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Medication Administration: Vaccines for Immunizations (Ambulatory) - CE/NCPD
ALERT
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Take steps to eliminate interruptions and distractions during medication preparation.
OVERVIEW
Vaccination typically begins shortly after birth and continues into adulthood. During infancy and childhood, vaccine administration is more frequent, and multiple vaccines are typically administered, according to the recommended immunization schedule.4 If vaccines are missed, there are alternative schedules available to make up for the needed vaccines;3 however, this also means that the child may receive more vaccinations in one visit. During adolescence and into adulthood, the frequency of immunizations decreases; however, the human papillomavirus (HPV) vaccine is typically added for this age group. During young and middle adulthood, the frequency of scheduled vaccinations decreases. Additional booster vaccines may be given depending on the age at that initial immunization.2 By late adulthood, the addition of the pneumococcal vaccine (PCV) is recommended for those age 65 years and older.2 During pregnancy and while breastfeeding, there are certain vaccines that could pose a risk to the fetus and, therefore, are not recommended.1 As with any medication, vaccine administration should be at the practitioner’s discretion.
Vaccines can be given in combination when more than one inoculant is in one prefilled syringe (e.g., measles, mumps, and rubella [MMR] vaccine). This allows more immunizations with fewer injections. Combination vaccines are those that are licensed and sold already combined in a single syringe or those combined at the point of care as recommended by the manufacturer.
Simultaneous inoculation is defined as multiple vaccines given during the same visit. Giving simultaneous vaccines can allow for fewer visits but should be balanced with the discomfort of receiving several vaccines in one day. If the family seems unlikely to return for additional vaccines or is unwilling to comply with a catch-up schedule, simultaneous vaccines should be provided.10 Consideration should be given to the patient’s age and size and to vaccines with a greater risk of causing a local reaction (e.g., PCV; diphtheria, tetanus, and pertussis [DTaP]). Two live vaccines should not be given in the same muscle mass.5,10
The manufacturer’s instructions for use should be followed for storage and administration of vaccines. Prefilled syringes are considered activated once the cap is removed or a needle is attached. Activated vaccines should be used by the end of the facility’s day and then discarded. Activation should be avoided until the vaccine is needed.
There are very few strict contraindications for vaccines. Generally, a previous severe anaphylactic reaction or encephalopathy not attributable to another cause is a contraindication. Precautions surrounding specific vaccines should be reviewed (e.g., live attenuated vaccines should not be given to immunosuppressed patients).
There are several routes by which vaccines may be given, including oral, intramuscular (IM), intradermal, subcutaneous (Figure 1), and intranasal. The manufacturer’s instructions should be followed for recommended routes. For IM injections, aspiration before injection and slow injection of the medication are not required for vaccine administration.5 The vastus lateralis (Figure 2) and deltoid muscle (Figure 3) are the only two sites recommended for vaccine administration because they do not contain large vessels that are within reach of the needle.5 For children older than 3 years5,10 and adults, the upper outer aspect of the deltoid is recommended. For subcutaneous injections, the skin over the lateral thigh or upper outer aspect of the upper arm is recommended. The Centers for Disease Control and Prevention’s (CDC’s) guidelines should be followed for needle sizes and lengths according to the patient’s age and weight, injection site, and the amount of adipose tissue in the chosen injection site (Table 1).5,6
The deltoid muscle is most commonly used for vaccination injections and is located by fully exposing the patient’s upper arm and shoulder and asking the patient to relax the arm at the side or by supporting the patient’s arm and flexing the elbow. Next, the lower edge of the acromion process, which forms the base of a triangle in line with the midpoint of the lateral aspect of the upper arm, is palpated. The health care team member measures 2- to 3-finger widths7 down from the acromion process and visualizes a triangle, with the base at the acromion process and the apex pointing toward the elbow. The injection site is found in the center of the triangle (Figure 3). To avoid shoulder injury related to vaccine administration (SIRVA), the health care team member should always sit to inject into the arm of a seated patient to ensure that the angle of the needle is correct. If the patient’s shirt cannot be removed, the sleeve should be rolled up, so that landmarks can be visualized and used appropriately.7
Adverse reactions rarely occur after vaccinations but may include anaphylaxis, anaphylactic shock, and neurologic deficits.10 Vaccine adverse event reporting is monitored by the CDC.
If the patient expresses concern regarding the accuracy of a medication, the medication should not be given. The patient’s concern should be explored, the practitioner notified, and the order verified.
SUPPLIES
See Supplies tab at the top of the page.
EDUCATION
Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
Explain the importance of vaccination and keeping to the schedule as much as possible.
Explain the risks related to the procedure, including hematoma formation, nerve injury, and allergic reaction to the vaccine.
Instruct the patient regarding the potential side effects of the medication.
Instruct the patient to observe injection sites for complications and provide instructions on when to seek additional care.
Prepare the patient for the possibility of signs and symptoms of illness associated with the vaccine. Explain that this is a normal reaction and not an actual illness.
Instruct the patient to take an up-to-date list of medications (over-the-counter [OTC], supplements, and prescriptions) to every practitioner visit.9
Encourage questions and answer them as they arise.
PROCEDURE
Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
Introduce yourself to the patient.
Verify the correct patient using two identifiers.
Explain the procedure and ensure that the patient agrees to treatment.
Ensure that evaluation findings are communicated to the clinical team leader per the organization’s practice.
Evaluate the patient for specific contraindications or precautions related to vaccine administration (e.g., previous anaphylaxis with vaccine) and advise the practitioner accordingly.
