PARENTERAL MEDICATIONS (Step-by-step procedure)

I. PREPARING INJECTABLE MEDICATIONS

Injectable medications can be prepared by withdrawing the medication from an ampule or

vial into a sterile syringe, using prefilled syringes, or using needleless injection systems.
Ampules and Vials are frequently used to package parenteral medications.

A. AMPULE
✓ A glass container that usually holds a single dose of a drug.
✓ Made of clear glass and has a constricted neck.
✓ Some ampule necks have colored marks around them and some are scored. If the neck is
not scored, it is filed with a small file before opening.
✓ Vary in sizes from 1ml to 10 ml or more.
✓ Frequently the drug is in upper stem of the ampule above the neck as well as in the main
portion of the ampule.

Preparing Medication from the Ampule

1. Check the medication order.
2. Gather necessary equipment.
3. Wash hands.
4. Flick the upper stem of the ampule several times with a fingernail.
5. File the neck of the ampule if necessary.
6. Use an ampule opener or place a piece of sterile gauze or cotton ball between your
thumb and the ampule neck or around the ampule neck and break off the top by
bending it toward you to ensure the ampule is broken away from yourself. (To break
the ampule, hold the top firmly with your right hand and the bottom with the fingers
of your left hand. Break the ampule at the narrow point of the neck. Light pressure
will cause the ampule to break cleanly while too much pressure may cause the ampule
to shatter).
Rationale: The sterile gauze or cotton ball protects the nurse’s fingers from the glass.
7. Place the ampule on a flat surface.
8. Assemble the syringe and needle, if not preassembled. Hold the barrel of the syringe
in the middle, and insert the plunger. Maintain sterility except at the uppermost end
of the syringe, which is the only part touched by the hand. Attach the needle to the
barrel by holding the hub of the needle. Maintain the sterility of the remainder of the
needle and the tip of the syringe.
9. Remove the cap from the hypodermic needle and holds ampule upside down or place
on a flat surface. Inserts a hypodermic needle into the center of the ampule opening
and withdraws the amount of drug required. Do not touch the rim of the ampule with
the needle tip or shaft (Broken rim of an ampule is considered contaminated and when
inverted, solution comes out if needle tip or shaft touches rim of ampule). If the
ampule contains a single dose, the nurse may need to tip the ampule slightly to obtain
all the medication.
10. Cover the needle to maintain its sterility.
11. Replace the needle.
12. Expel the air bubbles from the syringe by inverting the syringe and gently pushing on
the plunger until a drop of solution can be seen in the needle bevel. If the air bubbles
still remain, flick the side of the syringe barrel.
13. Place the syringe on the tray or cart.
14. Dispose used supplies.
B. VIAL
✓ A small glass bottle sealed with a rubber cap.
✓ It may contain only a single dose but often hold multidose.
✓ With metal or plastic cap that protects the rubber seal; the cap is readily removed.
✓ Contains liquid or powder forms of medications. Medications that are unstable in solution
are packaged dry. The vial label specifies the solvent or diluent used to dissolve the
medication and the amount of diluent needed to prepare a desired medication
concentration. Several drugs (e.g., Penicillin) are dispensed as powder in vial.

RECONSTITUTION – is a technique of adding diluent to a powdered drug to prepare it for

administration. Diluent is a liquid in which is added to a powdered medication before it
can be injected. Commonly used diluents are sterile water or sterile normal saline.

❖ When reconstitution is necessary, the drug label lists the following: type of diluent to
use; amount of diluent to add; dosage per volume after reconstitution; directions for
storing the drug.

Examples of preparation of powdered drugs:

1. Single-dose vial
✓ Instruction for preparing a single-dose vial state that 1.5ml of sterile water be
added to the sterile dry powder, thus providing a single dose of 2ml., the
0.5ml is the volume of drug powder
✓ In other instances, the addition of a solution does not increase the volume.
Therefore, it is important to follow the manufacturer’s directions.
2. Multiple-dose
✓ One vial is to many or more than one doses to a certain patient

❖ It is recommended that the nurse should use a FILTER NEEDLE when withdrawing
medications from ampules and vials to prevent withdrawing glass and rubber
particles.
❖ After withdrawing the medication into the syringe, the filter needle is replaced with
the regular needle for injection (these prevent tracking of the medication through the
client’s tissue during the insertion of the needle, which minimizes discomfort.
❖ In addition, it is important to remember that when powdered drugs have been
reconstituted, the date and time should be written on the label of the vial. Many of
these drugs may have to be used within certain time period following reconstitution,
so the nurse’s needs to know the expiration time after it has been reconstituted.

