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Home , Injection (medicine), Intramuscular injection

Copyright EMAP Publishing 2018 This article is not for distribution except for journal club use

Clinical Practice Keywords Intramuscular / administration/ Practical procedures This article has been Injection technique double-blind peer reviewed Injection technique 1: administering via the intramuscular route

rugs administered by the intra- concerns that nurses are still performing Author Eileen Shepherd is clinical editor muscular (IM) route are depos- outdated and ritualistic practice relating to at Nursing Times. ited into vascular muscle site selection, aspirating back on the Dtissue, which allows for rapid (Greenway, 2014) and skin cleansing. Abstract The intramuscular route allows absorption into the circulation (Dough- for rapid absorption of drugs into the erty and Lister, 2015; Ogston-Tuck, 2014). Site selection circulation. Using the correct injection Complications of poorly performed IM Four muscle sites are recommended for IM technique and selecting the correct site injection include: administration: will minimise the risk of complications. l  – strategies to reduce this are l Vastus lateris; outlined in Box 1; l Rectus femoris Citation Shepherd E (2018) Injection l Bleeding; l Deltoid; technique 1: administering drugs via l  formation; l Ventrogluteal (Fig 1, Table 1). the intramuscular route. Nursing Times l Cellulitis; Traditionally the dorsogluteal (DG) [online]; 114: 8, 23-25. l Muscle fibrosis; muscle was used for IM injections but this l Injuries to and blood vessels muscle is in close proximity to a major (Small, 2004); and nerves, with sciatic l Inadvertent intravenous (IV) access. injury a recognised complication (Small, These complications can be avoided if 2004). In addition, absorption from the site for injection is accurately identi- the DG muscle may be slower than other fied and a skilled evidence-based tech- sites and this can lead to a build-up of nique is used (Greenway, 2014). drugs in the tissues and risk of overdose (Malkin, 2008). Many patients find the use Evidence base of the DG site intrusive and are reluctant to The procedure for IM injection has been dis- undress to give access to the relevant area. cussed widely in the literature but there are For these reasons, the DG muscle is no

Fig 1. Sites for

Deltoid Vastus lateralis and rectus femoris

Greater trochanter of femur

Scapula Rectus femoris Deep brachial Box 1. How to reduce pain artery Vastus caused by injection technique lateralis Radial nerve l Use the correct technique Vastus Humerus l Rotate injection site to prevent medialis indurations or l Explain the benefits of the injection Dorsogluteal (NOT RECOMMENDED) Ventrogluteal to the patient Posterior l Position the patient so the muscles superior iliac Iliac crest spine are relaxed Anterior superior l Use distraction Gluteus medius iliac spine l Insert and remove the needle Gluteus Gluteus medius smoothly and quickly maximus l Hold the syringe steady during the Greater Greater procedure trochanter of trochanter of femur l Inject slowly but smoothly femur Source: Dougherty and Lister (2015) PETER LAMB PETER

