Administering Intradermal Injections Extended Text PDF

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Skills Administering Intradermal Injections Extended Text ALERT • Do Do not not aspirate aspirate during during intradermal intradermal injection, injection, because because the the dermis dermis is is relatively relatively avascular. avascular. • Stay with the patient for several minutes after providing the injection to watch for signs of an allergic reaction. Dyspnea, Dyspnea, wheezing, wheezing, and and circulatory circulatory collapse collapse signify signify severe severe anaphylactic anaphylactic reaction. reaction. • Take Take steps steps to to eliminate eliminate interruptions interruptions and and distractions distractions during during medication medication preparation. preparation. • If If the the patient patient expresses expresses concern concern regarding regarding accuracy accuracy of of aa medication, medication, do do not not give give the the medication. medication. Explore Explore the the patient’s patient’s concern, notify the practitioner, and verify the order.

OVERVIEW You typically give intradermal (ID) injections for skin testing (e.g., tuberculosis screening and allergy tests). For allergy skin testing, an allergen extract is injected under the skin. 11 For the Mantoux TB skin test, a substance called purified protein derivative (PPD), which is derived from TB, is injected under the skin. 22 Because such medications are potent, you inject them into the dermis, where blood supply is reduced and drug absorption occurs slowly. A patient may have an anaphylactic reaction if the medications enter the circulation too rapidly. For patients with a history of multiple allergies, the physician may perform skin testing. Skin testing often requires you to visually inspect the test site; therefore make sure that the ID sites are free of lesions and injuries and relatively hairless. The inner forearm and upper back are ideal locations. Inactivated influenza vaccinations are administered intramuscularly with the exception of Fluzone intradermal, which is administered intradermally, preferably over the deltoid region of the upper arm, using a prefilled syringe and is indicated for use in patients between the ages of 18 and 64 years.33,44 The manufacturer’s prefilled microinjection syringe is used to administer a 0.1-ml dose into the dermal layer of the skin. The syringe contains a 30-G, 1.5-ml microneedle, which is inserted perpendicular to the skin until the entire bevel is covered and lies just under the skin.33 For the Mantoux technique, a TB syringe with a short (6 to 13 mm [¼ to ½ inch]), fine-gauge (27-G) needle with a short bevel is used to administer an injection intradermally. 55 The correct needle insertion angle for an intradermal injection is 5 to 15 degrees. 55Only small amounts of the PPD (0.1 ml) are injected intradermally. 22 If a bleb does not appear or if the site bleeds after needle withdrawal, the medication may have entered subcutaneous tissues, and skin test results are invalid. A new alternative to the traditional method of TB testing is a microneedle patch. 66 This patch is a simpler, less expensive alternative to current diagnostic tests and has the potential to be a reliable alternative to the Mantoux technique. 77 The microneedle length on the patches is standardized and provides consistent PPD delivery that is not dependent on needle insertion depth and angle. 66The patch can be used for diagnosing both active and latent tuberculosis. With the advancement of intradermal devices, the organization’s practice should be reviewed regarding the type of needle used and the manufacturer’s instructions for use. 44

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PATIENT AND FAMILY EDUCATION • • • • • • •

Instruct patient not to squeeze medication out of injection site. Teach patients that negative skin tests may not rule out allergies, especially when low concentrations of medication are used. Instruct the patient to keep the site of injection clean and dry and avoid applying cream, lotions, or adhesive bandages. Patient should wear medical identification band listing all allergies. Caution patient not to wash off pencil markings around injection site. Explain to patient how to observe for skin reactions. Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION • Check the accuracy and completeness of each medication administration record (MAR) against the health care provider’s orders. Confirm the patient’s name, medication name, dosage, route of administration, and time of administration. Clarify incomplete or unclear orders with the health care provider. • Assess baseline vital signs and medication history. • Note if the patient has allergies. • Understand drug reference information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, common adverse effects, and nursing implications, if needed. • Assess the patient’s history of allergies including the known allergen types, and the patient’s typical allergic reaction. • Ascertain any contraindications to intradermal injections. Assess for a history of severe adverse reactions or necrosis following previous intradermal injection. • Determine if the patient understands the reason for the skin test and knows what responses to report. • Prepare the medication for injection. Check the label of the allergen, PPD, or vaccine against the MAR two times. A third check will take place at the bedside. Obtain the medication and note the expiration date of the medication. Inspect allergen, vaccine, or PPD for particulates, discoloration, or other loss of integrity. • If the syringe is prepared away from the patient’s bedside, label it with the name and dose of medication in the syringe. • Verify the patient’s actual admission weight in kilograms. Reweigh the patient if appropriate. 88

