Influenza Vaccination Procedure

Clinical Procedure for Administering Flu Shots


Store vials at 35-46 degrees F. Do not freeze.

For transport/temporary storage, you may pack vials of vaccine in their boxes in a cooler with cool packs. Be sure to place a barrier between boxes and cold packs.


Shake vial before withdrawing each dose. If in pre-filled syringe, shake syringe to re-suspend. It is preferable to draw up vaccine immediately before administering but if pre-loading is done, vaccine should not be drawn up more than 30 minutes prior to administration and should be labeled.


  • All preparations of 2009 Fluzone are latex-free. Use latex-free syringes and gloves so latex allergy is not a contraindication.
  • Gloves are not necessary when administering intramuscular injections since bleeding is not anticipated.  If a blood spill occurs, wipe spill with alcohol solution and wash and sanitize hands.
  • Hands must be cleansed with alcohol skin sanitizer between patients. If hands become visibly soiled, soap and water must be used
  • Clean deltoid site with alcohol. Non dominant arm is preferred in case of local tenderness/swelling.
  • Flu vaccine is administered intramuscularly into the deltoid muscle. Use a 22-25 g needle at least one inch in length to ensure penetration into muscle, not subcutaneous tissue. In obese individuals, use 1.5" needle.
  • If an individual is taking blood thinning agents, care must be taken to apply pressure to the site after IM administration to prevent bleeding.

Contraindications and Precautions

  • History of Guillain-Barre.  Not an absolute contraindication but individual should be aware that GB has been associated with a previous flu vaccine.  Past history of GB may increase risk of recurrent GB.  If GB is a concern, do not give the flu shot unless the individual has discussed this with his/her primary care physician.
  • History of "bad reaction." This depends on the reaction. If anaphylaxis or life threatening reaction, defer vaccination. If local reaction or lethargy/myalgias, can receive.
  • Egg/chicken allergy. Gastrointestinal intolerance or "allergy to egg but I can eat eggs when cooked," ok to give. If history of hives or respiratory symptoms after ingesting eggs or chicken, defer vaccination.
  • Sick with fever. There are 2 reasons to defer. First, the person will blame the shot on continuing symptoms of whatever illness they have. Second, may not have adequate antibody response to vaccine. If significantly ill with cough or fever, would defer. May return when well. If slight "sniffles" may give vaccine.
  • Medications that thin blood (except aspirin): not a contraindication but need to apply pressure after injection.  May alter the INR in patients taking warfarin.
  • Insert says nothing about thimerosol allergy. Risk is very low. Only the single dose syringes do not contain thimerosol and those are reserved for pregnant individuals and children.

Assessment/management of vaccine reactions in adult patients:


  • Soreness, itching or swelling at injection site. Apply cold compress to site.
  • Slight bleeding: Apply compressive bandage. If bleeding continues, apply direct and firm pressure and observe.
  • Near syncope (usually vagal reaction): Lay patient down with feet elevated. Assess airway, blood pressure/pulse and consciousness.

Syncope: Check for neck or head injury before moving patient. Lie supine with feet elevated. Assess breathing, blood pressure and pulse. If consciousness not immediately regained, call 911.

Anaphylaxis: Generalized itching or hives, angioedema (swelling of lips, face or tongue), wheezing, shortness of breath, hypotension, faintness.

  • Call for physician backup if in immediate area or 911.
  • Protect airway.
  • Administer 0.3-0.5 cc of 1:1000 dilution of aqueous epinephrine IM (IM is preferable to SQ) ( Epi Pen gives 0.3 cc)
  • Administer diphenydramine 50-100 mg orally or 50-100 mg IM
  • Monitor patient; assess vital signs and consciousness every 5 minutes. Call 911 if vital signs deteriorate or patient loses consciousness. Begin CPR as appropriate.
  • May repeat epinephrine dose after 10 minutes for up to 3 doses.

Supplies for Emergency Kit:

  • Aqueous epinephrine 1:1000 in ampules or an EpiPen. If EpiPen, must have 3 adult EpiPens in kit.
  • Diphenhydramine injectable (50 mg/ml) or oral tablets (25-50 mg)
  • Syringes for IM administration of epinephrine and diphenhydramine
  • Adult airways
  • BP cuff
  • Stethoscope
  • Ventilation mask with one-way valve
  • Flashlight for evaluating mouth and throat
  • Tongue depressors