Nursing Times [online] August 2018 / Vol 114 Issue 8 23 www.nursingtimes.net Copyright EMAP Publishing 2018 This article is not for distribution except for journal club use Clinical Practice For more Practical procedures articles, go to Practical procedures nursingtimes.net/procedures longer recommended for IM injections – in Table 1. from the ampoule. Some are spite of this, many nurses continue to use Injectable volumes available in pre-filled and manu- it (Ogston-Tuck,2014; Walsh and Brophy, per site in adults facturer’s instructions should be followed. 2011; Malkin, 2008). Site Maximum volume 7. Disperse air bubbles from the syringe. Ventrogluteal 2.5ml Needles (recommended) Safety needles should be used for IM injec- 8. Change the needle. Doing so will ensure tions to reduce the risk of needle-stick Vastus lateralis 5ml that the needle used for the injection is injury (Health and Safety Executive, 2013). (recommended) sharp, thereby reducing pain (Agac and Needle size is measured in gauges Deltoid 1ml Günes, 2011). A safety-engineered needle (diameter of the needle). A 21G is com- should be used as this reduces the risk of Rectus femoris 5ml monly used but selection depends on the sharps injury. viscosity of the being injected Dorsogluteal 4ml (Dougherty and Lister, 2015). (not recommended) 9. Dispose of the used needle in a sharps England (2013) recommends 23G or 25G container according to local policy. Source: Adapted from Dougherty and Lister needle for IM . (2015) Needles need to be long enough to 10. Place the filled syringe in a tray and take ensure the drug is injected into the muscle; it to the patient, along with a sharps bin so length depends on: important to aspirate if the DG muscle site the used sharps can be disposed of immedi- l Muscle mass; is used – because of proximity to the gluteal ately after the procedure. l Patient’s weight; artery – it is not required for other IM injec- l Amount of subcutaneous fat. tion sites (PHE, 2013; Malkin, 2008). 11. Check the patient’s identity, according Women have more subcutaneous fat to local medicines management policy. than men (Zaybak et al, 2007) and consid- Gloves eration needs to be given to using longer The World Health Organization (2010, 2009) 12. Position the patient comfortably with needles for patients who are obese. PHE states that gloves need not be worn for this the injection site exposed (Fig 1). The site is (2013) recommends that a 25mm or 38mm procedure if the health worker’s and influenced by the assessment of the patient, needle is used in adults. patient’s skin are intact. It also notes that the drug and the volume to be injected Traditionally nurses have been taught to gloves do not protect against needle-stick (Table 1) (Dougherty and Lister, 2015). leave a few millimetres between the skin and injury. Nurses need to risk assess individual the hub of the needle in case the needle patients (Royal College of Nursing, 2018) 13. Check the site for signs of oedema, breaks off during the injection. This practice and be aware of local policies for glove use. or skin lesions. If any of these are is not evidence based, may cause medication present, select a different site. to be delivered into the subcutaneous fat Procedure layer and, with modern single-use needles, Equipment: 14. Wash and dry hands. is no longer necessary (Greenway, 2014). l Needles – one of which should be a safety-engineered device; 15. If gloves are considered necessary, Skin preparation l Syringe; following the risk assessment, these There is some debate about using - l Drug for administration; should be applied. impregnated swabs to clean injection sites. l Medicines administration chart/ PHE (2013) suggests that, if a patient is phys- prescription; 16. Ensure the skin is clean and follow local ically clean and generally in good health, l Receiver or tray to carry the drug; policy on skin cleansing. swabbing the skin is not required. l Sharps container. In older or immunocompromised 17. If skin cleansing is considered neces- patients, skin preparation using an alcohol- 1. Explain the procedure and gain consent. sary, swab for 30 seconds with isopropyl impregnated swab may be recommended alcohol and allow to dry for 30 seconds (70% isopropyl alcohol) (Dougherty and 2. Screen the patient to ensure privacy (Dougherty and Lister, 2015). Lister, 2015). Follow local policy. during the procedure. 18. Inform the patient you are going to Aspiration 3. Before drug administration, check carry out the procedure. Use distraction It is common practice to draw back on a whether the patient has any allergies. and relaxation techniques to reduce pain if syringe after the needle is inserted to check needed (Box 1). whether it is in a blood vessel. While it is 4. Check the prescription is correct, fol- lowing the ‘five rights’ of drug administra- Box 2. Five rights of Professional responsibilities tion (Box 2) and local medicines adminis- medicines administration tration policy to reduce the risk of error. This procedure should be undertaken l Right patient only after approved training, supervised 5. Wash and dry hands to reduce the risk of l Right drug practice and competency assessment, infection. l Right time and carried out in accordance with local l Right policies and protocols. 6. Assemble the syringe and needle, and l Right route withdraw the required amount of drug

Nursing Times [online] August 2018 / Vol 114 Issue 8 24 www.nursingtimes.net Copyright EMAP Publishing 2018 This article is not for distribution except for journal club use Clinical Practice Practical procedures