Preparing medication from a vial

1. Check the medication order.
2. Gather necessary equipment.
3. Wash hands.
4. Mix the solution, if necessary, by rotating the vial between the palms of the hands, not by
shaking.
Rationale: Some vials contain aqueous suspensions, which settle when they stand. In
some instances, shaking is contraindicated because it may cause the mixture to foam. For
vials containing only a powder and requiring the addition of a liquid such as sterile water,
the nurse follows the manufacturer’s directions.
a. Remove the protective metal cap and clean the rubber seal with alcohol swab by
rubbing in a circular motion, and allow it to dry.
 Rationale: The disinfectant cleans the seal so that the needle will not be
contaminated when it is inserted. Allowing alcohol to dry prevents needle from
being coated with alcohol and mixing with medication.
b. Remove the needle cap, taking care to pull the cap straight off to avoid
contaminating the needle. Then draw up into the syringe an amount of air equal
to the volume of the medication to be withdrawn.
c. Carefully insert the needle into the vial through the center of the rubber cap,
maintaining the sterility of the needle.
d. Inject the air into the vial with the bevel of the needle above the surface of the
medication.
Rationale: The air creates positive pressure inside the vial, which allows the
medication to be drawn out easily. The bevel is kept above the medication to
avoid creating bubbles.
e. Invert the vial, ensure the needle tip is below the fluid level and hold it at eye level
while withdrawing the correct dosage of the drug into the syringe.
Rationale: Keeping the tip of the needle below the fluid level prevents air from
being drawn into the syringe.
f. Withdraw the needle from the vial and replace the cap over the needle, thus
maintaining its sterility.
g. Replace the aspirating needle of the correct gauge and length for injection. If
necessary, tap the syringe barrel to dislodge any air bubbles present in the syringe.
h. Place the syringe on the tray or cart.
i. Dispose the vial or return it to its storage place for multidose.

II. ADMINISTERING INJECTIONS

A. Intradermal Injection
An intradermal (intracutaneous) injection is the administration of a drug into the
dermal layer of the skin just beneath the epidermis. Usually only a small amount of liquid is
used, e.g., 0.1 ml. This method of administration is frequently indicated for skin testing or
diagnosing allergies and sensitiveness and for vaccinations. The medication is injected into the
dermis, where blood supply is reduced and medication absorption occurs slowly.

Common sites for Intradermal Injection:

✓ Inner lower arm
✓ Upper chest
✓ Back beneath the scapulae.

Administering an Intradermal Injection for Skin Test

1. Equipment:
❖ 1 ml syringe calibrated into hundredths of a milliliter (tuberculin syringe) and the
needle is short and fine, frequently a 25, 26 or 27 gauge ½ to 5/8 inch long
❖ Drugs as ordered
❖ Medication card
❖ Aspirating needle
❖ Distilled water
❖ Jar of cotton balls with 70% alcohol
❖ Jar of dry cotton balls
❖ Clean gloves
❖ Medication tray
2. Procedure
a. Check the medication order.
b. Wash hands and assemble the needed equipment (tuberculin syringe with a 26G, 5/8-
inch needle, alcohol swabs, dry cotton balls).
c. Prepare the medication:
Aspirate 0.9 cc of distilled water from a vial after introducing same amount of air as
that of the fluid to be withdrawn. Aspirate 0.1 cc of drug to be tested. Mix the drug
with the distilled water.
d. Take the medication to patient’s room.
e. Introduce self and identify the patient identity (ask the patient to state his/her name).
f. Explain the medication action and the procedure to the patient.
g. Provide privacy.
h. Don clean gloves.
i. Select a site (forearm) three to four finger widths below the antecubital space and a
hand width above the wrist. Avoid using sites that are tender, inflamed, or swollen
and those that have lesions.
j. Assist patient to a comfortable position (Have client extend elbow and forearm on flat
surfaces).
k. Cleanse the site with an alcohol swab, using a firm circular motion starting at the
center and widening the circle outward for about 2”. DO NOT use iodine solution to
cleanse the skin because residual iodine may interfere with interpreting the results of
the skin test. Allow the skin to dry thoroughly.
l. Holding the patient’s forearm in one hand, stretch the skin taut (grasp the dorsal
forearm and gently pull it to tighten the ventral skin). Taut skin allows for easier entry
of the needle and less discomfort.
m. Grasp the syringe in your dominant hand, close to the hub, holding it between the
thumb and forefinger. Hold the syringe almost parallel to the skin at a 10–15-degree
angle with the bevel of the needle pointing upward (medication is less likely to be
deposited into the tissues below the dermis).
n. Insert the needle through the epidermis so that the point of the needle is visible
through the skin. The needle should be advanced until it is approximately 1/8” (3 mm)
below the skin’s surface.
o. Gradually inject the medication. When you have completed the injection, observe for
wheal and blanching at the site.
Rationale: Indicates the drug is injected under the epidermis.
p. When the wheal or bleb appears, withdraw the needle. Never massage the area as
this may interfere with the test results.
Notes: When an intradermal injection is given for diagnostic purposes, e.g., to
determine sensitivity to an allergen, a control wheal is also made. The solution injected
is the same fluid without the allergen and the wheal is made on the opposite arm.
q. Mark the edges of the wheal with pen usually black or blue in color. Noting the drug
& time when interpretation is due.
r. Return the patient to a comfortable position.
s. Discard used equipment to appropriate receptacle.
t. Remove gloves and wash hands.
u. Record the name of the medication, the amount given, the time when will the
injection be read, usually after 30 minutes and the location of the test and control
sites. Always observe the patient for local (redness, itching) and systemic reactions
(anaphylaxis).
B. Subcutaneous Injection

