Administering an Intradermal Injection

Skill 5-6

Administering an Intradermal Injection

Intradermal injections are administered into the dermis, just below the epidermis. The intradermal route has the longest absorption time of all parenteral routes. For this reason, intradermal injections are used for sensitivity tests, such as tuberculin and allergy tests, and local anesthesia. The advantage of the intradermal route for these tests is that the body's reaction to substances is easily visible, and degrees of reaction are discernible by comparative study.

Sites commonly used are the inner surface of the forearm, the upper chest, and the upper back, under the scapula. Equipment used for an intradermal injection includes a tuberculin syringe calibrated in tenths and hundredths of a milliliter and a 3/8- to ½-inch, 26- or 27-gauge needle (Taylor et al., 2023). The dosage given intradermally is small, usually less than 0.5 mL (Taylor et al., 2023). The angle of administration for an intradermal injection is 5 to 15 degrees (see Figure 5-1 in the chapter opener on page 200).

Delegation Considerations

The administration of an intradermal injection is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, the administration of an intradermal injection may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Prescribed medication
Sterile syringe, usually a tuberculin syringe calibrated in tenths and hundredths, and a 3/8″ to ½″, 26- or 27-gauge needle
Antimicrobial swab
Disposable gloves
Small gauze square
Electronic Medication Administration Record (eMAR) or Medication Administration Record (MAR)
PPE, as indicated
Marking pen for indicating area for future assessment, if indicated

Assessment

Assess the appropriateness of the drug for the patient. Review the medical history and allergy, assessment, and laboratory data that may influence drug administration. Check the expiration date before administering medication. Assess the site on the patient where the injection is to be given. Avoid areas of broken or open skin. Avoid areas that are highly pigmented, and those that have lesions, bruises, or scars and are hairy. Assess the patient's knowledge of the medication. If the patient has a knowledge deficit about the medication, this may be the appropriate time to begin education about the medication Verify the patient's name, dose, route, and time of administration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Knowledge deficiency
Infection risk
Injury risk

Outcome Identification and Planning

The expected outcomes to achieve when administering an intradermal injection are that the medication is injected, and a wheal appears at the injection site. Other outcomes that may be appropriate include the following: the patient refrains from rubbing the site, the patient does not experience adverse effects, and the patient understands and engages with the medication regimen.

