Giving Shots A Shot

April 23rd, 2012

By Jennifer Olin, BSN, RN 

Just recently I was asked to give someone a shot. That’s a pretty commonplace activity for a lot of nurses, but since I work in the operating room, it’s rare to nonexistent that I pick up a needle and syringe and plunge it into someone’s body part.

We both survived the ordeal since it was a simple IM into the arm. I was having palpitations but my friend couldn’t see that—thank goodness. So, of course, this got me thinking. I am asked to step out of my usual arena sometimes and when I go on my medical missions there really is no telling what I might be asked to do. Besides, there are many areas of nursing that do not routinely require injection skills, but you never know what could happen in an emergency. You could be called upon to help someone with his or her allergy shots or insulin injection or you could be on the scene when someone has a severe allergic reaction. I decided it’s always good to brush up.

Parenteral administration

Parenteral administration is the fancy term for giving a shot. It means the administration of medication by needle instead of through the alimentary or digestive tract. The most common routes for parenteral administration are:

• Subcutaneous – Into the subcutaneous tissue, just below the skin.
• Intramuscular – Into the muscle.
• Intradermal – Under the epidermis (into the dermis).
• Intravenous – Into a vein.

There are some more less commonly used routes for parenteral administration like intra-arterial (into an artery); intracardiac (into heart muscle); intraosseous (into bone); and intrathecal or intraspinal (into the spinal canal), but these are less common and usually administered by physicians.

Getting Ready

The main advantage of giving a medication parentally is fast absorption. Because they are absorbed more quickly than oral medications and are irretrievable once given, the nurse must prepare and administer theses drugs carefully and accurately.

Before giving any drugs to any patient the nurse should assess the client’s health status to establish a baseline by which to evaluate the effectiveness of the medication. And, of course, the nurse will put the Six Rights into play:

1. Right client
2. Right drug
3. Right dose
4. Right time
5. Right route
6. Right documentation

Now that that’s done, all the nurse needs is the right equipment, a little sterile technique and some manual dexterity.

Now, For a Closer Look

Different medications and different diagnoses require different types of injections. Let’s take a closer look at each of the four most common injection types, whys and the hows.

• Common vaccines, some preoperative medications, narcotics, insulin, and heparin are all given subcutaneously (also called SC, SQ, sub-cu, or sub-Q). The most common sites on the body for sub-Q injections are the outside of the upper arms and fronts of the thighs. These areas are convenient and usually have good blood circulation. Other areas that can be used include the abdomen, the scapular area of the upper back, and the upper ventrogluteal and dorsogluteal areas (otherwise know as the top and sides of your behind). If the injection is something being given regularly (like insulin or heparin) the sites should be rotated to avoid tissue damage and discomfort and to aid in absorption.

  In general a short needle is used, the nurse checks to make sure no vein or artery is in the needle path by aspirating the syringe (pulling back on the plunger first to see if there is any blood) then using slow, even pressure inject the medication and quickly remove the needle. Massage the site lightly to disperse the medication into the tissue unless otherwise indicated (never with heparin or insulin) by the manufacturer.

• The intramuscular (IM) route is ordered for several reasons including speed. Meds given IM are absorbed faster than sub-Q since blood supply to the body muscles is greater. Also, muscles can usually hold a larger volume than sub-Q tissues with less discomfort. Unlike sub-Q injections, IM injections are given slowly (usually over 20 seconds or so) to allow the muscle tissue to accommodate the volume of medication. Only healthy muscle should be used for injections and the most common sites are the ventrogluteal, dorsogluteal, vastus lateralis or rectus femoris (quadriceps muscles) or the deltoids (rounded contour of the shoulder).

  Once the site for the injection has been decided upon, the nurse will pierce the skin at a 90-degree angle, aspirate by drawing back on the plunger and if all is ok, inject with a slow, steady hand. Withdraw the needle quickly and massage the site.

• Intradermal injections use tiny needles and tiny amounts of medications. They are most commonly used for allergy and tuberculin tests and for vaccinations. Common sites for an intradermal shot are the inner, lower arm; the upper chest, and the back, beneath the scapulae.

  The needle is typically held at about a 15-degree angle to the skin, inserted through the epidermis into the dermis and the fluid is injected. The drug will form a small bleb under the skin, and you do not massage the site because you don’t want the medication to disperse into the tissue or out through the needle insertion site. Intradermal injections are absorbed slowly through the capillaries.

• Because intravenous (IV) injections enter the patient’s bloodstream directly, they are used when a rapid effect is required (like during a cardiac arrest). This route is also used when the medications may be too irritating for the tissues to be given by other routes. This delivery system may include the following methods:

   

  • Continuous infusion or intravenous fluid container (IV)
  • intermittent infusion by piggy-back (IVPB) or partial fill (IVPF)
  • Volume-control administration set (most common for children)
  • Intravenous push (IVP, IV-push, or bolus)

  When an IV line is already established, this route is desirable because it avoids the discomfort of other parenteral routes. To prevent infection, the nurse must use sterile technique during all aspects of administration. Medications given IV are given slowly over a long period of time. The nurse must monitor the client for possible adverse effects at least every hour and discontinue immediately if there is an untoward reaction (remember that for your NCLEX, it’s always on the test in some way).

There you have it, injections 101. It’s not all you need to know, but it is a starting point or a good reminder if it’s been a while. And, if you want to practice, there are always flu shot clinics and community health fairs looking for volunteers. That’s at least enough practice to remember what it feels like to give the plunge.