PARENTERAL

INJECTIONS

Prepared by:
NAPOLEON C. ADAY
ROMEO C. BANAN JR.
MAREXIE V. CASTRO
CHRISTINE JOYCE O. DELA CRUZ
MA. PRINCES A. LLARENAS
JEWELL F. LLAVORE
JIMA J. MAMUNGAY
MONICA JANE N. MARZAN
SIEGFRED O. ROBLES
 TABLE OF CONTENTS
Introduction 3
Learning Outcomes 3
Directions 3
Lesson 1 Parenteral Injections 4
Lesson 2 Intravenous Therapy 13
Appendices
Intramuscular Injection Checklist 30
Intradermal Injection Checklist 34
Subcutaneous Injection Checklist 37
Intravenous Insertion Checklist 41

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 PARENTERAL INJECTIONS

INTRODUCTION
This module will help you review the various parenteral injections you will
be using in the delivery of care to patients who have problems with their various body
systems. This module will help you deliver appropriate and safe care and interventions
to patients who have illnesses that will hone you to become good and responsible nurses
in the future.

LEARNING OUTCOMES
On completion of this RLE module, you will be able to:

1. apply appropriate nursing concepts and actions holistically and

comprehensively in giving parenteral injections.
2. utilize the nursing process in the care and health education of patients in giving
parenteral injections.
3. ensure a well-organized and accurate documentation system of patient in the
delivery of care in giving parenteral injections.
4. show safe and appropriate care to patients based on their culture and practices
in giving parenteral injections.
5. integrate relevant legal, moral, and ethical standards of care in performing the
roles and responsibilities of a nurse in giving parenteral injections.
6. apply evidence-based practices in caring of a patient in giving parenteral
injections.
7. plan an effective care to promote, maintain, or restore functional health
patterns in giving parenteral injections.

DIRECTION
DIRECTIONS
There are 2 lessons in the module. Read each lesson
carefully. After reading each lesson, you are required to perform
the return demonstration when you report on your scheduled limited face-to-face.
Checklists are provided every after discussion.

Good luck and happy reading!!!

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Lesson 1
Skills Enhancement:
Parenteral Administration
Introduction

• Parenteral drug administration means any non-oral means of administration but is

generally interpreted as relating to injecting directly into the body, bypassing the
skin and mucous membranes.
• The common parenteral routes are intramuscular (IM), subcutaneous (SC) and
intravenous (IV).
• This lesson will discuss the purpose and importance of parenteral administration.
Furthermore, it will explain procedures on how to properly administer medications
using different routes.
• Each type of injections requires certain skills to ensure that the medications reach
the proper location. The effects of parenteral medications develop rapidly,
depending on the rate of medication absorption.

INJECTION TECHNIQUES

Intramuscular Injection
• It is a technique used to deliver a medication deep into the muscles.
• This allows the medication to be absorbed into the bloodstream

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 quickly.
• The basis of this process is that the bulky muscles have good
vascularity, and therefore the injected drug quickly reaches the
systemic circulation and thereafter into the specific region of action,
bypassing the first-pass metabolism.
• The purpose of administration is both curative and prophylaxis.

Anatomical Landmarks

Dorsogluteal Region
• 5 to 7.5 cm below the
iliac crest.
• Upper outer quadrant
of the upper outer
quadrant within the
buttocks.
• Up to 3ml of fluid can
be given in this site

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Ventrogluteal site
• Provides the greatest
thickness of gluteal
muscle (consisting of
both the gluteus medius
and gluteus minimus), is
free of penetrating
nerves and blood vessels,
and has a narrower layer
of fat of consistent
thinness than is present
in the dorsogluteal.
• The heel of the opposing
hand is placed in the
greater trochanter, the
index finger in the
anterior superior iliac
spine and the middle
finger below the iliac
crest.
• The drug is injected in
the
triangle formed by the
index, middle finger, and
the iliac crest

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 Deltoid
• Up to 3ml of fluid
may be given in this
site
• 2.5 to 5 cm below
the acromion
process
• This is a small site –
give only 1-2ml or
less of fluid in this
site

Vastus Lateralis
• The middle third of the line joining
the greater trochanter of the femur
and the lateral femoral condyle of
the knee
• Up to 2ml of fluid may be given into
this site

Subcutaneous Injections
• Involves placing the medications into the loose tissue under the dermis. ∙
Medication absorption is slower due to subcutaneous tissue is not richly

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 supplied with blood.
• Best subcutaneous site includes the outer posterior aspects of arms, the
abdomen from below the costal margins of the iliac crest and anterior
aspects of the thigh.
• Up to 0.5 ml to 1.5 ml of medications may be given

Intradermal Injections
• Typically use for skin testing (tuberculin screening and allergy test) ∙
The ID injection route has the longest absorption time of all
parenteral routes.