Implementation

Action	Rationale
1. Gather equipment. Check each medication prescribed against the original in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's health status and can also be used to educate the patient about the medication.
3. Perform hand hygiene.	Hand hygiene deters the spread of microorganisms.
4. Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room.	Organization facilitates error-free administration and saves time.
5. Unlock the medication supply system or drawer. Enter the passcode and scan employee identification, if required.	Locking the medication supply system or drawer safeguards each patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use. Entering the passcode and scanning ID allows only authorized users into the system and identifies the user for documentation by the computer.
6. Prepare medications for one patient at a time.	This prevents errors in medication administration.
7. Read the eMAR/MAR and read the label when selecting the proper medication from the medication supply system or the patient's medication drawer.	This is the first check of the label.
8. Read the label and compare the label with the eMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required.	This is the second check of the label. Verify calculations with another nurse to ensure safety.
9. If necessary, withdraw the medication from an ampule or vial as described in Skills 5-3 and 5-4.
10. Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, read the label and recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient.	This third check ensures accuracy and helps to prevent errors. Note: Many facilities require the third check to occur at the bedside, after identifying the patient and before administration.
11. Label the syringe with the medication's name, dose, and amount (The Joint Commission, 2021).	Unlabeled syringes are unidentifiable and may lead to a medication administration error (The Joint Commission, 2021).
12. Log out of and/or lock the medication supply system before leaving it.	Locking the medication supply system or drawer safeguards the patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use.
13. Transport medications to the patient's bedside carefully and keep the medications in sight at all times.	Careful handling and close observation prevent accidental or deliberate disarrangement of medications.
14. Ensure that the patient receives the medications at the correct time.	Check facility policy, which may allow for administration within a period of 30 minutes before or 30 minutes after the designated time.
15. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
16. Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods (The Joint Commission, 2021):	Identifying the patient ensures the right patient receives the medications and helps prevent errors. The patient's room number or physical location is not used as an identifier (The Joint Commission, 2021). Replace the identification band if it is missing or inaccurate in any way.
a. Check the name on the patient's identification band.	This requires a response from the patient, but illness and strange surroundings often cause patients to be confused.
b. Check the identification number on the patient's identification band.
c. Check the birth date on the patient's identification band.
d. Ask the patient to state their name and birth date, based on facility policy.
17. Close the door to the room or pull the bedside curtain.	This provides patient privacy.
18. Complete necessary assessments before administering medications. Check the patient's allergy bracelet, if present, or ask the patient about allergies. Explain the purpose and action of the medication to the patient.	Assessment is a prerequisite to administration of medications. Explanation provides rationale, increases knowledge, promotes patient engagement, and reduces anxiety.
19. Scan the patient's bar code on the identification band, if required (The Joint Commission, 2021).	This provides an additional check to ensure that the medication is given to the right patient.
20. Based on facility policy, the third check of the label may occur at this point. If so, read the label and recheck the labels with the eMAR/MAR before administering the medications to the patient.	Many facilities require the third check to occur at the bedside, after identifying the patient and before administration. If facility policy directs the third check at this time, this third check ensures accuracy and helps to prevent errors.
21. Put on gloves.	Gloves help prevent exposure to contaminants.
22. Select an appropriate administration site. Assist the patient to the appropriate position for the site chosen. Drape, as needed, to expose only site area to be used.	Using the appropriate site prevents injury and allows for accurate reading of the test site at the appropriate time. Draping provides privacy and warmth.
23. Cleanse the site with an antimicrobial swab while wiping with a firm, circular motion and moving outward from the injection site. Allow the skin to dry.	Pathogens on the skin can be forced into the tissues by the needle. Moving from the center outward prevents contamination of the site. Allowing the antimicrobial solution to dry completely (5 to 20 seconds) ensures complete antimicrobial effectiveness (Gorski et al., 2021; Slater et al., 2018), and prevents introducing alcohol into the tissue, which can be irritating and uncomfortable.
24. Remove the needle cap with the nondominant hand by pulling it straight off.	This technique lessens the risk of an accidental needlestick.
25. Use the nondominant hand to spread the skin taut over the injection site (Figure 1).	Taut skin provides an easy entrance into intradermal tissue.
26. Hold the syringe in the dominant hand, between the thumb and forefinger with the bevel of the needle up.	Using the dominant hand allows for easy, appropriate handling of the syringe. Having the bevel up allows for smooth piercing of the skin and introduction of medication into the dermis.
27. Hold the syringe at a 5- to 15-degree angle from the site. Place the needle almost flat against the patient's skin (Figure 2), bevel side up, and insert the needle into the skin. Insert the needle only about ⅛ inch with entire bevel under the skin.	The dermis is entered when the needle is held as nearly parallel to the skin as possible and is inserted about ⅛ inch.
28. Once the needle is in place, steady the lower end of the syringe. Slide your dominant hand to the end of the plunger.	This prevents injury and inadvertent advancement or withdrawal of needle.
29. Slowly inject the agent while watching for a small wheal to appear (Figure 3).	The appearance of a wheal indicates the medication is in the dermis.
30. Withdraw the needle quickly at the same angle that it was inserted. Do not recap the used needle. Engage the safety shield or needle guard.	Withdrawing the needle quickly and at the angle at which it entered the skin minimizes tissue damage and discomfort for the patient. Safety shield or needle guard prevents accidental needlestick injury.
31. Do not massage the area after removing needle. Tell the patient not to rub or scratch the site. If necessary, gently blot the site with a dry gauze square. Do not apply pressure or rub the site. Use the marking pen to mark the area for further assessment, if indicated.	Massaging or rubbing the area where an intradermal injection is given may spread the medication to underlying subcutaneous tissue.
32. Remove gloves and perform hand hygiene. Assist the patient to a position of comfort.	Removing gloves and performing hand hygiene reduces risk for contamination of other items and the spread of microorganisms. Assisting the patient to a position of comfort promotes patient comfort.
33. Discard the needle and syringe in an appropriate container, such as a sharps receptacle.	Proper disposal of the needle prevents injury.
34. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk of infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
35. Document the administration of the medication immediately after administration. See Documentation section below.	Timely documentation helps to ensure patient safety.
36. Evaluate the patient's response to the medication within the appropriate time frame.	The patient needs to be evaluated for therapeutic and adverse effects from the medication.
37. Observe the area for signs of a reaction at determined intervals after administration. Inform the patient of the need for inspection.	With many intradermal injections, you need to look for a localized reaction in the area of the injection at the appropriate interval(s) determined by the type of medication and purpose. Explanation provides rationale, increases knowledge, promotes patient engagement, and reduces anxiety.
38. If medication is intended for allergy skin testing, observe the patient for sensitivity to the injected allergen (Hoy & Ng, 2021).	Sensitivity to an allergen places the patient at risk for the development of anaphylaxis and may require the administration of epinephrine subcutaneously (Hoy & Ng, 2021). (Refer to Skill 5-7.)

