CONTRIBUTORS

dr. Bambang Suryono S, Sp.An,KIC,M.Kes,KNA

Department of Anethesiology and Reanimation
Faculty of Medicine, Universitas Gadjah Mada

dr. Lucia Kris Dinarti, Sp.PD,Sp. JP., FIHA

Department of Cardiology and Vascular Medicine
Faculty of Medicine, Universitas Gadjah Mada

dr. Yunita Widyastuti, Sp.An, M.Kes

Department of Anethesiology and Reanimation
Faculty of Medicine, Universitas Gadjah Mada

dr. Denny Agustiningsih, M.Kes, AIFM

Department of Physiology
Faculty of Medicine, Universitas Gadjah Mada

dr. Hera Nirwati, M.Kes

Department of Microbiology
Faculty of Medicine, Universitas Gadjah Mada

dr. Widyandana, MHPE

Department of Medical Education
Faculty of Medicine, Universitas Gadjah Mada

i
 INJECTION
(intradermal, subcutaneous, intramuscular, intravenous)

INTRODUCTION
Injection is one route of drugs administration. This procedure is considered as a
common procedure in clinical practice. Therefore, a medical doctor should be able to perform
safe injection to the patient as well as understand why, when, where the injection is performed
and what suitable drug to be given in the injection is.

Vignette
A-25-year-old woman comes to a clinic for premarital check up, after performing
anamnesis and physical examination, you as a doctor need to obtain the blood sample from the
patient to make the routine blood examination. You also have to administer Tetanus Toxoid
intramuscular injection as prevention for neonatal tetanus as well as a requirement for marital
administration.

How will you obtain the blood sample?

How will you perform the Tetanus Toxoid administration?
What preparations need to be done before doing those procedures?

From the illustration above, students should notice the importance of performing safe
injection. Moreover, this skill is one of back bone skills in many of emergency procedures.
The injection procedure is trained in the block 2.1, and is related with other skills; Simple
Skin Suturing (block 2.1), Baby Delivery (block 2.2), Circumcision (block 2.3), IV Line
Insertion (block 3.2), Minor Surgery (block 3.6), and Advanced Life Support (block 4.1).
In order to well accomplish this skill, each student need to review the anatomical
landmark of clinically importance of nerves, vessels and muscles, read the manual, and other
learning resources. So, in the end of this skills, students are able to :
a. choose the suitable route of injection (intradermal, subcutaneous, intramuscular and
intravenous)
b. determine proper sites of injection according to kinds of medicine and patient's condition.
c. choose appropriate needles, syringes.
d. perform injection properly (im,iv,sc,ic) with aseptic procedure and appropriate anatomical
site.

1
e. understand the risk and consequences of injection procedure. f. monitor the effects and
side effects of injection. g. collect venous blood sampling.

Let's start, and wish you enjoy the training.

BASIC CONCEPTS
Basically, there are two indications of choosing parenteral routes to administer the drug ;
first, If the immediate effects of the drug are needed and second, If the drug Is only available
in parenteral dosage form. Some drugs, for example, medroxyprogesterone acetate or
fluphenezlne, are released over a long period of time and need a route that will absorb the
drug steadily. There are some considerations regarding Injection which are the equipment,
route, site and technique.

I. EQUIPMENT
A. Syringes
Syringes are available In various sizes, shapes, and materials.
a. Glass Syringes
This kind of syringes is rarely used now since the plastic disposable syringes are
available.
b. Disposable Plastic Syringes
Disposable plastic syringes are widely used and are available in various sizes, with or
without needles attached. They are usually prepackaged, either in paper or in
cellophane wrapper or in a rigid plastic container. Syringes with needles already
attached are convenient and time saving if the needles are the correct size and length.
c. Prefilled Syringes and Cartridges
Prefilled syringes usually come with appropriate needles attached and with direction of
use. Especially helpful are syringes prefilled with drugs for emergency use. Prefilled
syringes are disposable. Prefilled cartridges contain medication and have appropriate
needles attached.
d. Insulin Syringes
Insulin syringes are marked in units specifically to measure dosages of insulin. They
are available in both plastic (disposable) and glass (reusable) version. U-100 insulin
means that there are 100 units of insulin in 1 ml. The syringe holds 1 ml and is marked
directly in units. A small syringe, which holds 0.5 ml Or 50 units, is also available for

2
 giving doses of less than 50 units. When given a choice, the 0.5 should be used for
injecting less than 50 units to increase accuracy. An insulin syringe is the safest to use
when administering insulin, but insulin can also be measured accurately in tuberculin
syringe.
e. Tuberculin Syringes
Tuberculin syringes are usually chosen for the administration cf very small amounts of
medication because they are marhed-

in 0.01 ml increments. They are called tuberculin syringes because they were originally used
to administer small amounts of test material to check for exposure to tuberculosis. These
syringes are also available in disposable plastic (figure 1) and reusable glass forms.

