Administer Vaccines

Giving vaccinations is an important job in many healthcare settings, and knowing the do’s and don’t’s will make the experience easier for you and your patient. Administering vaccines starts with good communication with your patient and a careful health screening. You want your patients to feel comfortable and informed! Then be sure to choose the correct materials, use safe procedures when giving the vaccine, and support your patient with aftercare. This will make for an easy, positive vaccination experience for you both.

Steps

Following a Vaccination Schedule

1. Obtain and use the latest immunization schedule. The U.S. Centers for Disease Control and Prevention (CDC) is the government body that regulates the vaccination schedule in the United States. They have downloadable vaccination schedules for babies, kids and teens, and adults available on their website. Follow these basic guidelines when deciding which vaccines to administer to your patients.
   • Immunization schedules may vary a little depending on factors like where your patients live and what medical conditions they have.
2. Learn what immunizations are recommended in your country. People in different parts of the world need somewhat different vaccines, based on what illnesses are more common there. Use this interactive tool created by The World Health Organization (WHO) to enter your country and get a custom vaccination schedule for anywhere in the world.
   • The European Centre for Disease Prevention and Control has a similar tool for European countries.
3. Screen for contraindications. Before administering a vaccine, do a complete history and physical exam and review your patient’s vaccination history. Ask if your patient is taking any medications, has any allergies, or has ever reacted to a vaccine previously. If they have ever had a severe allergic reaction (anaphylaxis) to any part of the vaccine, do NOT give it. If your patient is moderately to severely ill, weigh the risks and benefits – wait for them to get better, if possible. Be aware of the following contraindications to specific vaccines, and avoid the vaccine if any are present:
   • Hepatitis B: yeast allergy
   • Rotavirus: history of intussusception; severe combined immunodeficiency (SCID)
   • Diptheria/Tetanus/Pertussis: history of encephalopathy within a week of previous dose of DTP, DTaP, or Tdap
   • Hib: younger than 6 weeks old
   • Measles/Mumps/Rubella (MMR), Varicella, and Herpes Zoster: severe immunodeficiency, including HIV; pregnancy