Evaluate the patient’s knowledge regarding the vaccine(s) to be received.
Evaluate the patient’s history of allergies, including medication or food allergies, and previous allergic reactions.
Review the patient’s previous verbal and nonverbal responses to injections.
Obtain the patient’s vital signs and medical and medication history.
Obtain the patient’s actual weight in kilograms.8 Stated, estimated, or historical weight should not be used.8
Obtain the medication, check the practitioner’s order, verify the expiration date, and inspect the medication for particulates, discoloration, or other loss of integrity.
Do not use medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe.
Review medication reference information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, and common side effects and implications.
Ensure the rights of medication safety.
Label all medications, medication containers, and other solutions. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them.9
Provide privacy for the patient. Have the patient remove clothing, as needed, depending on the injection site.
Assemble the appropriate-size needles, syringes, and other administration supplies, as needed.
Perform hand hygiene and don gloves.
Select the appropriate site for injection based on the patient’s age, weight, muscle tissue mass, and medication volume and viscosity.
Assist the patient to a comfortable position that is appropriate for the chosen injection site (e.g., sitting, lying flat, side-lying, prone).
Rationale: A comfortable position reduces strain on the muscle and minimizes injection discomfort.
Cleanse the site with alcohol or an antiseptic swab, per the organization’s practice. Allow the skin to dry completely. Optional: Use a vapocoolant spray (e.g., ethyl chloride) for pain relief just before injection.
Rationale: A vapocoolant spray decreases pain at the injection site.
Administer the vaccine to the patient per the manufacturer’s instructions for use (Figure 1) (Figure 2) (Figure 3) (Table 1).
Apply gentle pressure to the site; do not massage. Evaluate the site for bleeding and apply a bandage if needed.
Rationale: Massage damages underlying tissue.
Assist the patient to a comfortable position and have the patient replace clothing as needed.
Discard the uncapped needle (or needle enclosed in the safety shield) and attached syringe into a puncture-proof and leakproof receptacle.
Rationale: Discarding the uncapped needle helps prevent injury to the patient and health care team members. Recapping needles increases the risk for a needlestick injury.11
Monitor the patient for adverse and allergic reactions to the medication. Recognize and immediately treat respiratory distress and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization’s practice for emergency response.
Assess, treat, and reassess pain.
Monitor for burning, numbness, or tingling at the injection site.
Discard supplies, remove PPE, and perform hand hygiene.
Document the procedure in the patient’s record.
EXPECTED OUTCOMES
Medication administered per the rights of medication safety
Acceptable level of comfort after injection
Patient able to explain purpose of vaccination
Desired effect of medication with no adverse reactions or signs of allergies
UNEXPECTED OUTCOMES
Medication not administered per the rights of medication safety
Adverse reaction to the medication, with signs of urticaria, eczema, pruritus, wheezing, or dyspnea
Patient complaints of localized pain, bleeding, or continued burning at injection site, indicating potential injury to nerve or vessels
Unmanaged pain
Patient unable to explain the purpose of vaccination
DOCUMENTATION
Vaccine name, dose, route, site, and time and date of administration
Patient’s response to medication, including any adverse reactions
Unexpected outcomes and related interventions
Education
Patient’s weight in kilograms per the organization’s practice
Comprehensive list of current medications and those recently discontinued
Evaluation findings communicated to the clinical team leader per the organization’s practice
PEDIATRIC CONSIDERATIONS
Pediatric patients can be very anxious or fearful of needles. Assistance is sometimes necessary to hold and position the patient properly. Distraction, such as blowing bubbles and applying pressure at the injection site before giving the injection, may help alleviate the patient’s anxiety.
If possible, a topical analgesic should be applied to the injection site with sufficient time allowed for peak action before the IM injection. A vapocoolant spray (e.g., ethyl chloride) may also be used just before injection to decrease pain. The health care team member should collaborate with the practitioner to obtain orders for pain prevention before injection.
OLDER ADULT CONSIDERATIONS
Older adult patients may have decreased muscle mass, which reduces drug absorption from IM injections.
Centers for Disease Control and Prevention (CDC). (2023). Immunization schedules: Adult immunization schedule by age. Recommendations for ages 19 years or older, United States, 2023. Table 1. By age. Retrieved April 23, 2023, from https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html (Level VII)
Centers for Disease Control and Prevention (CDC). (2023). Immunization schedules: Catch-up immunization schedule for children and adolescents who start late or who are more than 1 month behind. Recommendations for ages 18 years or younger, United States, 2023. Table 2. Catch-up schedule. Retrieved April 23, 2023, from https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html (Level VII)
Centers for Disease Control and Prevention (CDC). (2023). Immunization schedules: Child and adolescent immunization schedule by age. Recommendations for ages 18 years or younger, United States, 2023. Table 1. By age. Retrieved April 23, 2023, from https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html (Level VII)
Institute for Safe Medication Practices (ISMP). (2022). 2022-2023 Targeted medication safety best practices for hospitals. Retrieved April 23, 2023, from https://www.ismp.org/guidelines/best-practices-hospitals (Level VII)
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
Elsevier Skills Levels of Evidence
Level I - Systematic review of all relevant randomized controlled trials
Level II - At least one well-designed randomized controlled trial
Level III - Well-designed controlled trials without randomization
Level IV - Well-designed case-controlled or cohort studies
Level V - Descriptive or qualitative studies
Level VI - Single descriptive or qualitative study
Level VII - Authority opinion or expert committee reports