Figure 1. Disposable tuberculin syringe

© Janice, R; 1996; Modules for Basic Nursing Skills

A. Needles
The needles most commonly used are'/ to 2 inches in length and 18 to 25 gauges. Needles
currently used are disposable to prevent the transmission of infection.
The larger the gauge numbers of a needle, the smaller the lumen. A needle with a small
lumen is less painful to the patient when in serted. The choice of needle is based on the
relative viscosity or thickness of the medication. For example, the clearest fluid solutions can
be given intyramuscularly with 22-23-gauge needle. Subcutaneous injections of these kinds of
fluids can be given with 25-or 26-gauge needle. More viscous opaque medications given
intramuscularly may require a 20-or 21- gauge needle. Larger needles are used primarily for
blood transfusion and for injecting special intravenous fluids.

3
 Figure 2.The parts of needle
© Janice, R; 1996; Modules for Basic Nursing skills
Block 5 - Injection & Health Promotion

A. Medication Containers
1. Vial

A vial is a small, glass, round container with an airtight rubber stopper sealed the glass by
a metal rim.

Procedure for Withdrawing Solutions from Vial

 Perform handwashing
 Clean the rubber top of the vial with a firm circular motion by using alcohol swab. Allow
the alcohol to dry to obtain maksimum antibacterial action.
 Prepare the syringe and needle. Be careful to keep the needle, the syringe tip, the inside of
the barrel, and the side of the plunger sterile to prevent contamination of the medication.
 Draw as much air into the syringe as the volume of solution you have calculated you will
need.

4
 Inject the air into the vial by pushing the plunger of the syringe into the barrel. Doing this
prevents a vacuum when you withdraw the medications.
 Pick up the vial in your nondominant hand and hold the vial upside down at the eye level.
Pull the plunger down to withdraw the necessary amount of medication. Make sure the
needle tip is beneath the fluid level in the inverted vial and that you do not touch the sides
of the plunger as you withdrawn the medication.
 Examine the medication for air bubbles and remove any that are present by keeping the
syringe vertical and flicking your index finger againts the side of the side of the syringe
over the air bubble. You can then push up the on the plunger and expel the air into the
vial. If the bubble does not rise when the syringe is tapped, you may have to push the
medication back into the vial and draw up the medication again.
 Once all air is removed from the syringe, make sure that you have the exact volume
needed.
 Remove the needle from the vial
 Change the needle if the medication is irritating to the tissue and if the tip of the needle is
blunt because already used to puncture the vial.

Figure 4. Parts of a syringe to be kept sterile

© Janice, R; 1996; Modules for Basic Nursing Skills

1. Ampule
The ampule is an all-glass container thet has a narrow neck. The top of the ampule must
be broken off to remove the medication.

5
Procedure for Withdrawing Solutions from Ampule
1. Perform handwashing
2. If the medication is in the upper part of the ampule, grasp the ampule by the top and shake
it firmly downward, as you do with a thermometer.
3. Clean the narrowest part of the ampule by alcohol swab with a firm circular (twisting)
motion.
4. Prepare the syringe and needle. Always use sterile technique.
5. Wrap a swab or gauze square around the neck of the ampule to protect your hand from
cuts. Break off the top of the ampule away from you. To do this, hold the base of the
ampule in one hand, grasp the top firmly with the other hand, and exert pressure. (Figure
6) Discard the top in the disposal container.
6. Remove the needle guard.
7. Hold the ampule firmly in your nondominant hand, either resting on the counter or
supported in your hand, between your index and middle fingers. Insert the needle into the
open and of the ampule; be careful to touch the ampule with the needle on the inside only.
(Figure 7)
8. Pull the plunger of the syringe back; be careful to keep the needle in the solution to avoid
drawing air into the syringe.
9. Withdraw the needle from the ampule when you have drawn slightly more than the
amount of solution needed.
10. With the needle pointing vertically, pull back slightly to aspirate the fluid from the needle
into the syringe.
11. Push the plunger gently into the barrel until 1 drop of medication appears at the point of
the needle. This drop can be removed with a gentle shake of the syringe and needle over a
sink or container. If extra fluid must be ejected, the syringe can now be pointed
downward over a sink or receptacle so excess medication does not flow back over the
needle.
12. Make sure you have the exact volume needed.
13. Change the needle if the medication is irritating to tissue.