DELEGATION The skill of administering an intradermal injection may not be delegated to nursing assistive personnel (NAP). Be sure to inform NAP of the following: • Review the potential side effects of the medication. • Instruct NAP to report such side effects to you.

PROCEDURE 1. Verify the health care provider's orders. 2. Prepare injection for one patient at a time, using aseptic technique; avoid distractions. Keep together all pages of the MAR or computer printout for one patient, or look at only one patient’s electronic MAR at a time. Check the label of the medication carefully against the MAR or the computer printout twice during preparation of the medication. You will do a third check at the patient’s bedside. 3. Take the medication to the patient at the correct time (see agency policy). During administration, apply the Six Rights of Medication Administration. Refer to the Video Skill "Ensuring the Six Rights of Medication Administration." 4. Gather the necessary equipment and supplies. When preparing an injection away from the patient’s bedside, be sure to label the syringe properly.99 5. Provide for the patient's privacy. 6. Perform hand hygiene and don gloves.

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7. Introduce yourself to the patient and family, if present. 8. Identify the patient using two identifiers. Compare these identifiers with the information in the patient’s MAR or medical record. Ask the patient if he or she has allergies. 9. At the patient’s bedside, again compare the MAR or the computer printout with the names of the medications on the medication labels and with the patient’s name. 10. Explain the procedure to the patient and ensure that he or she agrees to treatment. Discuss the purpose of the intradermal injection, its action, and its possible adverse effects. Allow the patient to ask questions. Tell the patient that the injection will cause a slight burning or stinging sensation. Instruct the patient to report any itching or shortness of breath. 11. Raise the bed to a comfortable working height. 12. Keep a sheet or gown draped over portions of the body that do not require exposure. 13. Select an appropriate site. a. Allergy and TB tests: Select an injection site on the palm side of the forearm about 5 to 10 cm (2 to 4 inches) below the elbow. 55 Use the left or right forearm according to the organization’s practice. If the forearm cannot be used, inspect the upper back. If necessary, use sites that are appropriate for subcutaneous injection. b. Intradermal influenza vaccine: Select site over the deltoid muscle. 14. Help the patient into a comfortable position. a. Allergy and TB tests: Have the patient extend his or her elbow, and support the elbow and forearm on a flat surface. b. Influenza vaccine: Have patient relax entire arm. 15. Apply clean gloves. 16. Clean the site with an antiseptic swab. Starting from the center of the injection site, rotate the swab outward in a circular direction for about 5 cm (2 inches). Option: Use a vapocoolant spray, such as ethyl chloride, before the injection. 17. Hold a swab or a piece of gauze between the third and fourth fingers of your nondominant hand. 18. Remove the needle cap from the needle by pulling it straight off. 19. Hold the syringe between the thumb and forefinger of your dominant hand, with the bevel of the needle pointing up. 20. Administer the injection: a. Using your nondominant hand, stretch the skin over the site with your forefinger or thumb. b. With the needle almost against the patient’s skin and the bevel of the needle facing upward, insert the needle slowly at a 5- to 15degree angle until you feel resistance. Advance the needle through the epidermis to a depth of about 3 mm (⅛ inch) beneath the skin. You will see the bulge of the needle tip through the skin. Intradermal influenza vaccine: If the injection is to be performed with an intradermal microneedle, insert the needle perpendicular to the skin. c. Inject the medication slowly. d. As you inject the medication, a small bleb (approximately 6 mm [¼ inch]) resembling a mosquito bite will form on the skin surface. e. Withdraw the needle, and apply an alcohol swab or gauze pad gently to the site. Do not massage. f. TB tests: If the TB test must be repeated, attempt administration at least 5cm (2 inches) from the original site or use an appropriate alternate location. 55 21. Help the patient into a comfortable position. 22. Remove your gloves, and perform hand hygiene. 23. Stay with the patient for several minutes to watch for any allergic reaction. The patient should not be left alone when undergoing allergy testing. 11 24. Place toiletries and personal items within reach. 25. Place the call light within easy reach, and make sure the patient knows how to use it to summon assistance. 26. To ensure the patient's safety, raise the appropriate number of side rails and lower the bed to the lowest position. 27. Leave the patient's room tidy. 28. Document and report the patient’s response and expected or unexpected outcomes.

