Vaccine Administration Guidelines

This article covers vaccine administration guidelines such as what you need to do in preparation, how to properly administer the vaccines, and what education to give to your patients and their caregivers.

Obtain Health History

You always want to review a patient’s health history prior to administering immunizations to check for any reactions to previous vaccines or current health conditions which might contraindicate certain immunizations. For example, an MMR vaccination is not recommended for patients with a history of anaphylactic reaction to eggs or neomycin.

Follow Manufacturer's Guidelines

You want to follow the vaccine manufacturer’s guidelines regarding reconstitution, storage, and administration. Be sure to check expiration dates prior to administration. If the vaccine needs to be refrigerated, then do not store it in the door—you want to store it on a central shelf where temperature changes will not decrease the vaccine’s potency.

Consent & Documentation

Informed consent needs to be obtained before vaccine administration. You should also provide a vaccine information document to the patient. For documentation, you will need to record the date, manufacturer & lot number of vaccine, your name & credentials, and the site & route of the vaccine.

Education & Interventions

Educate the patient and primary caregivers regarding reactions to the vaccine. Erythema, tenderness, edema at the injection site for 48-72 hours can be normal side effects. Low-grade fever up to 102°F, drowsiness, irritability, and decreased appetite are also common side effects.

Education you can provide to parents includes “bicycling” the baby’s legs every so often to decrease soreness. They can give Tylenol (acetaminophen) every 4 to 6 hours. Parents can also administer Motrin (ibuprofen) every 6 hours if the baby is at least 6 months old. Advise them to call their health care provider if the patient has a high fever or if high-pitched crying occurs. They should call 911 if seizures or an anaphylactic reaction occurs.

Cold compresses may be applied to painful, inflamed injection sites during the first 24 hours after the vaccine. Both cold and warm compresses may be applied after the first 24 hours.

Contraindications

Live attenuated vaccines, including but not limited to, varicella, MMR (measles mumps rubella), and zoster are contraindicated in immunocompromised patients or if the patient lives with an immunocompromised individual. Advise patients that the common cold is NOT a contraindication for immunizations.

Parenteral Vaccines

Parenteral vaccines should be administered in separate syringes, appropriate needle sizes, and into different injection sites. Proper needle size and injection sites help to minimize local side effects.

IM, or intramuscular, vaccines should be administered in the vastus lateralis or ventrogluteal muscles. The dorsogluteal site (buttocks) is not recommended. The deltoid muscle can also be used for IM injections if the patient is at least 3 years old. IM needles need to be between 22-25 gauge and at least 1 inch long as to reach the muscle and not erroneously inject the vaccine into subcutaneous tissue. IM injections should also be given at a 90° angle.

Subcutaneous (SC) vaccines can be properly administered in the lateral upper arms, abdomen outside of two-inch area surrounding the umbilicus, and anterior thighs. The needle should be 23-25 gauge and 5/8 inch in length. Administer SC vaccines at a 45° angle.

References

Silvestri, L. (2014). Saunders Comprehensive Review for the NCLEX-RN® Examination 6th edition. St. Louis, Missouri: Saunders.

Upchurch, S. L., Henry, T., Pine, R., & Rickles, A. (2014). HESI Comprehensive Review for the NCLEX-RN Examination 4th edition. St. Louis, Missouri: Elsevier.