6
I. ROUTE, SITE AND TECHNIQUE

Four routes of injection will be trained in skill's topic; those are intradermal,
subcutaneous, intramuscular, and intravenous routes. The discussion of each route includes
their sites and technique.

A. Intradermal
The intradermal route is commonly used for diagnostic purposes such as allergy,
tuberculin testing, or for local anesthetics. It has the longest absorption of all the
parenteral routes. Because a very small amount of drug is used, a 1-ml, or tuberculin,
syringe is used, with a short (1/4-5/8 inch), fine gauge (25-27) needle.
The needle is inserted at a 10-15° angle, bevel up, just under the epidermis, and inject the
medication until a wheal appears on the skin surface (Figure 8) If it is used for allergen
testing, the area should be labeled indicating the antigen so that an allergic response can
be monitored after a specified time lapse.

Figure 8. Skin wheal caused by intradermal injection

7
 The sites suitable for intradermal testing are similar to those for subcutaneous injections
(Figure 9) but also include the inner forearm and shoulder blades. The inner surface of the
forearm is the most common site.

B. Subcutaneous
The greatest disadvantage of subcutaneous administration is that it penetrates the body's
first line of defense, the skin. Thus, it is imperative that sterile technique be used for the
patient's safety. The maximum amount of solution that can be comfortably given through
subcutaneous route is from 1.5 to 2 ml. In many facilities, the smallest regular syringe
available is 3 rnl. Insulin and tuberculin syringes that hold 0.5 to 1 ml can also be used for
fewer amounts.
The subcutaneous injection is usually given at a 45-60° of angle into a raised skinfold
except for the use of insulin needles S5,6 or 8 mm), the recommendation for insulin
injection is now an qngle of 90° . The skin should be pinched up to lift the adipose tissue
away from the underlying muscle, especially in thin patients and it is no longer necessary
to aspirate after needle insertion before injecting subcutaneously.
The site for subcutaneous injection is described on the picture below (Figure 9)

Figure 9. Anatomical sites for Intradermal and subcutaneous injection

© Workman,B., (1999) Safe Injection Techniques

Avoid any areas that are tender or have signs of scarring, swelling, or inflammation. It is
important to rotate sites for patients who receive subcutaneous injection frequently to decrease
any local site irritation.

8
 A special concern regarding heparin is commonly given by subcutaneous injection. This
drug commonly causes bruising. When giving this drug, do not aspirate or massage the site
afterward. These actions might increase the capillary damage and contribute to bruising.

A. Intramuscular
The absorption intramuscular route is faster than subcutaneous, because of the greater
vascularity of muscle tissue; therefore, we can inject relatively large doses; from 1 ml in the
deltoid site to 5 ml elsewhere in adults (these values should be halved for children) by using
19-to-22- gauge needle. Irritating drugs are commonly given intramuscularly because very
few nerve endings are in deep muscle tissue. Despite that, intramuscular injection also has
some disadvantages including the penetration of the skin, the possibility of nerve damage,
pain that may linger after the injection, and the potential for abscesses. In the intramuscular
injection, aspiration for checking false route to the blood vessel is still recommended.
The proposed site for injection should be inspected for any sign of inflammation,
swelling, and infection, and any skin lesion should be avoided. Older and emaciated patients
are likely to have less muscle than younger, more active patients, and therefore the proposed
sites should be assessed for sufficient muscle mass. If the patient has reduced muscle mass it
is helpful to 'bunch up' the muscle before injection (Figure 10).

Figure 10. `Bunch up' of muscle in emaciated or older patients©

Workman,B., (1999) Safe Injection Techniques

There are five sites that are availble for im (intramuscular) injection. The point that
should to paid attention is identifying their anatomical Landmark.

9
 1. The Deltoid
The deltoid, muscle in upper arm, is
commonly used for vaccine such as hepatitis
B and tetanus toxoid.
Although it is easily accessible, its use is
limited because this smaller muscle is not
capable of absorbing large amount of
medication, moreover, it is danger of injury
to the radial nerve. The deltoid site is
rectangularly shaped . The upper boundary is
two to three fingerbreadths down from the
acromion process on the outer aspect of the
arm. The lower boundary is roughly opposite
Figure 11. Deltoid site for
the axilla. Lines parallel to the arm, one third Intramuscular injection
© Workman,B., (1999) Safe
and two thirds of the way around the outer InjectionTechniques

lateral aspect of the arm, form the side

boundaries.