Evaluation

The expected outcomes have been met when the medication has been injected and a wheal has formed at the injection site, the patient has refrained from rubbing the site, the patient did not experience adverse effects, and the patient has verbalized an understanding of the medication regimen.

Documentation

Guidelines

Record each medication administered on the eMAR/MAR or health record using the required format, including date, time, and the site of administration, immediately after administration. Some facilities recommend circling the injection site with ink. Circling the injection site easily identifies the intradermal injection site and allows for future careful observation of the exact area. If using a bar-code system, medication administration is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the health care team as appropriate. This verifies the reason medication was omitted and ensures that health care personnel providing care for the patient are aware of the occurrence.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

You do not note a wheal or blister at the injection site: The medication has been inadvertently injected subcutaneously. Document according to facility policy and notify the health care team as appropriate. You may need to obtain an order to repeat the procedure.
Medication leaks out of the injection site before the needle is withdrawn: The needle was inserted less than ⅛ inch. Document according to facility policy and notify the health care team as appropriate. You may need to obtain an order to repeat the procedure.
You stick yourself with the needle before injection: Discard the needle and syringe appropriately. Follow facility policy regarding needlestick injury. Prepare a new syringe with medication and administer to the patient. Communicate and document the incident according to facility policy.
You stick yourself with the needle after injection: Discard the needle and syringe appropriately. Follow facility policy regarding needlestick injury. Communicate and document the incident according to facility policy.

Special Considerations

Fluzone® Intradermal is the only vaccine in the United States administered by the intradermal route and is available for patients ages 18 to 64 years (CDC, 2015b; Prescriber's Digital Reference [PDR], 2021; Sanofi Pasteur, 2017). The site of administration for this vaccine is the deltoid region of the upper arm, and the needle is inserted perpendicular to the skin (PDR, 2021). This vaccine should not be administered into the forearm or other site used to administer other intradermal medications. The single-dose prefilled microinjection syringe administers a 0.1-mL dose (Sanofi Pasteur, 2017). No other influenza vaccine formulations should be administered by the intradermal route. Follow the manufacturer's directions for appropriate administration.
Ongoing assessment is an important part of nursing care for both evaluation of patient response to administered medications and early detection of adverse reactions. If an adverse effect is suspected, withhold further medication doses and notify the health care team. Additional intervention is based on type of reaction and patient assessment.

section name header

Skill 5-6