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Part 3: Injections

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PPD PLACEMENT

PPD = 25 gauge needle in the skin (intradermal). 18 gauge needle to load the vial (larger needles needed to penetrate the rubber stopper). 1cc vial (0.1 cc incremental markings on the side).

1) Review In Basket Orders folder on left-hand side of screen for messages of laboratory orders that have already been signed by the attending.

2) Prepare and perform the PPD; MAKE SURE YOU HOLD ON TO THE VIAL AND THE BOX! The LOT # and manufacturer is printed on the vial and box and you will need to document them.

3) Send a staff message through your In Basket by clicking on New Message, then clicking on the To: button and type in “IMA Firm A” in the Pools section. Select “IMA Firm A Nurse Pool” and then click on the Add ‘To’ button. Repeat this same process for IMA Firms B, C, and D. (Send this email to all 4 pools). Notify them in the message that you are from EHHOP and you have just planted a PPD in the patient’s arm; note in which arm the PPD was placed, and inform them that they should expect the patient to follow-up at IMA on Monday/Tuesday to have the test read.

Regular staff message

Add nurse pools

4) Document the shot in the patient’s chart in EPIC

ALL OTHER Immunizations/Injections

Tdap, Hep A, Hep B: Given as IM injections. Some come in prefilled syringes, while others come in single use vials that require you to load the syringe.

In general, IM injections need a 23-25 gauge, 1 inch needle – depending on the weight of your patient (use 1.5 inch as specified depending on BMI)**

Flu Shot:

If age 65+ yrs:

If age 6 mo to 64 yrs:

MMR Vaccine: Comes in two parts as a powder and a sterile solution. It must be reconstituted in the sterile solution before injecting. Usually, in the fridge you will find a box of the sterile solution (it does not have to match the lot number). You must use a syringe to transfer the sterile solution from the vial (single use) to the vaccine (single use). Mix the vaccine until the solution is clear, yellow in color. This vaccine must be injected SUBCUTANEOUSLY. Usually the easiest site is the biceps, using a 30 degree angle (to avoid the muscle and not give the injection intradermally). ASK THE ATTENDING, if you have questions!

Zoster vaccine: EHHOP does NOT have permission to use IMA Zostavax vaccines due to prohibitive costs. If vaccine is necessary, please consult with Chief TS and Dr. Meah directly after clinic.

Gardasil vaccine: As of 7/2013, this 3-part vaccination is now available for EHHOP patients through IMA. They are recommended from ages 9-26 for males and females. The schedule is 0, 1, and 6 months.

Consult the CDC website for more specific questions!

DOCUMENTATION PROTOCOL:

1) Review In Basket Orders folder on left-hand side of screen for messages of laboratory orders that have already been signed by the attending.

2) Prepare and perform the immunization/injection. MAKE SURE YOU HOLD ON TO THE VIAL AND THE BOX!!!

3) Document the shot in the patient’s chart in Epic

4) Once all labs are complete, select the messages corresponding to the immunization(s)/injection(s) and click Done to remove those messages from the In Basket.

IF you forgot to document an immunization or notice that patient received a vaccine but it was never documented (this happens when the “Administer vaccine” order is not placed along with the actual vaccine itself), you can still document that it was given. To do so, click on Snapshot –> Immunizations –> Historical Admins –> Select Adult Immunization Log from the drop down menu –> Enter the information into the appropriate columns.

Confirm your addition by clicking Accept. Now click on the individual vaccine (blue link) and you should see the new result you placed. You should only do this if you know the lot number and site of injection for the patient. You may now edit the result by clicking on each vaccine administration date.