure.
20. Chart the procedure correctly on the progress note
and appropriate logs.
Injecting the medication too quickly can cause discom-
fort to the patient and not allow the medication to be
absorbed appropriately.
This helps to prevent trauma to the tissue.
Massaging the area helps to disburse the medication,
unless contraindicated.
This protects you from an accidental needlestick from
a contaminated needle.
This prevents contamination and the spread of infection.
Allergic reactions usually occur within 20 to 30 minutes
of the procedure.
Documentation illustrates that the procedure was
performed.

DOCUMENTATION EXAMPLE:
05-22-XX Hepivax 0.5 mL, IM, R. Deltoid per Dr. Jones. Manf. – Kline Beecham, Lot number–K449, exp. date – 12/XX.
3:15 p.m. Pt. tolerated well, instructions given to pt. for site care and VIS sheet provided and consent form signed
and filed. No problems during post check. Sherri Jones, CMA (AAMA)

PROCEDURE 34-9 Administer a Z-Track Medication

Objective:
To administer an injection by the Z-track method

Equipment/Supplies:
❖ Appropriate sized needle and syringe unit ❖ Medication tray
with correct medication ❖ Sharps container
❖ Antiseptic wipe ❖ Disposable gloves
❖ Gauze 2x2 sponges ❖ Adhesive bandage
PROCEDURAL STEPS RATIONALE
1. Wash your hands. This prevents the spread of infection and contamina-
tion during the procedure
2. Assemble the equipment. Perform the Seven
Rights of Drug Administration.
3. Identify the patient using two identifiers, identify This ensures that you do not give the wrong patient the
yourself, and explain the procedure. medication.

continues

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 880 ❖ CHAPTER 34
continued
PROCEDURAL STEPS
4. Ask the patient about drug allergies, latex allergies,
or adhesive allergies.
5. Locate the proper injection site (usually the dorso-
gluteal site).
6. Cleanse the site with antiseptic and allow to air
dry completely. (Cleanse in a circular motion
working outward to an area of 2 to 3 inches.)
7. Prepare the equipment and apply gloves.
8. Remove the needle cap. Pull the cap straight off,
never twist.
9. Using your nondominant hand, pull the tissue to
be injected laterally 1 to 2 inches away from the
injection site.
10. Using your dominant hand, insert the needle at a
90° angle with a quick and smooth motion.
11. Stabilize the needle within the tissue.
12. Aspirate using the one-hand technique to ensure
the needle is not in a blood vessel. If medication is
in a blood vessel, remove the needle and prepare a
new setup.
13. Inject the medication slowly and steadily.
14. Wait 10 seconds before removing the needle.
15. Remove the needle quickly at the same angle of
insertion.
16. Release the tissue after removing the needle from
the site.
17. Place a cotton ball or gauze sponge over the
injection site. Do not massage the site for a Z-track
injection.
18. Properly engage the safety device and dispose of
the needle–syringe unit into the sharps container.
Apply a bandage to the site to prevent the patient’s
clothes from becoming contaminated with blood.
19. Remove gloves and wash your hands.
27187_34_c34_p835-882.indd Sec1:880
RATIONALE
Giving the patient a drug or using products that the
patient is allergic to can cause an anaphylactic reaction.
Cleansing the site reduces microorganisms on the skin.
Allowing the site to air dry helps to take away the sting
when inserting the needle.
Gloves help to prevent contamination by bloodborne
pathogens during the procedure in the event the site
bleeds.
Twisting may loosen the needle attached to the syringe.
This displaces the tissue so when the tissue is released,
the tissue will return to a normal position to prevent
the medication from leaking out of the site and into sur-
rounding tissue.
Unnecessary movement of the hand holding the syringe
can cause tissue damage and pain.
Using the one-hand technique when aspirating frees the
other hand to keep the tissue retracted.
Injecting the medication too quickly can cause discom-
fort to the patient and not allow the medication to be
absorbed properly.
This allows the medication to settle in the tissue.
This allows the displaced tissue to return to a normal
position and blocks the insertion path of the needle,
preventing the medication from leaking into the sur-
rounding tissues.
Massaging could possibly cause malabsorption of the
medication, discoloration to the tissue surrounding the
site, or even leakage of the medication from the injec-
tion site.
Engaging the safety device keeps you from accidentally
getting stuck with a contaminated needle.
This prevents contamination and the spread of
infection.
9/4/08 6:51:35 PM
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PROCEDURAL STEPS RATIONALE

20. Give related patient educational materials and
waiting instructions.
21. Perform post-check of the patient and site 20 to Allergic reactions usually occur within 20 to 30 min-
30 minutes following the procedure. utes of the procedure.
22. Chart the procedure correctly in the progress note Documentation proves that you performed the
and appropriate logs. procedure.