Fig 2. Z-track technique

(a) The skin to be pulled down by (b) The drug is administered (c) The skin is allowed to return to its 2a. Pull about the 2.5cm skin byand about held during 2.5-3.75cm the 2b. While holding the skin, adminster 2c.normal Allow position the skin trapping to return the to drug its in (Malkin,injection 2008) to displace the the injection thenormal muscle position, trapping the drug underlying tissue in the muscle

19. Hold the syringe and needle in your 23. Depress the plunger slowly at a rate of the prescribed medicine and any problems dominant hand and gently stretch the skin 1ml/10 seconds; this aids absorption of the with the injection site. NT around the injection site using the non- drug and reduces pain (Dougherty and dominant hand. This displaces the subcu- Lister, 2015). References Ağaç E, Güneş UY (2011) Effect on pain of changing taneous tissue and aids needle entry the needle prior to administering medicines (Dougherty and Lister, 2015). 24. Wait for 10 seconds to allow the drug to intramuscularly: a randomized controlled trial. diffuse into the tissue and then quickly Journal of Advanced Nursing; 67: 3, 563-568. 20. A Z-track technique can be used to pre- withdraw the needle (Dougherty and Dougherty L, Lister S (2015) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. vent backtracking and leakage from the Lister, 2015). Oxford: Wiley-Blackwell. injection site (Fig 2). Greenway K (2014) Rituals in nursing: 25. Dispose of the sharps directly into the intramuscular injection. Journal of Clinical Nursing; 23: 23-24, 3583-3588. 21. Insert the needle at a 90-degree angle sharps bin and the syringe according to Health and Safety Executive (2013) Health and using a dart-like action. This prevents local policy. Safety (Sharp Instruments in Healthcare) accidental depression of the plunger Regulations 2013: Guidance for Employers and during insertion of the needle (Malkin, 26. Ensure the patient is comfortable and Employees. hse.gov.uk/pubns/hsis7.htm Malkin B (2008) Are techniques used for 2008) (Fig 3). wash your hands. intramuscular injection based on research evidence? Nursing Times; 104: 50/51, 48-51. 22. Aspiration to check whether the 27. Record administration on the prescrip- Ogston-Tuck S (2014) Intramuscular injection needle is in a blood vessel is not usually tion chart, as well as the administration technique: an evidence-based approach. Nursing Standard; 29: 4, 52-59. necessary (PHE, 2013). Aspiration is only site as repeated injections into the same Public Health England (2013) Immunisation required when the DG site is used, which site can lead to induration and abscesses. Procedures: The Green Book, Chapter 4. Bit.ly/ is not recommended (Greenway, 2014; GreenBookCh4 Royal College of Nursing (2018) Tools of the Trade: Malkin, 2008). 28. Monitor the patient for any effects of Guidance for Health Care Staff on Glove Use and the Prevention of Contact . Bit.ly/RCNGloves Small SP (2004) Preventing sciatic nerve injury Fig 3. The needle should be inserted at 90 degrees and from intramuscular injections: literature review. penetrate the muscle layer Journal of Advanced Nursing; 47: 3, 287-296. Walsh L, Brophy K (2011) Staff nurses’ sites of choice for administering intramuscular injection to adult patients in the acute care setting. Journal of Advanced Nursing; 67: 5, 1034-1040. Skin World Health Organization (2010) WHO Best Practices for Injections and Related Procedures Muscle Toolkit. Bit.ly/WHOinjection2010 World Health Organization (2009) WHO Guidelines on Hand Hygiene in Health Care. Bit.ly/WHOHands2009 Zaybak A et al (2007) Does obesity prevent the needle from reaching muscle in intramuscular injections? Journal of Advanced Nursing; 58: 6, 552-556.

CLINICAL SERIES Injection technique series

Part 1: Intramuscular route Aug Part 2: Subcutaneous route Sep PETER LAMB PETER

Nursing Times [online] August 2018 / Vol 114 Issue 8 25 www.nursingtimes.net