Skills: Administering Medications

Assess:
• Allergies to medication
• Specific drug action, side effects, and adverse reactions
• Client’s knowledge and learning needs about the medication
• Status and appearance of subcutaneous site for lesions, erythema,
swelling, ecchymosis, inflammation, and tissue damage from
previous injections.
• Ability of client to cooperate during the injection
• Client’s age and weight, to determine site and needle size
• Previous injection sites used
• Patient’s medical and medication history of allergies
• Client’s ability or willingness to cooperate

Assemble equipment and supplies:

• Medication Administration Record or computer printout
• Vial or ampoule of the correct sterile medication
• Syringe and needle of a size appropriate for the amount of solution to be
administered
• Antiseptic swabs
• Dry sterile gauze for opening an ampoule (optional)
• Disposable gloves

Step Rationale

Check accuracy and completeness of MAR The physician’s order sheet is the most
with physician’s order. 12 Rights of reliable source and only legal record of
Medication Administration. You can use medications that patient is to receive.
the acronym DEAR PT RED
Right to

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D- Documentation
E- Evaluation
A- Assessment
R- Reason

P- Patient
T- Time

R- Route; Refuse
E- Expiration date; Education
D- Drug; Dose

Review pertinent information related to Allows anticipation of drug effects and

medication: action, purpose, indications, observe patient
route peak action, and interventions.

Assess patient’s medical and medication Reveals needs for medication. A history
history of allergies. of allergies may aid in preventing
patients with known allergies from
receiving drugs that may endanger their
health.

Assess for contraindications: Reduced tissue perfusion and atrophied

• Subcutaneous – assess for factors muscle interferes with the medication
such as shock or reduced local absorption and distribution.
tissue perfusion.
• IM- assess factors such as muscle
atrophy reduced blood flow or
circulatory shocks

Assess patient’s knowledge. Determine if there is a need for patient

education.

Perform Hand Hygiene. Ensures that medication is sterile.

Close room curtain or door. Provides privacy.

Identify the 12 rights before Ensure correct patient. For accuracy

administration of medications. checks. To avoid error or mistakes.

Explain steps of procedures to client. Helps minimize patient’s anxiety.

Apply clean gloves. Reduces transfer of microorganisms.

Select appropriate injection sites. Injection sites needs to be free of

Inspect skin surface over sites for abnormalities that interfere to
bruises, inflammation, or edema medication absorption

Subcutaneous- Palpate site for mass or Subcutaneous injections are sometimes

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 tenderness given in muscle, especially in
abdomen and thigh sites.

IM- Note integrity and size of muscle For better absorption

and palpate tenderness or hardness

ID- Note for lesions or discoloration of The site needs to be clear so you can
the skin see results of the skin test and
interpret correctly.

Help patient into comfortable position. Relaxation of the site minimizes

discomfort.

Relocate site using anatomical landmarks. Injection into correct anatomical

site prevents injury to nerves,
bones, and blood vessels.

Clean site with antiseptic swab. Apply Mechanical action of swab

swab at the center and rotate outward removes secretions containing
in circular direction for approximately microorganisms
5cm.

Hold swab or gauze between third Gauze swab remains readily

and fourth fingers of non-dominant accessible with needle is withdrawn.
hand.

Remove needle cap of sheath from Prevent needle from touching sides of
needle by pulling it straight off. cap prevents contamination.

Hold syringe between thumb and Quick smooth injection requires

forefinger of dominant hand. manipulation of syringe parts.
Subcutaneous- Hold as dart, palm
up. With bevel up, medications is less likely
IM- Hold as dart, palm down to be deposited into tissue below
ID- Hold bevel pointing up dermis.

Administer injection:

Subcutaneous

For average –size patient pinch skin Pinching skin elevates subcutaneous
with non-dominant hand tissue and desensitizes area.

Inject needle quickly and firmly at 45- Quick firm injections minimize
90 degrees angel. Release skin discomfort.

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Inject medications slowly Minimize discomfort.

Intramuscular

Position ulnar aspect of your non- Z track creates zigzag path through
dominant hand just below site and pull tissues that seals needle track to
skin approximately 2.5 to 3.5 cm down avoid tracking of medications.
or laterally to administer Z-track. With
dominant hand inject needle quickly at
90 degrees angle into muscle.

Option: If patient muscle mass is small, Ensures that medications reach the
grasp body of muscle between thumb muscle mass.
and fingers

Insert needle into muscle with smooth, Smooth, steady motion reduces pain
steady motion. After needle pierces the at moment of injections.
skin grasp lower end of syringe barrel
with nondominant hand. Move dominant
hand to end of plunger. Do not move
syringes

Pull back on plunger 5 to 10 seconds. If Ensure that the needle is not low-flow
no blood appears, inject medicine blood. Aspiration of blood in the
slowly at rate of 1ml-10 seconds. Note: syringe indicates intravenous
DO NOT aspirate when giving placement of needle. The CDC (2015)
immunizations no longer
recommend the aspiration when
administering immunization.

Wait 10 seconds. Then smoothly Allows medication to absorb into

and steadily withdraw needle and muscle before removing syringe rather
release skin. than leaking back out through track
that needle created.

Intradermal

With non-dominant hand stretch Needle pierces tight skin more easily.
the site with forefinger or thumb.

With needle almost against the Ensures that needle tip is in dermis.
patient’s skin, insert it slowly with
bevel up at 5 to 10 degree angle until
resistance is felt. Advance it through
epidermis to
approximately 3mm below skin
surface

Inject medication slowly. Slow injection minimizes discomfort at

site.

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While injecting medication, notice that Bleb indicates that medication is
small bleb approximately 6 mm (1/4 deposited in the dermis.
inches) in diameter appears on the
surface of the skin.

Withdraw needle while applying alcohol Support if tissue around injection sure
swab or gauze gently over site. minimizes discomfort.