Selecting and Using the Right Materials

1. Consult a dosing chart. You do not have to memorize the dosage guidelines of every vaccine. Consult a dosing chart such as this one at immunize.org or from the CDC.
2. Choose the correct route of delivery. Most vaccines can be given directly into the muscle (intramuscular), but some are administered by the subcutaneous (Subcut, or into the fatty layer), nasal, intradermal (ID, or into the skin), or by mouth. Consult an immunization chart or ask your supervisor if you’re unsure about the best route of delivery. Follow these general guidelines:
   • IM vaccines: Diptheria/Tetanus/Pertussis (including DTaP, DT, Tdap, and Td), Hib, HepA, HepB, HPV, inactivated and recombinant influenza (the most common flu shot), meningococcal conjugate and serogroup B, pneumococcal conjugate, pneumococcal polysaccharide (can also be given Subcut), polio (or Subcut)
   • Subcutaneous: MMR, meningococcal polysaccharide, varicella, zoster, MMRV (ProQuad)
   • Intranasal spray: live attenuated influenza (LAIV, also called Flumist)
   • Intradermal: Fluzone influenza
   • Oral: Rotavirus
3. Give IM injections at a 90° angle with a 22-25 gauge needle. Most vaccines are delivered by the IM route. Deliver an IM injection directly into the muscle belly of a large muscle group. Insert the needle perpendicular to the patient’s body using a quick thrust motion. The muscle lies below the fatty layer, so a longer needle is needed than for a subcutaneous injection.
   • Choose a needle that is between 22 and 25 gauge. The length should be dictated by the patient’s body size.
4. Choose the appropriate IM needle length for the patient’s age and body size. Select the right needle length for IM vaccines to make the injection more comfortable for your patient and to ensure that all the vaccine gets into the muscle. Needle length is based on your patient’s age and body size, as follows:
   • Newborns (<1 month): 5/8” into the upper, outer (anterolateral) thigh
   • Infants (1-12 months): 1” into the anterolateral thigh
   • Toddlers (1-2 years): 1-1.25” into the anterolateral thigh, or 5/8-1” into the deltoid (upper outer arm)
   • Kids and teens (3-18 years): 5/8-1” into the deltoid, or 1-1.25” into the anterolateral thigh
   • Adult <130lb (59 kg): 5/8-1” into the deltoid
   • Adults 130-152lb (59-69kg): 1” into the deltoid
   • Females 153-200lb (69-90kg) and males 130-260lb (59-118kg): 1-1.5” into the deltoid
   • Females 200+ lb (69kg) and males 260+ (118kg) lb: 1.5” into the deltoid
5. Use a 5/8” needle for subcutaneous injections. Both adults and children can receive Subcut injections with a 5/8” needle that is between 23-25 gauge. Give the injection into the fatty tissue over the upper, outer (anterolateral) thigh muscle for infants age 1-12 months. For anyone over 12 months, you can use the anterolateral thigh as well, or the fatty area over the triceps muscle.
   • Insert the needle at a 45° angle to the patient’s body while gently pinching up the skin into a tent to allow for better access. Inject into the fatty tissue below the skin and above the muscle layer.
6. Administer ID vaccines into the top layer of skin. Use a short, narrow needle for ID vaccines, like a 15mm, 26 gauge needle. Insert the needle just shy of parallel to the skin, into the topmost layer of skin. To give an intradermal vaccine with a pre-filled injection device, first gently shake the device then follow these instructions:
   • Hold the device with your thumb and middle finger, keeping your index finger free
   • Insert the needle at a 90° angle into the deltoid, using a short, quick motion
   • Hold light pressure on the skin and push the plunger with your index finger.
   • Remove the needle from the skin in a quick motion. Direct the needle away from you and other people and push the plunger with your thumb to activate the needle shield until you hear a click. Throw it away in a sharps container.
7. Give FluMist intranasally. FluMist, the live attenuated flu vaccine, cannot be injected. Remove the rubber tip protector. Place the tip inside your patient’s nostril while they’re in an upright position. Tell them to breathe normally. Push the plunger as quickly as possible in a single motion – the dose-divider clip will stop you halfway. Pinch the dose-divider clip and remove it, then repeat the procedure in the other nostril.
8. Keep accurate patient records. Record the date, dose, and injection site any time you give a vaccine. Do this in your EMR (Electronic Medical Records) or paper records, as advised by your administrator. Enter the data into an immunization information system if one is used in your setting.
   • In the pediatric population, provide a vaccination schedule for the parents indicating which are completed and which are next.
   • A Vaccine Information Statement (VIS) contains information about the benefits and risks of each vaccine. If possible, give your patients and patients’ parents a copy of a VIS with each vaccination.

Applying Safe Vaccination Procedures

1. Check and prepare the vaccine you’re about to give. Check and re-check the vial label of the vaccine you’re about to give. Check the expiration date – throw it away if it's expired and use a new one. Before using a vaccine, check the labeling to see if it requires specific handling, for instance shaking the vaccine vial and/or using the reconstituting mix (diluent).
   • If you’re administering more than one vaccine, draw them up, label them appropriately, and re-check the labeling.
   • Use the “Rights” checklist: Right patient, right vaccine and diluent (when applicable), right time (right patient age, time interval, vaccine isn’t expired), right dosage, right route/needle, right site, right documentation.
2. Wash your hands. Wash your hands thoroughly with warm water and soap. Lather the soap for at least 30 seconds and scrub under your nails, between your fingers, and up your wrists. Dry your hands with a clean paper towel.
   • Put on disposable gloves to administer the injection. Make sure your patient doesn’t have a latex allergy; if so, use non-latex gloves.
3. Use an alcohol wipe on the injection site. Choose and locate the right injection site. Open a new, sterile alcohol wipe. Rub the site in a circular motion starting in the center and extending out 2-3 inches. Let the alcohol dry.
   • If giving more than one vaccine, use a separate injection site for each one.
4. Administer the shot using smooth, firm motions. Stabilize the arm or leg that will receive the injection with your non-dominant hand. Using the appropriate IM or Subcut needle, hold the needle about an inch from your patient. Insert it quickly at the appropriate angle. Push down on the plunger with steady pressure to inject the vaccine. Remove the needle at the same angle you inserted it.
   • Dispose of the needle in a sharps container.
5. Wipe and bandage the area. Apply gentle pressure to the area immediately after removing the needle. Cover this with a small piece of gauze and hold it in place with medical tape. Tell your patient they can remove the bandage later that day.