2. Dorsogluteal site
The dorsogluteal site use the gluteus maximus muscle. Possible complication of injection in
this site is injury to the sciatic nerve or superior gluteal artery.
Patient should be positioned lying on their side with their knees are slightly flexed, or prone
with their toes pointing inwards. If the legs are slightly flexed ate muscles are more relaxed
and the injection is less painful.
The landmarks of the dorsogluteal site are the upper iliac crest, the inner crease of the
buttocks, the outer lateral edge of the patient's body, and the lower edge of the buttock
(inferior gluteal fold). These landmarks should be palpated, not merely located by sight.
Errors can easily be made, particularly in the location of the iliac crest. When you have
established the location of the upper outer quadrant, give 5 - 7,5 cm below the crest of the
illium.
The second method for locating the same site is more accurate when the patient is in the
side-lying position. Draw an imaginary line between the posterior superior iliac spine and

10
the greater trochanter of the femur. An injection given laterally and superiorly to this line is
away from the sciatic nerve because the line runs lateral to the nerve.

3. Ventrogluteal site
The ventrogluteal site is a safer option which accesses the gluteus medius muscle. No large
nerves or blood vessels are in the area, it is generally less fatty, and the patient on bed rest
has to neither be turned nor lie directly on the injection site. In addition, because the gluteal
muscle is not completely developed in small children, this site is preferred rather than
dorsogluteal site at least until the child is walking. The landmark of the ventrogluteal site
are the greater trochanter,the crest of the illium, and the anterior superior iliac spine. To
identify the site, first locate this landmark to the patient. Then place the heel of your palm
on the greater trochanter. Point one finger toward the anterior superior iliac spine and the
adjacent finger toward the crest of the illium, forming a triangle of the iliac bone. (The size
of your hand and the patient's bone structure may require small adjustments in hand
position to form this triangle). Use your nondominant hand to locate the site so that your
dominant hand is free to manipulate the syringe. The injection site is near the middle of this
triangle, approximately 2.5 cm below the iliac bone.

Figure 13. Ventrogluteal site

© Janice, R; 1996; Modules for Basic Nursing Skills

11
 4. Rectus Femoris
The rectus femoris muscle is located in anterior surface of midlateral thigh. The patient's
position should be in recumbent or sitting position.
It is smaller than the vastus in the adult and is used only for small injections and for infants
who are not yet walking and whose gluteal muscles are therefore not well developed.
The rectus femoris is in the middle third of the anterior thigh. In children and older people,
or emaciated adults, the muscle may need to be bunch up in a handful to provide sufficient
muscle depth.

4. Vastus Lateralis

The vastus lateralis muscle is quadriceps muscle located in lateral thigh. This area is relatively free of major
nerve and blood vessels. The site is recommended particularly for infants and small children up to seven moths,
whose gluteal muscle is still undeveloped.
In adults, the superior boundary is a hand breadth below the greater trochanter. The inferior boundary is a hand's
breadth above the knee. On the front of the leg, the midanterior thigh serves as a boundary. On the side of the leg, the
midlateral thigh is the boundary. The result is a narrow band (approximately 3 inches wide) that is suitable for
intramuscular injection. Insert the needle only to a depth of 1 inch and hold it parallel to the surface of the bed.

12
 Injection technique of intramuscular route needs angle of 90° to ensure the needle reach
the muscle and to reduce pain. Therefore, to ensure entry at the right angle , commence the
injection with the heel of your palm resting on the thumb of the non dominant hand, and by
holding the syringe between the thumb and forefinger, a firm and accurate thrust of the needle
at the correct angle can be achieved. Nowadays, there is an intramuscular injection technique
known as The Z track that results in less patient discomfort and fewer complications than the
traditional method.
Initially, the Z tract was used for a tissue stained drug or irritative drug. It involves
pulling the skin downwards or to one side at the intended site. This moves the cutaneous and
subcutaneous tissues by approximately 1-2 cm. When identifying the site of injection, it is
important to remember that moving the skin may distract you from the intended needle
destination. Therefore, once the surface location has been identified, you need to be able to
visualize the underlying muscle that is to receive the injection, and aim for that location rather
than a distinguishing mark on the skin. The needle is inserted and the injection is given. Allow
ten seconds before removing the needle to allow the medication to diffuse into the muscle. On
removal, the retracted skin is released. The tissues then close over the deposit of medication
and prevent it from leaking from the site.
The equipment used for this technique is generally the same as for routine intramuscular
injection, except that a 1% inch needle is desirable. The dorsogluteal area is the easiest site to
use for a Z track injection.