Apply gentle pressure. Do not massage Massage causes underlying tissue

site. Apply bandage if needed. damage.

Help patient to comfortable position. Gives patient sense of well-being.

Discard uncapped needle or needle Prevents injury to patient and health

enclosed in safety shield and attached care provider.
syringes into punctured proof, leak
proof receptacle.

Remove gloves and perform hand Reduces transmission of

hygiene microorganism.

Stay with the patient and observe for Dyspnea, wheezing, and circulatory
any allergic reactions. collapse are signs of severe
anaphylactic reaction, which is life
threatening emergency.

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Lesson 2
Skills Enhancement:
Intravenous Therapy
Introduction

Intravenous therapy, also known as IV therapy, is the administration of liquid

substances directly into a vein. It can be intermittent or continuous; the latter is referred
to as an intravenous drip. The term intravenous simply means "within a vein," but it is
most commonly associated with IV therapy. The intravenous route is the quickest way to
deliver fluids and medications throughout the body when compared to other routes of
administration.

Learning Outcomes

1. Describe the relevant anatomy and physiology of the peripheral venous system.
2. Critically analyze the potential complications associated with cannulation and
discuss appropriate actions to prevent and/or treat these complications.
3. Define the steps required to prepare the patient for cannulation including
equipment required.
4. Demonstrate familiarity with equipment components and appropriate selection to
meet the goals of IV therapy.
5. Identify peripheral veins suitable for cannulation.
6. Cannulate peripheral veins safely under simulated conditions.
7. Identify measures to minimize and address difficulties encountered during cannulation

Purposes of Intravenous (IV) Therapy

• To supply fluid when clients are unable to take in an adequate volume of fluids
by mouth.
• To provide salts and other electrolytes needed to maintain electrolyte
imbalance.
• To provide glucose (dextrose), the main fuel for metabolism.
• To provide water-soluble vitamins and medications.
• To establish a lifeline for rapidly needed medications.

Types of Intravenous Solution

1. Isotonic Solution
a. It has the same concentration of solutes as blood plasma and often used to
restore vascular volume.
b. Used to increase the extracellular fluid volume due to blood loss, surgery,
dehydration, fluid loss that has been loss extracellularly
c. Example: 0.9 % Sodium Chloride (NaCL) or Normal Saline, Lactated Ringer’s
Solution, 5% Dextrose in Water (D5W), 5% Dextrose Water in 0.225% saline (D5W
¼ Normal Saline)

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0.9 % Sodium Chloride
(NaC)/Normal Saline

Lactated Ringer’s Solution

5% Dextrose Water

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 5% Dextrose Water in
0.225% Normal Saline

2. Hypotonic Solution
a. It has a lower concentration of solutes than body
fluids or plasma. It is used to provide free water
and treat cellular dehydration and promotes
waste elimination by the kidneys.
b. The cell has a low amount of solute
extracellularly and it wants to shift inside the
cell to get everything back to normal via
osmosis. This will cause CELL SWELLING which
can cause the cell to burst or lyses.
c. Used when the cell is dehydrated, and fluids
need to be put back intracellularly. This happens
when patients develop diabetic ketoacidosis
(DKA) or hyperosmolar hyperglycemia.
d. Important: Watch out for depleting the
circulatory system of fluid since you are trying to
push extracellular fluid into the cell to re-
hydrate it. Never give hypotonic solutions to
patient who are at risk for increased cranial
pressure (can cause fluid shift to brain tissue),
extensive burns, trauma (already hypovolemic)
because you can deplete their fluid volume.
e. Example: 0.45 % Sodium Chloride (NaCl) (1/2
Normal Saline), 0.33 % Sodium Chloride (NaCl) 0.45% Normal Saline
(1/3 Normal Saline), 0.223% Sodium Chloride
(NaCl) (1/4 Normal Saline)

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 3. Hypertonic Solution
a. It has a greater concentration of solutes than plasma, draws fluid out of the
intracellular and interstitial compartments into vascular compartments thus
expanding vascular volume.
b. The cell has an excessive amount of solute extracellularly and osmosis is
causing water to rush out of the cell intracellularly to the extracellular area
which will cause the CELL TO SHRINK.
c. Used very cautiously, most likely to be given in the ICU due to quickly arising
side effects of pulmonary edema/fluid overload.
d. Used via central line because it is vesicant on the veins and the risk for
infiltration.
e. Example: 5% Dextrose in Normal Saline (D5NSS), 5% Dextrose in 0.45% Normal
Saline (D5 ½ NSS), 5% Dextrose in Lactated Ringers (D5LRS), 3% Saline, 5%
Saline, 10% Dextrose in Water (D10W)

5% Dextrose in
Lactated Ringers
(D5LRS)

5% Dextrose in
Normal Saline
(D5NSS)

Vein Anatomy and Physiology

Veins are unlike arteries in that they are:
1. superficial
2. display dark red blood at skin surface
3. have no pulsation

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Parts: (outer to inner)
1. tunica adventitia
2. tunica media
3. tunica intima
4. vein valve