Common sites for SQ injection:

✓ Outer aspect of the upper arm
✓ Anterior aspect of the thighs. A and B are two areas are convenient and normally have
good blood circulation
✓ Other sites: abdomen, scapular area of the upper back, the lower ventrogluteal and
dorsogluteal area

Administering a Subcutaneous Injection

1. Equipment
❖ medication tray
❖ jar of cotton balls with alcohol
❖ jar of dry cotton balls
❖ sterile 2 ml syringe with 25 g needle
❖ medication card
❖ vials or ampules of medication
❖ bottle of diluent (if necessary)
❖ clean gloves
2. Procedure
a. Check the medication order.
b. Gather the needed equipment.
c. Wash hands.
d. Prepare the medication.
e. Introduce self and identify the patient identity.
f. Explain the purpose of the medication and procedure to the patient.
g. Assist the client to a comfortable position.
h. Select a site free of tenderness, hardness, swelling, scarring, itching, burning or
localized inflammation. Select a site that has not been used frequently.
Rationale: These conditions could hinder the absorption of the medication and
may also increase the likelihood of injury and discomfort of the injection site.
These signs could also increase the likelihood of an infection in the injection site.
i. Provide privacy.
Rationale: The use of some body sites, e.g., the abdomen, necessitates exposure of
the patient.
j. Don clean gloves.
k. Clean the site with an antiseptic swab. Start at the center of the site and clean in a
widening circle to about 5 cm. Allow the area to dry thoroughly. Place dry cotton
between the third and fourth fingers of the non-dominant hand for later use.
Rationale: The mechanical action of swabbing removes skin secretions, which contain
microorganisms.
l. Remove the needle cap while waiting for the antiseptic to dry. Pull the cap straight off
to avoid contaminating the needle.
m. Grasp the syringe in your dominant hand by holding it between your thumb and
fingers with your palm facing upward for a 45º angle insertion.
n. Using the non-dominant hand, pinch or spread the skin at the site and pierce it with
the bevel upward for a 45º angle using a firm steady push.
Rationale: Recommendations vary about whether to pinch or spread the skin.
Pinching the skin is thought to desensitize the area somewhat and thus lessen the
sensation of needle insertion. Spreading the skin can make it firmer and facilitate
needle insertion. Some recommended neither pinching nor spreading the skin. The
 nurse needs to judge which method to use depending on the patient/s tissue firmness.
If client has more than ½ in. adipose tissue at site, spread the skin and inject at 90-
degree angle. If the patient is thin or lean, pinch the site and insert needle at 45–60-
degree angle.
o. When the needle is inserted, move your non dominant hand to the barrel of the
syringe and your dominant hand to the end of the plunger.
p. Aspirate by pulling back on the plunger. (Except when giving Heparin because this can
damage the surrounding tissue and cause bleeding and bruising. According to
American Diabetes Association in 2004, routine aspiration is no longer recommended
with insulin administration.) If blood appears in the syringe, withdraw the needle,
discard the syringe, and prepare a new injection. If blood does not appear, continue
to administer the medication.
Rationale: This step determines whether the needle has entered a blood vessel.
Subcutaneous medications may be dangerous if placed directly into the blood stream;
they are intended for the subcutaneous tissues, where they are absorbed more
slowly.
q. Inject the medication by holding the syringe steady and depressing the plunger with
a slow, even pressure.
Rationale: Holding the syringe steady and injecting the medication at an even
pressure minimizes discomfort for the patients.
r. Remove the needle quickly, pulling along the line of insertion and supporting the
tissues with dry cotton on your non dominant hand.
Rationale: This step minimizes the patient’s discomfort.
s. Apply dry cotton or gauze gently over site and gentle pressure. Do not massage site.
If bleeding occurs, apply pressure to the site until it stops. Bleeding rarely occurs after
subcutaneous injection.
t. Assist the patient to a comfortable position.
u. Dispose of supplies according to the agency procedure. Needle covers should be
reapplied. In some agencies there are needle receptacles provided which makes
recapping unnecessary. In fact, accidental sticking of the nurse’s fingers usually occurs
when recapping the needle.
Rationale: Proper disposal protects the nurse and others from injury and
contamination.
v. Remove gloves and wash hands.
w. Record the medication given, dosage, time, route, any complaints of the patient, and
your signature.
x. Assess the effectiveness of the medication 15 to 30 minute after the injection or as
appropriate depending on the medication.

