Copyright EMAP Publishing 2018 This article is not for distribution except for journal club use Clinical Practice Keywords Intramuscular injection/ Medicine administration/Absorption Practical procedures This article has been Injection technique double-blind peer reviewed Injection technique 1: administering drugs 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concerns that nurses are still performing Author Eileen Shepherd is clinical editor muscular (IM) route are depos- outdated and ritualistic practice relating to at Nursing Times.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 syringe 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 Pain – 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 Abscess 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 nerves and blood vessels muscle is in close proximity to a major (Small, 2004); blood vessel and nerves, with sciatic nerve l Inadvertent intravenous (IV) access. injury a recognised complication (Small, These complications can be avoided if 2004). In addition, drug 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 intramuscular injection Deltoid Vastus lateralis and rectus femoris Greater trochanter Deltoid muscle 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 abscesses 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 medication slowly but smoothly femur Sciatic nerve Source: Dougherty and Lister (2015) PETER LAMB 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 medicines are spite of this, many nurses continue to use Injectable volumes available in pre-filled syringes 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 liquid being injected Dorsogluteal 4ml (Dougherty and Lister, 2015). Public Health (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 vaccines. (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. infection 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 alcohol- 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 dose 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. Pullabout 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).