DOCUMENTATION EXAMPLE:
05-22-XX Methylcobalamin, 1.0 mL, Deep IM (Z-Track), L. Dorsogluteal per Dr. Raymond. Manf. – Kline Beecham, Lot
3:15 p.m. number–K449, exp. date – 12/XX. Pt. tolerated well, –complications during post injection check. Sherri
Jones, CMA (AAMA)

Chapter Summary
By learning the information provided in this chapter and performing the competencies, medical assistants will come
to realize the importance of performing safe and competent invasive procedures for their patients’ health care needs.
The practice of performing invasive procedures must be methodical, focused, and performed with the utmost care,
not given light thought or compromising the quality of services provided. The standard of care demands a high level
of achievement and understanding, for the protection of the patient and the provider’s practice.

FIELD APPLICATION CHALLENGE

The physician asks you to administer a hormone 1. What are some possible causes for the difficulty
shot that is very viscid and oily. As you go to with- in pulling back the plunger?
draw the medication, you notice that you are having
2. What should you have done when the patient
a great deal of trouble pulling back on the plunger.
asked for the injection in the arm? What would
After preparing the medication, you go back to the
have been a better location?
patient’s room with the medication tray. You ask
the patient where he wants to have the medication 3. What would have been an appropriate sized
administered. The patient replies his arm and rolls needle to use for this injection based on the
up his sleeve. You start to administer the injection. new location of the injection and the viscosity
You notice that it is very difficult to push forward of the medication?
on the plunger as you inject the medication into the
4. Why do you suppose that the patient’s arm red-
patient’s deltoid. The patient appears to be experi-
dened and a knot appeared in the area where
encing a great deal of pain. Following the injection,
the injection was given?
the skin over the site is very reddened and a hard
knot now appears at the injection site.

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 882 ❖ CHAPTER 34

Chapter Assessment Web Activity

1. What is the most important aspect of administra-
tion of medication to a patient?
a. Documentation of the procedure
b. Documentation of the medication administered
to the patient
c. Proper identification of the patient
d. Proper technique in administering the
medication
2. Tuberculin syringes come in what syringe size?
a. 1 mL syringes
b. 3 mL syringes
c. 5 mL syringes
d. 10 mL syringes
3. The gauge of the needle indicates:
a. the size of the lumen.
b. the length of the needle.
c. the length of the hub.
d. the size of the syringe.
4. A subcutaneous injection is usually given at what
degree for angle of insertion?
a. 10°
b. 15°
c. 45°
d. 90°
5. The two vaccines that are contraindicated for
pregnant women are:
a. hepatitis B and tetanus.
b. Varicella and MMR.
c. PPD and hepatitis B.
d. small pox and hepatitis A.
1. The Centers for Disease Control and Prevention
National Immunization Program provides infor-
mation on the importance of vaccinations. Go to
http://www.cdc.gov and look up this important
information. Prepare a one-page summary that
depicts why the benefits of immunizing far out-
weighs the risks of immunizing.
CONNECTION
Using your StudyWARE CD-ROM:
❖ Complete the Concentration activity for this
chapter.
❖ Complete the Quiz for this chapter in Test Mode.
THE DVD LINK
On your StudyWARE CD-ROM,
go to the DVD Challenge for
this chapter. View the DVD clip
and respond to the following
questions:
1. Once you load the cartridge into the injector
device and lock it into place, what should
you do with the medicine in the syringe to
finalize the preparation of the syringe needle
unit?

6. The gauge used for an injection is determined by: 2. After administering the injection, what steps
a. the viscosity of the medication. should you take to dispose of the cartridge
b. the site of the injection. unit?
c. the amount of fat the patient has.
d. all of the above.
7. Parenteral routes include all but which of the
following?
a. Intramuscular
b. Intravenous
c. Oral
d. Intra-articular

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