Steps

Rationale/Points of Emphasis

1 If needed, review vaccine information with the family and answer questions regarding the immunizations to be given. Provide the following information to the family: purpose of the vaccination, its route of administration, care of the child after administration, and possible side effects.

Assists family in understanding the benefits and possible side effects of vaccines.

Prepares family to assist with vaccine administration and to comfort child.

Giving discharge instructions before administration of vaccine allows the family member to dedicate his or her attention to comforting the child afterward.

caREminder

Redness and tenderness at the site of injection, crankiness, and a low-grade fever are the most common side effects of vaccine delivery.

2 Encourage the family member to comfort child during and after immunization administration.

Ensures family member has active positive role in the child’s healthcare.

3 Institute age-appropriate pain and distress relief measures e.g., sweet tasting solutions/breastfeeding, sucking, topical anesthetic according to manufacturer’s instructions, breathing exercises, distraction, combined cognitive-behavioral interventions, have a child sit-up, have a parent hold an infant, stroke the skin or apply pressure close to the injection site before and during injection, perform a rapid intramuscular injection without aspiration (see Chapter 7 ).

Pain management measures reduce distress and trauma for the child.

4 Perform hand hygiene.

Reduces transmission of microorganisms.

5 Gather and prepare all needed supplies (e.g., draw up and label vaccine, open adhesive bandage) before entering the child’s room. See Chapter 6 for principles of pharmacologic management.

Labeling the vaccine ensures correct vaccine given by the correct route, particularly when multiple vaccines are administered. Preparing ahead of time ensures that the nurse can administer the vaccination quickly after entering room, which, in turn, can decrease child and family anxiety.

6 Don gloves and administer vaccines via route indicated on immunization schedule; follow procedures as outlined in Chapters 62 and 71 .

Standard precaution to reduce transmission of microorganisms. Vaccine must be administered via indicated route to elicit immune response.

caREminder

IPV, MMR, and Varivax vaccines are given subcutaneously. Hepatitis, HIB, DTaP, Tdap, influenza, pneumococcal conjugate meningococcal, and HPV vaccines are given intramuscularly.

7 If the child requires multiple injections, administer the injections in different extremities. If multiple injections must be given in the same extremity, leave at least 1 inch between the injection sites. Attempt to give the injections that have the greatest chance of local irritation (e.g., pneumococcal conjugate) in an extremity without another injection.

Allows for optimal absorption of vaccine and decreases irritation at sites of injection and overlapping local reactions.

As with any medication, rare severe systemic reactions such as anaphylaxis or generalized urticaria are possible. Because of the potential for anaphylaxis with the administration of a vaccine, any child receiving a vaccine should be observed for several minutes after the vaccine is given for signs of immediate allergic or anaphylactic reaction.

8 Apply adhesive bandages to immunization sites as needed. Evaluate necessity of adhesive bandage use in young children as it may present a choking hazard.

Aids in stopping bleeding and provides comfort measure for child.

9 Dispose of equipment and waste in appropriate receptacles.

Standard precautions.

10 Provide family with information about time frame for child’s next scheduled immunizations.

Reinforces immunization schedule to improve compliance.