13
A. Intravenous
Intravenous injection is indicated for collection of samples of venous blood for diagnostic
purposes or for the certain or rapid administration of systemic medication. Intravenous
therapy may be indicated when speed of administration is required, and when other routes of
drug administration are ineffective, impossible, or hazardous. Despite that, this method also
has several contraindications such as: (1) cellulites over the proposed sites, (2) phlebitis, (3)
venous obstruction, (4) lymphangitis in the extremitiy and (5) presence of administration of
intravenous fluid distal to the proposed site.
The common location of intravenous injection and for drawing blood samples is usually
in upper extremity, the superficial vein in the arm:
a. Antecubital vein
The superficial basilic and cephalic veins run just under the skin on the volar side of the
forearm. They run along the medial and lateral edge of the antecubital fossa at the elbow
crease. If one of these veins is accessible, use it. Palpate the antecubital fossa with the tip
of index finger, and feel the buoyant resilience of a distended vein. When the veins are
non visible, they must be located by palpation. Even a small vein deep in the
subcutaneous tissue may be detected on the basis of its resilient feel.
b. Arm veins
c. If a patients's antecubital vein can not be found, examine the forearm on both the volar
and the dorsal surfaces. Look for faint bluish color of a vein under the skin, or better yet,
feel for a vein with the tip of the index finger.
d. Hand veins
If no vein is found on the forearm, proceed to the dorsal surface of the hand, and use one
of the superficial veins on the hand.

The puncture site and the direction of needle insertion must be correct. In selecting a vein
to be punctured, we have to consider the size and visibility of the vein. Besides we have to
consider tho location has limited movement and does not disturb patient's activity. Choose the
straight vein (without or with minimal branches), most distal part from the heart, and avoid
choosing on joint proximal site from the elbow.
Carefully palpate the arm 2 or 3 times if necessary. A vein suitable for venipuncture may
be obscured (eq, by hair) and may therefore be missed on initial examination. Occasionally,
slapping repeatedly over the vein with the pads of the first and second fingers will help to dis-

14
tend faint vein, or the patient can dangle the arm over the side of the bed to achieve the same
result. Do not thrust blindly at abluish mark on the patient's arm without first palpating the
area to confirm that a patent vein is underneath.

After the vein has been identified, then the technique to insert the needle is by aligning
the needle with the course of the vein, and make sure that the bevel is facing up. With a quick
but smooth motion, push the needle through the skin at an angle of about 10-20°. Then care-
fully advance the needle into the lumen of the vein with a smooth motion. When the vein has
been properly penetrated, blood will flow back into the needle when the plunger is pulled
away from the needle, after that injection of drug or drawing blood sample can be proceeded.
If venous blood is not obtained on the first attempt, reassess the course of the vein. Try
palpating the vein proximal to the needle site. Withdraw the needle to just below the skin, and
attempt a second veinpuncture.

PROCEDURE
There are several precautions that should be obeyed before prac
ticing injection:
1. Check for the expired date of the drug
Before drawing the drug from ampule or vial, please check the expired date listed on the
drug purchasing.
2. Drug
Make sure that the ampule or vial is containing a suitable drug with appropriate dosage.
3. Sterility
Aseptic procedure should be applied in giving injection to maintain sterility.
15
4. No air embolism
Make sure there is no air embolism caused by injection procedure, especially for
intravenous injection.
5. Obey the universal precaution and be careful of puncturing ourselves by the needle.
6. Discard the disposable equipments appropriately.

General Procedure of giving injection:

1. Obtain the inform consent related to the procedure and Putting patient at ease.
2. Determine whether any medications are to be administered to an individual patient.
3. Calculate the correct dosage that will be given to the patient. Most medication orders are
written in terms of milligrams of the drug. You will need to read the label to determine
how many milligrams are found in each milliliter, to calculate how many milliliters you
are to give.
4. Prepare the equipment that is consists of appropriate needle and syringe, alcohol swabs (if
you use an alcohol soaked cotton, do not forget to squish it properly), clean gloves and
tourniquet (for intravenous injection).
5. Adjust the position of the patient.
6. Wash your hand, dry it and wear the gloves aseptically.
7. Draw up the correct dosage, using the techniques described for drawing up from vial or
an ampule (vial or ampule is held by assistant) and change the needle.
8. Select the appropriate injection site and clean it with a swab, using a circular motion and
moving from the middle site outward.
9. Allow the skin to air dry.
10. Remove the needle guard; be careful to pull it straight off and away from the needle.
Again, the needle should touch only the inside of the guard and use one hand technique in
removing and putting on the guard into the needle.
11. Perform injection technique specifically to injection route.*
12. After the injection is performed, leave the patient in a comfortable position.
13. Discard the syringe and needle in the closest "sharps" container without replacing the
needle guard. If the "sharp" container is centrally located, replace the needle guard using
one hand technique to prevent our hand from needle pricking.
14. Evaluate for the correct site was used, effectiveness of the medication and adverse effect
that is once identified should bepromptly manage.

