Safety

Follow the Six Rights of Medication Administration: right medication, right dose, right patient, right route, right time, and right documentation.

• Do not aspirate during intradermal injection, because the dermis is relatively avascular.
• Wear clean gloves during intradermal injection to limit contact with bodily fluids.
• Use strict asepsis when preparing and administering an intradermal injection.
• Observe a “No Interrutption Zone” while preparing medications.
• The skin of older adults is less elastic and must be held taut to ensure correct administration of the intradermal injection.
• Stay with the patient for several minutes after providing the injection to watch for signs of an allergic reaction. Dyspnea, wheezing, and circulatory collapse signify severe anaphylactic reaction.

Equipment

(Roll cursor over items to see labels)

Syringe: 1-mL tuberculin syringe with 25-gauge or 27-gauge, 3/8 to 5/8 inch needle

Small gauze pad

Alcohol swab

Vial or ampule of medication

Clean gloves

Marker (skin safe)

Tape (to label syring, if necessary)

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.

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.
• Note if the patient has allergies.
• Review the medication reference information about expected reactions to skin tests for specific allergens or medications, and note the appropriate time to read the site.
• 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 medication against the MAR two times. A third check will take place at the bedside. Note the expiration date of the medication.
• If the syringe is prepared away from the patient’s bedside, label it with the name and dose of medication in the syringe.

Follow-up

• Return to the patient’s room in 15 to 30 minutes, and ask her if she feels any acute pain, burning, numbness, or tingling at the injection site.
• 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 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, 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.

Documentation

• 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.