MONITORING AND CARE • Monitor the patient for adverse and allergic reactions to the allergen, PPD, or vaccine. Recognize and immediately treat dyspnea, wheezing, and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization’s practice for emergency response. https://connect.elsevierperformancemanager.com/#/content/skills/13710/extended-text

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• Ask the patient to discuss the implications of skin testing and the signs of hypersensitivity. • Inspect the bleb. As an option, use a skin pencil and draw a circle around the perimeter of the injection site. • Read a tuberculin (TB) test site at 48 to 72 hours; look for induration—a hard, dense, raised area—around the injection site. The size of the indurated area varies depending on the patient’s condition. The test is positive if you see: • An induration of 15 mm or more in a patient with no known risk factors for TB. • An induration of 10 mm or more in a patient who is a recent immigrant, injection drug user, resident or employee in a high-risk setting, mycobacteriology laboratory personnel, patient with a specified chronic illness, a child younger than 4 years of age, or an infant, child, or adolescent who has been exposed to a high-risk adult. • An induration of 5 mm or more in a patient who is human immunodeficiency virus (HIV)-positive, has fibrotic changes on a chest x-ray consistent with a previous TB infection, has had an organ transplant, or has immunosuppression.

EXPECTED OUTCOMES • Patient experiences no adverse reactions or side effects. • Correct medication, allergen, PPD, or vaccine is administered correctly according to the six rights of medication safety. • Patient experiences very mild burning sensation during injection but no discomfort after injection. • Small, light-colored bleb approximately 6 to 10 mm (¼ inch) in diameter forms at the injection site and gradually disappears. Minimal bruising is present at the injection site. • Patient is able to identify signs and significance of a skin reaction.

UNEXPECTED OUTCOMES • • • • •

Medication is not administered correctly according to the six rights of medication safety. Raised, reddened, or hard zone (induration) forms around intradermal test site. Adverse reaction or side effects from medication develops within minutes. Medication error occurs. Patient is unable to explain the signs and significance of a skin reaction.

DOCUMENTATION Documentation Guidelines: • Record the drug, dose, route, site, time, and date on the MAR immediately after administering the intradermal injection, and not before. For hard-copy documentation, include the time and your initials or signature per agency policy. • Record the location of the intradermal injection and the appearance of the patient’s skin afterward. • Document any adverse effects according to your agency’s policy, and report them to the health care provider. • Record any patient teaching, validation of understanding, and the patient’s response to the intradermal injection. • Document unexpected outcomes and related nursing interventions. • Record patient’s weight in kilograms per the organization’s practice.