Talking to Patients and Providing Aftercare

1. Answer your patients’ questions and alleviate their fears. Many patients, especially parents thinking about vaccinating their child, are nervous about vaccines. They may think that vaccines can make their child ill or cause autism. Address these questions calmly and directly:
   • Ask outright, “Do you have any fears or concerns about vaccines that we can discuss?”
   • Offer a lead-in to the conversation like, “I know some parents worry that vaccines can cause autism or health problems. If you have those concerns, I’d like to discuss them until you understand and feel comfortable.”
   • Don’t get outwardly frustrated or talk down to your patients.
2. Use language your patient understands. Be direct and honest in your discussions but remember that your patient probably isn't medically trained. Use language to explain and answer questions that the average person will understand.
   • Avoid terminology like, “MMR is a live attenuated vaccine in which the virulence of the pathogen is reduced.” Instead, say something like, “The measles vaccine uses a weak form of the virus. It’s strong enough to get your body to made defenses to it, but not strong enough to make you sick.”
3. Explain common side effects of vaccines to your patient. Immunizations can cause minor reactions like soreness, swelling, and redness at the injection site, and a low fever. Notify your patient that this is not dangerous or uncommon, and it is not a sign that the vaccine is making them or their child sick. Explain that it is their immune system making the defenses it needs.
4. Provide medical management options for common reactions. If your patient complains of swelling, redness, pain, itching, or mild bleeding at the injection site, let them know this is normal. Then take steps to make them feel more comfortable:
   • For pain, redness, swelling, or itching, apply a cold compress to the area. Give them a mild pain reliever like ibuprofen.
   • If the injection site is bleeding, apply a bandage over the area. If it continues to bleed, place a thick gauze pad over the site and tell your patient to apply constant pressure.
   • Raise their arm above the level of their heart for several minutes to slow bleeding.
5. Manage fear and fainting calmly. If your patient expresses fear or anxiety about getting the shot, or complains of blurred vision, dizziness, or lightheadedness, they may pass out. Try to avoid this by having your patient lie down for the vaccination, sit with their head between their knees for several minutes, and apply a cool damp cloth to their face and neck. Be patient and wait until they're ready to give the vaccine.
   • If your patient falls or passes out, check for injury before moving them. Then place them on their back with their feet elevated. Call for emergency services if they do not recover within a few minutes. Be comforting and offer them juice or candy to help raise their blood sugar, which can help them feel better more quickly.
6. Tell your patients what danger signs to watch out for. Rarely, a patient may experience a severe allergic reaction to a vaccine called anaphylaxis. Watch out for the following signs, and alert your patient or a second party to do the same and seek medical care if they arise:
   • Starting to itch all over
   • Sudden or severe skin redness or hives
   • Swelling of the lips, face, tongue, or throat
   • Wheezing or shortness of breath
   • Abdominal cramps
   • Drop in blood pressure and possible loss of consciousness
7. Give epinephrine for severe reactions. Unless the redness and itching is localized only to the area of the injection, the best treatment is to give epinephrine. If you are a trained healthcare provider, administer aqueous epinephrine 1:1000 dilution (1mg/ml) IM. If you are not a trained professional or do not have epinephrine available, call emergency services right away. Give them Benadryl while waiting for help to arrive, if they are conscious and can swallow.
   • Use the patient’s EpiPen if they have one.

Tips

• If giving more than one vaccine, use separate injection sites. If using the same limb, choose sites at least 1-2 inches apart so you can monitor for reactions.
• Have an emergency kit available that contains epinephrine in case the patient has a severe reaction.

Warnings

• Do not mix multiple vaccines in the same syringe.

Sources and Citations

See also

• Treat Farmer's Lung
• Give the Measles, Mumps, and Rubella (MMR) Vaccine
• Diagnose Farmer's Lung
• Live With an Allergy to Aspirin
• Reduce Your Exposure to Pollen
• Recognize Peanut Allergies
• Know When to Take Antihistamines
• Get Your Nose to Stop Running With Allergies
• Get Tested for Food Allergies
• Fight Hay Fever

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