Veins of the Upper Extremities

1. Digital Vessels: Along lateral
aspects fingers, infiltrate easily,
painful, difficult to immobilize
and should be your LAST RESORT.
2. Metacarpal Vessels: Located
between joints and metacarpal
bones (act as natural splint) -
Formed by union of digital veins
• Geriatric patients often lack
enough connective / adipose
tissue and skin turgor to use this
area successfully
3. Cephalic (Intern’s Vein): Starts at
radial aspect of wrist. Access
anywhere along entire length
(BEWARE of radial artery/nerve)
4. Medial Cephalic (“On ramp” to
Cephalic Vein): Joins the Cephalic
below the elbow bend. Accepts
larger gauge catheters, but may
be a difficult angle to hit and
maintain
5. Basilic: Originates from the ulnar
side of the metacarpal veins and
runs along the medial aspect of
the arm. It is often overlooked
because of its location on the “back” of the arm, but flexing the elbow/bending the
arm brings this vein into view
6. Medial Basilic: Empties into the Basilic vein running parallel to tendons, so it is not
always well defined. Accepts larger gauge catheters. BEWARE of Brachial Artery/Nerve

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Complications of IV Therapy
I. Infiltration
• Infiltration occurs when I.V. fluid or medications leak into the surrounding
tissue.
• Infiltration can be caused by improper placement or dislodgment of the
catheter.
• Patient movement can cause the catheter to slip out or through the blood
vessel lumen.

Signs and symptoms

∙ Swelling, discomfort, burning, and/or tightness
∙ Cool skin and blanching
∙ Decreased or stopped flow rate

Prevention
∙ Select an appropriate I.V. site, avoiding areas of flexion.
∙ Use proper venipuncture technique.
∙ Follow your facility policy for securing the I.V. catheter.
∙ Observe the I.V. site frequently.
∙ Advise the patient to report any swelling or tenderness at the I.V. site.

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 Management
Stop the infusion and remove the device.
Elevate the limb to increase patient comfort; a warm compress
may be applied.
Check the patient's pulse and capillary refill time.
Perform venipuncture in a different location and restart
the infusion, as ordered.
Check the site frequently.
Document your findings and interventions performed.

II. Extravasation
• Extravasation is the leaking of vesicant drugs into surrounding tissue.
• Extravasation can cause severe local tissue damage, possibly leading to
delayed healing, infection, tissue necrosis, disfigurement, loss of function,
and even amputation.

Signs and symptoms

Blanching, burning, or discomfort at the I.V. site
Cool skin around the I.V. site
Swelling at or above the I.V. site
Blistering and/or skin sloughing

Prevention
Avoid veins that are small and/or fragile, veins in areas of flexion,
veins in extremities with pre-existing edema, or veins in areas with
known neurologic impairment.
Be aware of vesicant medications, such as certain antineoplastic
drugs (doxorubicin, vinblastine, and vincristine), and hydroxyzine,
promethazine, digoxin, and dopamine.
Follow your facility policy regarding vesicant administration via a
peripheral I.V.; some institutions require that vesicants are

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 administered via a central venous access device only.
Give vesicants last when multiple drugs are ordered.
Strictly adhere to proper administration techniques.

Management
Stop the I.V. flow and remove the I.V. line, unless the catheter should
remain in place to administer the antidote.
Estimate the amount of extravasated solution and notify the prescriber.
Administer the appropriate antidote according to your facility's
protocol.
Elevate the extremity.
Perform frequent assessments of sensation, motor function, and
circulation of the affected extremity.
Record the extravasation site, your patient's symptoms, the estimated
amount of extravasated solution, and the treatment.
Follow the manufacturer's recommendations to apply either cold or
warm compresses to the affected area

III. Phlebitis
• Phlebitis is inflammation of a vein.
• It is usually associated with acidic or alkaline solutions or solutions that
have a high osmolarity.
• Phlebitis can also occur as a result of vein trauma during insertion, use of
an inappropriate I.V. catheter size for the vein, or prolonged use of the
same I.V. site.

Signs and Symptoms

Redness or tenderness at the site of the tip of the catheter or along
the path of the vein
Puffy area over the vein

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 Warmth around the insertion site

Prevention
Use proper venipuncture technique.
Use a trusted drug reference or consult with the pharmacist for
instructions on drug dilution, when necessary.
Monitor administration rates and inspect the I.V. site
frequently.
Change the infusion site according to your facility's
policy.

Management
Stop the infusion at the first sign of redness or pain.
Apply warm, moist compresses to the area.
Document your patient's condition and interventions.
If indicated, insert a new catheter at a different site, preferably on the
opposite arm, using a larger vein or a smaller device and restart the
infusion.

IV. Hypersensitivity
• An immediate, severe hypersensitivity reaction can be life-threatening, so
prompt recognition and treatment are imperative.

Signs and Symptoms

Sudden fever
Joint swelling
Rash and urticaria
Bronchospasm
Wheezing

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 Prevention
Ask the patent about personal and family history of allergies.
For infants younger than 3 months, ask the mother about her allergy history
because maternal antibodies may still be present.
Stay with the patient for five to 10 minutes to detect early signs and
symptoms of hypersensitivity.
If the patient is receiving the drug for the first or second time, check
him every five to 10 minutes or according to your facility's policy.

Management
Discontinue the infusion and notify the prescriber
immediately.
Administer medications as ordered.
Monitor the patient's vital signs and provide emotional support.

V. Infection
• Local or systemic infection is another potential complication of I.V.
therapy.

Signs and symptoms

Redness and discharge at the I.V. site
Elevated temperature

Prevention
Perform hand hygiene, don gloves, and use aseptic technique during I.V.

