Chapter 11 Parenteral Administration: Intradermal, Subcutaneous, and Intramuscular Routes Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Lesson 11.1 Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Describe the technique that is used to administer a medication via the intradermal route.  Identify the equipment needed, and describe the technique that is used to administer a medication via the subcutaneous route. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Intradermal Route Any skin surface can be used, but the preferred sites are upper chest, inner aspect of the forearms, and scapular area of the back Two methods used for allergy testing Intradermal injection method Skin-prick test (SPT) method Measure reaction in millimeters—wheal and erythema, no reaction is referred to as anergic. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 11-1 Intradermal injection technique Note the 15-degree angle of insertion Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question 1 Which route of administration is used for allergy testing? Intravenous Intramuscular Subcutaneous Intradermal Answer: D Rationale: Intradermal injections are made with very small volumes of fluid that are placed just under the epidermal layer of skin, forming a bleb. The site is then observed for signs of reaction. The other forms of injection are not used for allergy testing. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Subcutaneous Route Medication is deposited in the loose connective tissue between the dermis and muscle layer Common drugs injected subcutaneously Heparin Insulin Enoxaparin Sites commonly used include upper arm, anterior thighs, and abdomen The usual amount of fluid administered with this type of injection is 1 mL or less. Rate of absorption is slow and drug action is generally longer with this route than IM or IV injections. It is important to rotate injection sites to enhance absorption and prevent atrophy of the subcutaneous tissue. Injections can be given at 45- or 90-degree angles, depending on the amount of tissue present. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 11-3 Subcutaneous injection technique Note the 45-degree angle of insertion for the needle Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 11-4 Subcutaneous injection sites and rotation plan These are commonly used injection sites. If injections are given frequently, the sites should be rotated. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question 2 The nurse is to administer a dose of insulin subcutaneously to an adult with a very thin build. After prepping the intended injection site and bunching the skin, at what angle of entry does the nurse inject the drug? 15 degrees 30 degrees 45 degrees 90 degrees Answer: C Rationale: For a very lean adult or a child, a 45-degree angle should be used as stated by the American Diabetes Association Clinical Practice Recommendations. A 90-degree angle is typically used for average-sized adults. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Lesson 11.2 Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives (cont.) Describe the technique used to administer medications intramuscularly. Describe the landmarks that are used to identify the vastus lateralis muscle, the rectus femoris muscle, the ventrogluteal area, and the deltoid muscle site before medication is administered. Identify suitable sites for the intramuscular administration of medication in an infant, a child, an adult, and an older adult. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Intramuscular Route Injection deep into muscle mass Sites Vastus lateralis muscle Rectus femoris muscle Ventrogluteal area Dorsogluteal area Deltoid muscle Age and muscle mass are factors to consider when giving IM injections The drug volume differs for each of the sites according to muscle size. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 11-5 Intramuscular injection technique Note the angle of needle insertion is 90 degrees Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question 3 Of the following dosage amounts ordered for an adult patient, which one causes the nurse to question the amount? 4 mL IM 5 mL IV 0.05 mL intradermal 1 mL subcutaneous Answer: A Rationale: An IM amount of 4 mL exceeds the recommended amount of 0.5 to 2 mL, or a maximum of 3 mL, per injection. If larger amounts are required, they should be given in two separate injections at different sites. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 15

Audience Response Question 4 When choosing a needle for an IM injection for an adult, which gauge range is most appropriate? 16 to 18 18 to 20 20 to 22 23 to 25 Answer: C Rationale: Adult IM doses are commonly administered with 20- to 22-gauge needles. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 16

Figure 11-6 Vastus lateralis muscle Note anatomical landmarks Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 11-8 Ventrogluteal site Note anatomical landmarks Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 11-11 Dorsogluteal site Note anatomical landmarks Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question 5 Which injection site must not be used in children younger than 3 years because of underdeveloped muscle? Rectus femoris Dorsogluteal Ventrogluteal Deltoid Answer: B Rationale: The dorsogluteal muscle is not yet well-developed from walking in children younger than 3 years and should be avoided. The ventrogluteal and rectus femoris muscles may be used for children under 3 years, with the rectus femoris being the more convenient of the two. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20

Intramuscular Route (cont.) Volume of medication 0.5 to 2 mL typical volume used for IM 1 mL or less is used for pediatric patients Needles used 1 to 1½ inches long Gauge commonly used: 20 to 22 Site commonly used in infants: vastus lateralis Sites commonly used in adults: gluteal area, deltoid, vastus lateralis Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Intramuscular Route (cont.) Deltoid muscle—not to exceed 1 mL in volume Landmarks for deltoid include the acromion process and axilla Identify correct sites for vastus lateralis muscle, rectus femoris muscle, and gluteal area Z-track method Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 11-14 Z-track method This method is used to administer medications that are irritating to tissues. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.