Key Takeaways
- Ventrogluteal is the preferred IM injection site for adults
- Do not aspirate for heparin or insulin subcutaneous injections
- Infiltration presents as cool, pale, swollen IV site; phlebitis presents as warm, red, tender
- Never crush enteric-coated, extended-release, or sublingual medications
- IV complications require immediate intervention—know the signs and appropriate responses
Routes of Administration
Understanding different medication routes is essential for safe and effective drug delivery. Each route has specific advantages, disadvantages, and nursing considerations within the LPN/VN scope of practice.
Oral Route (PO)
Most common route—convenient, economical, and generally safe.
| Advantages | Disadvantages |
|---|---|
| Non-invasive | Slower onset |
| Convenient | Variable absorption |
| Economical | Affected by GI function |
| Self-administration possible | First-pass metabolism |
Nursing Considerations:
- Assess swallowing ability before administration
- Follow instructions for timing with food
- Do not crush enteric-coated or extended-release medications
- Provide adequate fluids (120-240 mL) unless fluid restricted
- For sublingual medications: place under tongue, no water until dissolved
Parenteral Routes
Parenteral medications bypass the GI tract and are administered by injection.
Subcutaneous (SUBQ)
Injection into fatty tissue beneath the dermis
| Site | Maximum Volume | Needle Size |
|---|---|---|
| Outer upper arm | 1 mL | 25-27 gauge, 3/8-5/8 inch |
| Anterior thigh | 1 mL | 25-27 gauge, 3/8-5/8 inch |
| Abdomen (2 inches from umbilicus) | 1 mL | 25-27 gauge, 3/8-5/8 inch |
Technique:
- Pinch skin for thin patients; do not pinch for average/obese
- Insert at 45-90 degree angle depending on tissue depth
- Do NOT aspirate for heparin or insulin
- Rotate injection sites
Intramuscular (IM)
Injection into muscle tissue for faster absorption
| Site | Maximum Volume | Needle Size | Landmark |
|---|---|---|---|
| Ventrogluteal (preferred) | 3 mL | 22-25 gauge, 1-1.5 inch | Iliac crest, greater trochanter |
| Vastus Lateralis | 3 mL | 22-25 gauge, 1-1.5 inch | Outer middle third of thigh |
| Deltoid | 1 mL | 23-25 gauge, 5/8-1 inch | 2-3 finger widths below acromion |
| Dorsogluteal (least preferred) | 3 mL | 21-23 gauge, 1.5-2 inch | Upper outer quadrant |
Technique:
- Use Z-track for irritating medications
- Spread skin taut
- Insert at 90-degree angle
- Aspirate except for immunizations (CDC guidelines)
- Inject slowly (10 seconds per mL)
Intradermal (ID)
Injection into dermis, just below epidermis
- Used for TB skin test (Mantoux), allergy testing
- Volume: 0.1-0.5 mL
- Needle: 26-27 gauge, 3/8 inch
- Site: Inner forearm or upper back
- Angle: 5-15 degrees, bevel up
- Should form a small bleb (wheal)
Intravenous (IV) Route
Fastest onset; medication enters bloodstream directly
LPN/VN IV Responsibilities (varies by state):
- Monitoring IV infusions
- Adding medications to existing IV (some states)
- IV push medications (additional training required in most states)
- Discontinuing peripheral IVs
- Site assessment and documentation
IV Complications:
| Complication | Signs/Symptoms | Intervention |
|---|---|---|
| Infiltration | Cool, pale, swollen, painful site | Stop infusion, elevate, apply warm compress |
| Extravasation | Same as infiltration + tissue damage | Stop immediately, antidote if available, notify MD |
| Phlebitis | Red, warm, tender, swollen along vein | Stop infusion, apply warm compress, may need new site |
| Infection | Erythema, drainage, fever | Stop infusion, culture site, notify MD |
| Air Embolism | Sudden dyspnea, chest pain, hypotension | Clamp line, left Trendelenburg position, O2, call for help |
| Fluid Overload | Crackles, JVD, edema, dyspnea | Slow rate, elevate HOB, O2, notify MD |
Topical Routes
| Route | Examples | Nursing Considerations |
|---|---|---|
| Transdermal | Patches (nitroglycerin, fentanyl) | Rotate sites, wear gloves, remove old patch first |
| Ophthalmic | Eye drops, ointments | Pull lower lid down, apply to conjunctival sac |
| Otic | Ear drops | Warm to body temp; adults: pull pinna up and back |
| Nasal | Sprays, drops | Have patient blow nose first, insert tip slightly |
| Inhaled | MDI, nebulizer, DPI | Teach proper technique, spacer use, rinse mouth after steroids |
| Rectal | Suppositories, enemas | Left Sims' position, insert beyond sphincter |
| Vaginal | Suppositories, creams | Lithotomy position, provide privacy |
Medication Administration Techniques
Crushing Medications:
- NEVER crush: enteric-coated, extended-release, sublingual, buccal
- Check reference if unsure
- Crush separately to avoid interactions
- Mix with small amount of soft food if approved
Giving Medications via Feeding Tube:
- Verify tube placement first
- Use liquid forms when available
- Flush with 30 mL water before and after
- Give each medication separately with flushes between
- Check for drug-food interactions
Which intramuscular injection site is preferred for adults?
An LPN/VN observes that an IV site is cool, pale, and swollen. The patient reports discomfort at the site. What is the most likely complication?
When administering a subcutaneous injection of heparin, what should the LPN/VN do?