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 insertion.
Clean the site with approved skin antiseptic before inserting I.V. catheter.
Ensure careful hand hygiene before any contact with the infusion system or
the patient.
Clean injection ports before each use.
Follow your institution’s policy for dressing changes and changing of the
solution and administration set.

Management
Stop the infusion and notify the prescriber.
Remove the device, and culture the site and catheter as ordered.
Administer medications as prescribed.
Monitor the patient's vital signs.

With careful attention and skill, you’ll be able to recognize, prevent, and manage
these complications of peripheral I.V. therapy.

Types of IV Cannula

Size Color Recommended use

14G In massive trauma situations.

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16G Trauma, surgeries, or multiple large-volume infusions

18G Blood transfusion, or large volume infusions.

20G Multi-purpose IV; for medications, hydration, and routine therapies.

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22G Most chemo infusions; patients with small veins; elderly or pediatric
patients

24G Very fragile veins; elderly or pediatric patients

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 Skills: Intravenous Therapy
Assess:
• Intravenous access devices should be selected depending on individual patient needs.
• This requires comprehensive assessment of the patient, equipment, therapy,
environment, and operator skill.
• The following questions should be considered:
o Is the therapy short or long term?
o Is it continuous or intermittent therapy?
o What types of drugs or therapies are needed? (Osmolality, pH,
viscosity, speed/volume, and compatibility with other therapy)
o Does the patient have a history of lymphoedema, mastectomy,
previous access device insertion problems, surgical or radiotherapy
intervention to access site or fractures?
o Does the patient have pre-existing co-morbidities such as
coagulopathy, sepsis or immune compromised?
o What is the allergy status of the patient? (Local anesthetic, skin
antiseptic, dressings)
o Does the patient have good or poor venous access? (Poor venous
access may be obvious due to poorly visible, bruised, or thrombosed
arm vessels)
o What is the patient’s preference? What is the knowledge and skill of
the person inserting the cannula?

Equipment/Supplies:
• Gloves non-sterile
• Alcohol Wipe IV Dressing
• Selected cannula x 2
• Tourniquet
• Extension set/luer plug – primed with sodium chloride 0.9%
• Posiflush 10ml pre-filled syringe sodium chloride 0.9% or saline flush
• Sterile guard & blue plastic backed sheet
• Gauze swab

Steps Rationale

Gather all equipment and bring to Having equipment available save time and
bedside. Check IV solution. facilitate accomplishments of task.

Explain the need for IV and Helps minimize patient’s anxiety.

procedure to patient.

Perform Hand Hygiene. Ensures that medication is sterile.

Close room curtain or door. Provides privacy.

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Prepare IV Solution and tubing

Maintain aseptic technique when Asepsis is essential for preventing the

opening sterile package and IV spread of microorganisms.
solution.

Clam tubing, uncap spike and insert This puncture the seal in the IV tubing.
into entry site on bag as per
manufacturer

Squeeze drip chamber and allow it Suction causes fluid to move into drip
to fill at least halfway. chamber and prevents air from moving
down the tubing.

Remove cap at end of tubing, This removes air from tubing, in larger
release clamp, and allow fluid to amounts, air acts as an embolus.
fluid until air bubbles have to flow
until all air bubbles have
disappeared. Close clamp and recap
end of tubing, maintaining sterility.

Apply label if medication was added This provides administration of correct

solution with prescribed medication and
physician’s order.

Place patient in a low- fowler’s The supine position permits either arm to
position in bed. Place protective be used and allows body alignment.
towel or pas under the patient’s
arm.

Select an appropriate site and The use of appropriate site decreases

palpate accessible vein. discomforts for the patient and reduces
risk for damage to body tissue.

Apply tourniquet 5 to 6 inches above Interrupting the blood flow to the heart
the venipuncture site to obstruct causes the vein to distend. Distended
venous blood flow and distend the veins are easy to see, palpate and enter.
vein.

Ask the patient to close and open Contracting of muscle forces blood into
fist. the vein thereby distending them further.

Apply clean gloves. Reduces transfer of microorganisms.

Clean site with antiseptic swab. Mechanical action of swab removes

Apply swab at the center and rotate secretions containing microorganisms.

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outward in circular direction for
approximately 5cm.

Use the non-dominant hand, placed Pressure on the vein and surrounding
about 1-2 inches below entry site, to tissue helps prevent movement of the vein
hold the skin taut against the vein. as needle catheter is being inserted.
Avoid touching the prepared site.

Enter the skin gently, holding the This allows the catheter to enter the vein
catheter by hub in your dominant with minimal trauma.
hand, bevel side up, at 1 10 to 30
degrees angle. Catheter may be
inserted from directly over the vein
or the side of the vein advance the
needle or catheter into the vein.

The flashback of blood in the The tourniquet causes increased venous

catheter’s applicator will indicate pressure, resulting in automatic backflow.
that the vein has been hit, advance
the needle one more centimeter
(cm) into the vein.

Release the tourniquet. and dispose Bleeding is minimized and the patency of
the needle into the sharps bin. vein is maintained.

Secure the cannula in place with the The smooth structure of the vein does not
sterile dressing. resist the movement of the catheter.

Flush cannula with 5ml of saline No resistance means the catheter is in the
vein.