16
15. Document the injection procedure (name of the medication, dose, route, time, and
signature) in the patient's medical record.

In performing injection be aware for skin contact with any of patient discharge because it
can disseminate diseases. Drugs that are given parenterally have risk for anaphylactic shock,
so that you must pay attention for this reaction and do the skin test if needed before drug
administration.

Steps for performing specific injection technique:

A. Intradermal
1. Use your nondominant hand, stretch the skin at the selected site, make it taut.
2. Hold the syringe at a 10°-15° angle, with the bevel of the needle facing up.
3. Insert the needle just until the bevel is no longer visible. 4. Inject the medication
slowly.
4. Withdraw the needle.
5. Do not massage. A small wheal (raised area) is least at the point of injection.
6. Circle of the area of injection with a skin marking pen if the site must be assessed for
reaction.
7. Assess the site at the appropriate time interval for indurations.

B. Subcutaneous
1. Use your non dominant hand, gently pinch the skin at the site selected between thumb
and index finger to elevate the subcutaneous tissue. If the patient is obese, you may
have to spread the skin apart firmly to make the skin taut.
2. Use a 45° to 90° angle as selected for the individual patient.
3. Insert the needle through the skin with a quick dartlike thrust. Transfer your
nondominant hand to the barrel of the syringe to steady it, and transfer your dominant
hand to the plunger.
4. Pull back gently on the plunger (aspiration) to be sure the needle is not in a blood
vessel. In the remote event that blood appears in the syringe, the needle is in a blood
vessel. Withdraw the needle, obtain new sterile equipment and repeat the entire
procedure.
5. If no blood appears in the syringe, inject the medication by pushing the plunger into
the barrel with slow, even pressure.

17
 6. Using your nondominant hand , steady the tissue immediately adjacent to the puncture
site and quickly remove the needle. 7. Gently press the injection site with the alcohol
swab.

C. Intramuscular
1. Use your nondominant hand, pull the skin and tissue laterally until is it taut.
2. Hold the syringe like a dart, insert the needle at 90° angle.
3. As soon as the needle is inserted, use the thumb and index finger of your nondominant
hand to steady the syringe, using your dominant hand to aspirate.
4. Do not release the tissue that has been displaced laterally.
5. Inject the medication slowly. Wait for several seconds.
6. Remove the needle, and immediately release the skin being held tout by your non-
dominant hand. The skin layers will Close in Z configuration, preventing leakage. 7.
Do not massage the injection site.

D. Intravenous
1. Identify the vein and choose the easiest one. Place the part of body that contents the
vein lower than heart.
2. Fixate the arm or leg and clean the area thoroughly.
3. Put the tourniquet on, proximal to the puncture site. If the puncture site will be the
head, press the distal part of the vein by using your finger.
4. With skin retracted and needle bevel up, hold the needle at a 15 to 30 degree angle to
pierce the skin 0.5 cm beside the vein, followed by a decreased angle to enter the vein.
5. To ensure that the needle has entered the vein, draw the syringe's plunger. If small
amounts of blood enter the syringe, it means that the needle is in the correct position
(in the vein)
6. Put the tourniquet off
7. Push the syringe plunger and enter the drug to the blood current or draw the syringe
plunger to withdraw the blood if you will take the blood sample.
8. Withdraw the needle after finish and cover the wound with alcohol soaked cotton
wool, and apply tape.

18
There is recommendation of steps toward a painless injection:
a. Prepare patients with appropriate information before the procedure, so that they
understand what is happening and can comply with instructions.
b. Change the needle after preparation of the drug and before administration to ensure it is
clean, sharp and dry, and at the right length.
c. Make the ventrogluteal site at your first choice (if intramuscular route is used), to ensure
that the medication reaches the muscle layer (in adults and children over seven months )
d. Position the patient so that the designated muscle group is flexed and therefore relaxed.
e. If cleaning the skin before needle entry, ensure skin is dry before injecting.
f. Consider ice or freezing spray to numb the skin before injection, particularly in young
children or needle phobic patient.
g. Use the Z track technique for intramuscular injection.
h. Rotate sites so that right and left sites are used in turn and document rotation (in case of
regular injection should be given such as insulin injection in diabetic patient).
i. Enter the skin firmly with a controlled thrust, positioning the needle at an angle as near to
90° as possible, to prevent shearing and tissue displacement.
j. Inject medication steadily and slowly, about I ml per ten seconds to allow the muscle to
accommodate the fluid.
k. Allow ten seconds after completion of injection to allow the muscle to accommodate the
fluid.
l. Allow ten seconds after completion of injection to allow the medication to diffuse and
then withdraw needle at the same angle as it inserted.
m. Do not massage the site afterwards, but be prepared to apply gentle pressure with a gauze
swab