Sample Documentation: 1000 PPD 0.1 mL given intradermally into left forearm, inner aspect. 6 mm bleb noted at injection site, marked with skin pencil. Instructed not to wash the skin pencil off and to return to the clinic in 48 hours to read the results. Verbalized understanding. –D. Kastelic, RN 4/1/20 1020 No adverse response noted to PPD injection after 20 minutes. Denies itching, shortness of breath, or other complaints. Discharged home. — D. Kastelic, RN 4/1/20

PEDIATRIC CONSIDERATIONS https://connect.elsevierperformancemanager.com/#/content/skills/13710/extended-text

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• Children age 5 or older who are exposed to people with confirmed or suspected infectious tuberculosis should be tested using an interferon y-release assay (IGRA) rather than a TB skin test. 1100 • Children with ongoing exposure to high-risk individuals (e.g., HIV-infected, homeless, incarcerated) should be tested for tuberculosis every 2 to 3 years.22 • In infants, children, and adolescents who have been exposed to persons in high-risk categories, an induration of 10 mm or greater is considered positive. 22

GERONTOLOGICAL CONSIDERATIONS • The skin of the older adult is less elastic and must be held taut to ensure that ID injection is administered correctly.

REFERENCES 1. Lewis, S.L. and others (Eds.). (2017). Chapter 13: Altered immune responses and transplantation. In Medical-surgical nursing: Assessment and management of clinical problems (10th ed., pp. 191-212). St. Louis: Elsevier. 2. Centers for Disease Control and Prevention (CDC). (2013). Core curriculum on tuberculosis: What the clinician should know (6th ed.). Retrieved July 15, 2019, from http://www.cdc.gov/tb/education/corecurr/pdf/corecurr_all.pdf (https://www.cdc.gov/tb/education/corecurr/pdf/corecurr_all.pdf ) (Level VII) 3. Centers for Disease Control and Prevention (CDC). (2015). Vaccine administration. Retrieved July 15, 2019, from http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/vac-admin.pdf (http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/vacadmin.pdf ) (Level VII) 4. Grohskopf, L.A. and others. (2015). Prevention and control of influenza with vaccines: Recommendations of the advisory committee on immunization practices, United States, 2015-16 influenza season. Morbidity and Mortality Weekly Report, 64(30), 818-825. (Level VII) 5. Centers for Disease Control and Prevention (CDC). (2013). Mantoux tuberculin skin test: Facilitator guide. Retrieved July 15, 2019, from http://www.cdc.gov/tb/education/mantoux/pdf/mantoux.pdf (http://www.cdc.gov/tb/education/mantoux/pdf/mantoux.pdf ) (Level VII) 6. Wang, W. and others. (2019). Skin test of tuberculin purified protein derivatives with a dissolving microneedle-array patch. Drug Delivery and Translational Research, 9(4), 795-801. doi:10.1007/s13346-019-00629-y (Level VI) 7. Jin, J. and others. (2014). Chitin microneedles for an easy-to-use tuberculosis skin test. Advanced Healthcare Materials, 3(3), 349-353. doi:10.1002/adhm.201300185 (Level VI) 8. Institute for Safe Medication Practices (ISMP). (2017). 2018-2019 Targeted medication safety best practices for hospitals. Retrieved July 15, 2019, from https://www.ismp.org/sites/default/files/attachments/2017-12/TMSBP-for-Hospitalsv2.pdf (https://www.ismp.org/sites/default/files/attachments/2017-12/TMSBP-for-Hospitalsv2.pdf ) (Level VII) 9. Joint Commission, The. (TJC). (2019). National patient safety goals: Hospital accreditation program. Retrieved July 15, 2019, from https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2019.pdf (https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2019.pdf ) (Level VII) 10. Lewinsohn, D.M. and others. (2017). Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: Diagnosis of tuberculosis in adults and children. Clinical Infectious Diseases, 64(2), e1–e33. Retrieved July 15, 2019, from https://academic.oup.com/cid/article/64/2/e1/2629583 (https://academic.oup.com/cid/article/64/2/e1/2629583)

Elsevier Skills Levels of Evidence • • • • • • •

Level Level Level Level Level Level Level

I - Systematic review of all relevant randomized controlled trials II - At least one well-designed randomized controlled trial III - Well-designed controlled trials without randomization IV - Well-designed case-controlled or cohort studies V - Descriptive or qualitative studies VI - Single descriptive or qualitative study VII - Authority opinion or expert committee reports

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