Remove the protective cap in the Patency of the vein is maintained of the
tubing and attach tubing to the connection is made smoothly between the
catheter. catheter and the tubing.

Mark the date, time, site and type Other personnel working in the area will
and size of catheter used for know what type of device is being used.
infusion on the tape anchoring the
tubing.

Discard uncapped needle or needle Prevents injury to patient and health care
enclosed in safety shield and provider.
attached syringes into punctured
proof, leak proof receptacle.

Remove gloves and perform hand Reduces transmission of microorganism.

hygiene.

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Adjust the rate of the solution as
prescribed

Document the procedure and This provides accurate documentation and

patient’s response. ensures continuity of care.

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Name:_________________________________Date: _____________ Section/Group:________
Administering an Intramuscular Injection
CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
Criteria 3 2 1 0

Assess:
• Patient allergies to medication(s)
• Specific drug action, side effects, and adverse reactions
• Client’s knowledge and learning needs about the medication
• Status and appearance of subcutaneous site for lesions,
erythema, swelling, ecchymosis, inflammation, and tissue
damage from previous injections.
• Ability of client to cooperate during the injection
• Client’s age and weight, to determine site and needle size
• Previous injection sites used
• Patient’s medical and medication history of allergies
• Client’s ability or willingness to cooperate
Assess for contraindications:
• IM- assess factors such as muscle atrophy reduced blood flow
or circulatory shocks

Determine:
Whether the size of the muscle is appropriate to the amount of medication
to be injected.

Assemble equipment and supplies:

• Medication Administration Record or computer printout
• Vial or ampoule of the correct sterile medication
• Syringe and needle of a size appropriate for the amount of solution to
be administered
• Antiseptic swabs
• Dry sterile gauze for opening an ampoule (optional)
• Disposable gloves

Check the MAR (Medication Administration Record)

Check accuracy and completeness of MAR with physician’s order. 12 Rights of

Medication Administration

Review pertinent information related to medication: action, purpose,

indications, route peak action and interventions.

Check the label on the medication carefully against the MAR to make sure that
the correct medication is being prepared.

Page | 30
 Follow the “three checks” for administering the medication and dose. Read
the label on the medication:
• When it is taken from the medication cart
• Before withdrawing the medication
• After withdrawing the medication

Procedure

Wash hands and observe other appropriate infection control procedures.

Prepare the medication from the ampule or vial for drug withdrawal.

Provide for client privacy.

Prepare the client.

Check the client’s identification band.

Assist the client to a supine, lateral, prone, or sitting position, depending on

the chosen site.

Obtain assistance in holding an uncooperative client.

Explain the procedure, purpose of the medication and how it will help,
using language that the client can understand. Include relevant
information about effects of the medication. Always remember the 12
rights in medication administration

Select, locate ad clean the site

Select a site free of skin lesions, tenderness, swelling, hardness, or localized

inflammation, and one that has not been used frequently.

If injections are to be frequent, alternate sites. Avoid using the same site
twice in a row

Locate the exact site for the injection.

Put on clean gloves.

Clean the site with an antiseptic swab. Using a circular motion, start at the
center and move outward about 5 cm (2in).

Transfer and hold the swab between the third and fourth fingers of your
nondominant hand in readiness for needle withdrawal or position the swab
on the Client’s skin above the intended site. Allow skin to dry prior to
injecting medication.

Prepare the syringe for injection

Remove needle cap of sheath from needle by pulling it straight off.

Page | 31
If using a prefilled unit–dose medication, take caution to avoid dripping
medication on the needle prior to injection. If this does occur, wipe the
medication off the needle with sterile gauze.

Hold syringe between thumb and forefinger of dominant hand.

IM- Hold as dart, palm down

Administer injection (Intramuscular Injection)

Position ulnar aspect of your nondominant hand just below site and pull skin
approximately 2.5 to 3.5 cm down or laterally to administer Z-track. With
dominant hand inject needle quickly at 90 degrees angle into muscle.

Option: If patient muscle mass is small, grasp body of muscle between thumb
and fingers

Insert needle into muscle with smooth, steady motion. After needle pierces
the skin grasp lower end of syringe barrel with nondominant hand. Move
dominant hand to end of plunger. Do not move syringes

Pull back on plunger (Aspirate) 5 to 10 seconds. If no blood appears in the

syringe, inject the medication slowly at rate of 10 seconds per milliliter while
holding the syringe steady. Note: DO NOT aspirate when giving immunizations.
Also, if blood appears in the syringe, WITHDRAW the needle, DISCARD the
syringe, and prepare new injection.

After injection, wait 10 seconds.

Withdraw the needle

Smoothly and steadily withdraw needle and release skin.

Apply gentle pressure at the site with a dry sponge. Do not massage the site.

If bleeding occurs, apply pressure with dry sterile gauze until it stops.

Discard uncapped needle or needle enclosed in safety shield and attached

syringes into punctured proof, leak proof receptacle.

Remove gloves and perform hand hygiene

Help patient to comfortable position

Document all relevant information

Include the time of administration, drug name, dose, route, and the client’s
reactions.

Stay with the patient and observe for any allergic reactions. Assess
effectiveness of the medication at the time it is expected to act

Page | 32
For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.