C. Intramuscular Injection

Common sites for Intramuscular Injection

✓ Deltoid Muscle
✓ Dorsogluteal Site
✓ Ventrogluteal Site
✓ Vastus Lateralis
✓ Rectus Femoris

Administering an Intramuscular Injection

1. Equipment:
❖ medication tray
 ❖ sterile syringe and needles
❖ vial or ampule of medication
❖ bottle of diluent
❖ medication card
❖ cotton balls with alcohol
❖ dry cotton balls
❖ clean gloves

2. Procedure
a. Check the medication order.
b. Wash hands.
c. Prepare the medication.
d. Introduce self and identify the patient.
e. Explain the purpose of medication and procedure to the patient.
f. Provide privacy if the patient will be exposed.
g. Assist the patient to a comfortable position.
h. Don clean gloves.
i. Select the intramuscular site for adequate muscle mass. The skin surface over the site
should be free of bruises, abrasions and infection. Determine if the size of the muscle
appropriate to the amount of medication to be injected. Establish the exact site for
the injection and explain to the patient. See the discussion of sites earlier in this
section.
j. Clean the site with an antiseptic swab. Using a circular motion, start at the center and
move outward about 5 cm (2 inches). Hold dry cotton ball between the third and
fourth fingers of your non-dominant hand. Allow the skin to dry.
k. Remove the needle cover.
l. Use the non-dominant hand to spread the skin at the site.
Rationale: Spreading the skin makes it firmer and facilitates needle insertion. Under
some circumstances, e.g., when the patient is emaciated or an infant, the muscle may
be pinched.
m. Holding the syringe between the thumb and forefinger, pierce the skin quickly at a 90°
angle and insert the needle into the muscle.
Rationale: Using a quick motion lessens the patient’s discomfort.
n. Hold the barrel of the syringe steady with your non-dominant hand and aspirate by
pulling back on the plunger for 5 to 10 seconds (If the needle is in a small blood vessel,
it takes time for the blood to appear. If blood appears in the syringe, withdraw the
needle, discard the syringe and prepare a new injection.
Rationale: This step determines whether the needle is in a blood vessel.
o. If blood does not appear, inject the medication steadily and slowly (approximately 10
seconds per ml.) while holding the syringe steady.
Rationale: Injecting medication slowly permits it to disperse into the muscle tissue,
thus decreasing the patient’s discomfort. Holding the syringe steady minimizes
discomfort.
p. Withdraw the needle while supporting the injection site with dry cotton ball. Apply
gentle pressure at the injection site with a dry sponge or cotton ball. Do not massage.
Rationale: Use of alcohol swab may cause pain or a burning sensation.
q. Assist patient to a comfortable position.
r. Dispose used supplies.
s. Remove gloves and wash hands.
t. Record and conduct follow-up assessment to determine client’s response to
medication. Effectiveness of the medication is 15 to 30 minutes after injection.
CHARTING: Nature and quantity of drug or substance injected, time of administration,
reaction observed should be documented and signature of the nurse must be written.