19
 CHECKLIST INTRADERMAL INJECTION

Score
No. Aspects.
0 1 2
1. Obtain the inform consent related to the procedure and
putting patient at ease
2. Determine whether any medications are to be
administered to an individual patient. Explore
the drug allergy history of the patient.
3. Calculate the correct dosage that will be given to the
patient
4. Prepare the equipment
5. Adjust the position of the patient.
6. Wash your hand, dry it and wear the gloves aseptically

7. Draw up the correct dosage, using the

techniques described for drawing up from vial
or an ampule (vial or ampule is held by
8. assistant)
Select theand change the
appropriate needle.site and clean it with a
injection
swab, using a circular motion and moving from the
middle site outward.

9. Allow the skin to air dry.

10 Remove the needle guard, being careful to pull it
straight off and away from the needle.

11. Using your nondominant hand, stretch the skin at the

selected site, make it taut.

12. Hold the syringe at a 10°-15° angle, with the bevel of

the needle facing up.

13 Insert the needle just until the bevel is nolonger visible.

14 Inject the medication slowly (how many cclsecond or

minute)
15 Withdraw the needle.
16 Do not massage. A small wheal (raised area)
is least at the point of injection.
17 Circle of the area of injection with a skin marking pen /
if the site must be assessed for
reaction.
18 Discard the syringe and needle in the closest "sharps"
container without replacing the
needle guard. If the "sharp" container is
centrally located, replace the needle guard
using one hand technique
20
19 Assess the site at the appropriate time
interval for indurations.
20 Write the injection procedure (name of the
medication, dose, route, time, and signature)
in the patient's medical record

21
 CHECKLIST SUBCUTANEOUS INJECTION

No. Aspects. Score

0 1 2
1. Obtain the inform consent related to the
procedure and putting patient at ease
2. Determine whether any medications are to be
administered to an individual patient. Explore
the drug allergy history of the patient.
3. Calculate the correct dosage that will be given
_ to the patient
4. Prepare the equipment
5._ Adjust the position of the patient.
6. Wash your hand, dry it and wear the gloves
aseptically
7. Draw up the correct dosage, using the
techniques described for drawing up from vial
or an ampule (vial or ampule is held by
assistant) and change the needle.
8. Select the appropriate injection site and clean
it with a swab, using a circular motion and
moving from the middle site outward.
~ Allow the skin to air dry.
10 Remove the needle guard, being careful to
_ pull it straight off and away from the needle.
11. Use your non dominant hand, gently pinch the
skin at the site selected between thumb and
index finger to elevate the subcutaneous
tissue. If the patient is obese, you may have
to spread the skin apart firmly to make the
skin taut. Cgm
Use a 45° to >b° angle as selected for the
individual patient.
13 Insert the needle through the skin with a quick
dartlike thrust. Transfer your nondominant
hand to the barrel of the syringe to steady it,
and transfer your dominant hand to the
plunger.

22
No. Aspects. Score
0 1 2
14 Pull back gently on the plunger (aspiration) to
be sure the needle is not in a blood vessel. In
the remote event that blood appears in the
syringe, the needle is in a blood vessel.
Withdraw the needle, obtain new sterile
equipment and repeat the entire procedure.
15 If no blood appears in the syringe, inject the
medication by pushing the plunger into the
barrel with slow, even pressure.
16 Use your nondominant hand, steady the
tissue immediately adjacent to the puncture
site and quickly remove the needle.
17 Gently press the injection site with the alcohol
swab.
18 After the injection is performed, leave the
patient in a comfortable position.
19 Discard the syringe and needle in the closest
"sharps" container without replacing the
needle guard. If the "sharp" container is .
centrally located, replace the needle guard
using one hand technique.
20 Evaluate for the correct site was used,
effectiveness of the medication and adverse
effect that is once identified should be
promptly manage.
21 Write the injection procedure (name of the
medication, dose, route, time, and signature)
in the patient's medical record.

23
 CHECKLIST INTRAMUSCULAR INJECTION

Score
No. Aspects.
0 1 2
1. Obtain the inform consent related to the
procedure and putting patient at ease
2. Determine whether any medications are to be
administered to an individual patient. Explore
the drug allergy history of the patient.
3. Calculate the correct dosage that will be given
to the patient
. Prepare the equipment
Adjust the position of the patient.
6. Wash your hand, dry it and wear the gloves
aseptically
7. Draw up the correct dosage, using the
techniques described for drawing up from vial or f
an ampule (vial or ampule is held by assistant)
and change the needle.