Student’s signature: __________________

Evaluator’s Signature: __________________

Comments:__________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Page | 33
Name:_________________________________Date: _____________ Section/Group:________
Administering an Intradermal Injection
CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
Criteria 3 2 1 0

Assess:
• Patient allergies to medication(s)
• Specific drug action, side effects, and adverse reactions
• Client’s knowledge and learning needs about the medication
• Status and appearance of subcutaneous site for lesions,
erythema, swelling, ecchymosis, inflammation, and tissue
damage from previous injections.
• Ability of client to cooperate during the injection
• Client’s age and weight, to determine site and needle size
• Previous injection sites used
• Patient’s medical and medication history of allergies
• Client’s ability or willingness to cooperate
Assess for contraindications:
• ID- Note for lesions or discoloration of the skin
Determine:
Whether the size of the muscle is appropriate to the amount of medication to
be injected.

Assemble equipment and supplies:

• Medication Administration Record or computer printout
• Vial or ampoule of the correct sterile medication
• Sterile 1–ml syringe calibrated into hundredths of a milliliter (i.e.
tuberculin syringe) and a 25– to 27–gauge needle hat is ¼ to 5/8 inch
long
• Antiseptic swabs
• Dry sterile gauze for opening an ampoule (optional)
• Disposable gloves

Check the MAR (Medication Administration Record)

Check accuracy and completeness of MAR with physician’s order. 12 Rights of

Medication Administration

Review pertinent information related to medication: action, purpose,

indications, route peak action and interventions.

Check the label on the medication carefully against the MAR to make sure that
the correct medication is being prepared.

Page | 34
Follow the “three checks” for administering the medication and dose. Read the
label on the medication:
• When it is taken from the medication cart
• Before withdrawing the medication
• After withdrawing the medication

Procedure

Wash hands and observe other appropriate infection control procedures.

Prepare the medication from the ampule or vial for drug withdrawal.

Provide for client privacy.

Prepare the client.

Check the client’s identification band.

Assist the client to a supine, lateral, prone, or sitting position, depending on the
chosen site.

Obtain assistance in holding an uncooperative client.

Explain the procedure, purpose of the medication and how it will help, using
language that the client can understand. Include relevant information about
effects of the medication. The medication will produce a small wheal,
sometimes called bleb. Always remember the 12 rights in medication
administration.

Select, locate ad clean the site

Select a site free of skin lesions, tenderness, swelling, hardness, bruises, edema,
or localized inflammation, and one that has not been used frequently.
ID- Note for lesions or discoloration of the skin

Put on clean gloves.

Clean the site with an antiseptic swab. Using a circular motion, start at the
center and move outward about 5 cm (2in). Allow the area to dry thoroughly
before injecting the medication.

Prepare the syringe for injection

Remove needle cap of sheath from needle by pulling it straight off.

Expel any air bubbles from the syringe.

Hold syringe between thumb and forefinger of dominant hand.

ID- Hold the needle almost parallel to the skin surface with bevel pointing up

Administer injection (Intradermal Injection)

Page | 35
 With the nondominant hand, pull the skin at the site until it is taut.

Insert the tip of the needle far enough to place the bevel through the epidermis
into the dermis (5-to-10-degree angle). The outline of the bevel should be
visible under the skin surface.

Stabilize the syringe and needle, and inject the medication carefully and
slowly, so that it produces a small wheal on the skin (approximately 6mm or ¼
inches in diameter).

Withdraw the needle quickly at the same angle that it was inserted. Apply a
Band–Aid, if indicated.

Do not massage the area.

Discard uncapped needle or needle enclosed in safety shield and attached

syringes into punctured proof, leak proof receptacle.

Remove gloves and perform hand hygiene

Circle the injection site with ink (black or blue only) to observe redness or
induration per agency policy.

Help patient to comfortable position

Document all relevant information

Record the testing material given, the time, dosage, route, site, nursing
assessments, and client’s reactions.

Stay with the patient and observe for any allergic reactions. Assess
effectiveness of the medication at the time it is expected to act

For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.

Student’s signature: __________________

Evaluator’s Signature: __________________

Comments:___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Page | 36
Name:_________________________________Date: _____________ Section/Group:________
Administering a Subcutaneous Injection
CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
Criteria 3 2 1 0

Assess:
• Patient allergies to medication(s)
• Specific drug action, side effects, and adverse reactions
• Client’s knowledge and learning needs about the medication
• Status and appearance of subcutaneous site for lesions,
erythema, swelling, ecchymosis, inflammation, and tissue
damage from previous injections.
• Ability of client to cooperate during the injection
• Client’s age and weight, to determine site and needle size
• Previous injection sites used
• Patient’s medical and medication history of allergies
• Client’s ability or willingness to cooperate
Assess for contraindications:
• Subcutaneous – assess for factors such as shock or reduced local tissue
perfusion.

Determine:
Whether the size of the muscle is appropriate to the amount of medication to
be injected.

Assemble equipment and supplies:

• Medication Administration Record or computer printout
• Vial or ampoule of the correct sterile medication
• Syringe and needle of a size appropriate for the amount of solution to
be administered
• Antiseptic swabs
• Dry sterile gauze for opening an ampoule (optional)
• Disposable gloves

Check the MAR (Medication Administration Record)

Check accuracy and completeness of MAR with physician’s order. 12 Rights of

Medication Administration

Review pertinent information related to medication: action, purpose,

indications, route peak action and interventions.

Check the label on the medication carefully against the MAR to make sure that
the correct medication is being prepared.

Page | 37
Follow the “three checks” for administering the medication and dose. Read the
label on the medication:
• When it is taken from the medication cart
• Before withdrawing the medication
• After withdrawing the medication

Procedure

Wash hands and observe other appropriate infection control procedures.

Prepare the medication from the ampule or vial for drug withdrawal.

Provide for client privacy.

Prepare the client.

Check the client’s identification band.

Assist the client to a position in which the arm, leg, or abdomen can be relaxed,
depending on the site to be used.

Obtain assistance in holding an uncooperative client.

Explain the procedure, purpose of the medication and how it will help, using
language that the client can understand. Include relevant information about
effects of the medication. Always remember the 12 rights in medication
administration.

Select, locate ad clean the site

Select a site free of tenderness, hardness, swelling, scarring, itching, burning,

and localized inflammation. Select a site that has not been used frequently.

Put on clean gloves.

Clean the site with an antiseptic swab. Using a circular motion, start at the
center and move outward about 5 cm (2in).

Transfer and hold the swab between the third and fourth fingers of your
nondominant hand in readiness for needle withdrawal or position the swab on
the Client’s skin above the intended site. Allow skin to dry prior to injecting
medication.

Prepare the syringe for injection

Remove needle cap of sheath from needle by pulling it straight off.

Inject the medication

Grasp the syringe in your dominant hand by holding it between your thumb and
fingers. With palm facing to the side or upward for a 45–degree angle insertion,

Page | 38
or with the palm downward for a 90–degree angle insertion, prepare to inject.

Using the nondominant hand, pinch or spread the skin at the site, and insert the
needle, using the dominant hand and a firm steady push.

When the needle is inserted, move your nondominant hand to the end of the
plunger.

Inject the medication slowly by holding the syringe steady and depressing the
plunger with slow, even pressure.

Remove the needle

Smoothly and steadily withdraw needle and release skin.

Apply gentle pressure at the site with a dry sponge. Do not massage the site.

If bleeding occurs, apply pressure with dry sterile gauze until it stops.

Discard uncapped needle or needle enclosed in safety shield and attached

syringes into punctured proof, leak proof receptacle.

Remove gloves and perform hand hygiene

Help patient to comfortable position

Document all relevant information

Include the time of administration, drug name, dose, route, and the client’s
reactions.

Stay with the patient and observe for any allergic reactions. Assess
effectiveness of the medication at the time it is expected to act

Variation: Administering a Heparin Injection

Procedure
Select a site o the abdomen away from the umbilicus and above the level of the
iliac crests.

Use a 3/8–inch, 25– or 26–gauge needle, and insert it at a 90–degree angle. If a

client is very lean or wasted, use a needle longer than 3/8–inch, and insert it at
a 45–degree angle. The arms or highs may be used as alternate sites.

Do not aspirate when giving heparin by subcutaneous injection.

Do not massage the site after the injection.

Alternate the sites of subsequent injections.

Page | 39
For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.

Student’s signature: __________________

Evaluator’s Signature: __________________

Comments:___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Page | 40
Name:_________________________________Date: _____________ Section/Group:________
Intravenous Therapy
CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
Criteria 3 2 1 0

Gather all equipment and bring to bedside. Check IV solution.

Explain the need for IV and procedure to patient.

Perform Hand Hygiene.

Close room curtain or door.

Prepare IV Solution and tubing

Maintain aseptic technique when opening sterile package and IV solution.

Clam tubing, uncap spike and insert into entry site on bag as per
manufacturer

Squeeze drip chamber and allow it to fill at least halfway.

Remove cap at end of tubing, release clamp, and allow fluid to fluid until air
bubbles have to flow until all air bubbles have disappeared. Close clamp and
recap end of tubing, maintaining sterility.

Apply label if medication was added

Place patient in a low- fowler’s position in bed. Place protective towel or pas
under the patient’s arm.

Select an appropriate site and palpate accessible vein.

Apply tourniquet 5 to 6 inches above the venipuncture site to obstruct

venous blood flow and distend the vein.

Ask the patient to close and open fist.

Apply clean gloves.

Clean site with antiseptic swab. Apply swab at the center and rotate
outward in circular direction for approximately 5cm.

Page | 41
 Use the non-dominant hand, placed about 1-2 inches below entry site, to
hold the skin taut against the vein. Avoid touching the prepared site.

Enter the skin gently, holding the catheter by hub in your dominant hand,
bevel side up, at 10 to 30 degrees angle. Catheter may be inserted from
directly over the vein or the side of the vein advance the needle or catheter
into the vein.

The flashback of blood in the catheter’s applicator will indicate that the
vein has been hit, advance the needle one more centimeter (cm) into the
vein.

Release the tourniquet. and dispose the needle into the sharps bin.

Secure the cannula in place with the sterile dressing.

Flush cannula with 5ml of saline

Remove the protective cap in the tubing and attach tubing to the catheter.

Mark the date, time, site and type and size of catheter used for infusion on
the tape anchoring the tubing.

Discard uncapped needle or needle enclosed in safety shield and attached

syringes into punctured proof, leak proof receptacle.

Remove gloves and perform hand hygiene.

Adjust the rate of the solution as prescribed

Document the procedure and patient’s response.

For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.

Student’s signature: __________________

Evaluator’s Signature: __________________
Comments:___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Page | 42