- Select the appropriate injection site and clean it

8. with a swab, using a circular motion and moving `l
from the middle site outward. ,
9. Allow the skin to air dry.
_ 10 Remove the needle guard, being careful to pull
it straight off and away from the needle.
_ Use your nondominant hand, pull the skin and
11. tissue laterally until is it taut.
12. Hold the syringe like a dart, insert the needle at
_ 90° angle.
13 As soon as the needle is inserted, use the
thumb and index finger of your nondominant
hand to steady the syringe, using your dominant
hand to aspirate.
14 Do not release the tissue that has been /
displaced laterally.
15 Inject the medication slowly. Wait for several
seconds.

24
 Score
No. Aspects.
0 1 2
16 Remove the needle, and immediately release
the skin being held tout by your non-dominant
hand. The skin layers will dose in Z
configuration, preventing leakage.
17 Do not massage the injection site.
18 After the injection is performed, leave the
patient in a comfortable position.
19 Discard the syringe and needle in the closest ,
"sharps" container without replacing the needle
guard. If the "sharp" container is centrally
located, replace the needle guard using one
hand technique.
20 Evaluate for the correct site was used,
effectiveness of the medication and adverse
effect that is once identified should be promptly
manage.
21 Write the injection procedure (name of the
medication, dose, route, time, and signature) in
the patient's medical record

25
 CHECKLIST INTRAVENOUS INJECTION
Score
No. Aspects.
0 1 2
1, Obtain the inform consent related to the
procedure and putting patient at ease
2. Determine whether any medications are to be
administered to an individual patient. Explore
the drug allergy history of the patient.
3. Calculate the correct dosage that will be given
to the patient
4. Prepare the equipment
5. Adjust the position of the patient.
6. Wash your hand, dry it and wear the gloves
aseptically
7. Draw up the correct dosage, using the
techniques described for drawing up from vial
or an ampule (vial or ampule is held by
assistant) and change the needle.
8. Select the appropriate injection site and clean
it with a swab, using a circular motion and
moving from the middle site outward.
9. Allow the skin to air dry.
10 Remove the needle guard, being careful to /
pull it straight off and away from the needle.
11. Identify the vein and choose the easiest one.
Place the part of body that contents the vein
lower than heart.
12. Fixate the arm or leg and clean the area
thoroughly.
13 Put the toumi • uet on, proximal to the
puncture site. If the puncture site will be the
head, press the distal part of the vein by using
your finger.
14 With skin retracted and needle bevel up, hold
the needle at a 15 to 30 degree angle to
pierce the skin 0.5 cm beside the vein,
followed by a decreased angle to enter the
vein.

26
 Score
No. Aspects.
0 1 2
15 To ensure that the needle has entered the
vein, draw the syringe's plunger. If small
amounts of blood enter the syringe, it means
that the needle is in correct position (in the
vein)

16 Put the tourniquet off

17 Push the syringe plunger and enter the drug
to the blood current or draw the syringe
plunger to withdraw the blood if you will take
the blood sample.

18 Withdraw the needle after finish and cover the

wound with alcohol soaked cotton wool, and
apply tape.

19 After the injection is performed, leave the

patient in a comfortable position.
20 Discard the syringe and needle in the closest
"sharps" container without replacing the
needle guard. If the "sharp" container is
centrally located, replace the needle guard
using one hand technique.

21 Evaluate for the correct site was used,

effectiveness of the medication and adverse
effect that is once identified should be
promptly manage.

22 Write the injection procedure (name of the

medication, dose, route, time, and signature)
in the patient's medical record.

27
REFERENCES

1. Stone, K.C., Humphries,R., 2004, Current Emergency Diagnosis and Treatment 5"' ed.
USA: Mc-Graw Hill Company
2. Janice, R; 1996; Modules for Basic Nursing Skills; Lippincot - Raven Publishers;
Philadelphia
3. Workman,B., (1999) Safe Injection Techniques Nursing Standard.13,39, 47-53.
4. Moore,K.L., Dailey Il,A.,1999. Clinically Oriented Anatomy,4"1 ed. Philadelphia :
Lippincott.
5. Bruning, R. H., Schraw, G. J., Norby, M. M., & Ronning, R. R. (2004). Cognitive
psychologie and Instruction (4 ed.). New Jersey: Pearson, Upper Saddle River.
6. Maudsley G, Strivens J. Promoting professional knowledge, experiential learning and
critical thinking for medical students. Med Educ 2000;34:535-44.

28