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Dec.19.2019View related content

Medication Administration: Intramuscular Injection (Pediatric) - CE

ALERT

Give intramuscular (IM) injections in children only when the benefits outweigh the pain of injection.

Take steps to eliminate interruptions and distractions during medication preparation.

At the completion of the procedure, ensure all choking hazards (e.g., syringe caps, port caps, adhesive bandages, bits of tape) are removed from the infant’s, toddler’s, and preschool-age child’s bed.

OVERVIEW

The purpose of IM injections is to administer medication safely into the muscle below the subcutaneous layer. Many medications must be injected intramuscularly because of chemical properties, pharmacokinetics, desired onset, intensity and duration of the effect, and certain patient characteristics related to treatment compliance. An IM injection should be given only when less painful options are not feasible.

The injection site affects how much fluid can be given and how quickly the medication will be absorbed. The most appropriate sites for IM injections are the vastus lateralis (anterolateral thigh) for infants and toddlers and the deltoid muscle for children 3 years old or older.5 Selection of the injection site is based on the child’s age, muscle mass, medication volume, and medication viscosity.

Local anesthesia or tactile stimulation should be considered to decrease pain at the injection site.6 Breastfeeding or giving supplemental breast milk during the injection can reduce pain in infants. The combination of oral sucrose and radiant warmth is effective analgesia for healthy neonates and young infants receiving IM vaccination.3 Diversional activities and education may comfort a child receiving an IM injection. A child life specialist should be enlisted to support the child, if available.

No evidence exists for the practice of aspirating before an IM injection, which has been shown to cause increased pain.5 Because the recommended sites for pediatric IM injections for vaccines have no large blood vessels, the practice for immunization is unnecessary.2 However, aspiration is routinely used and is recommended when medications other than vaccines are administered.

If the child or family expresses concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified.

SUPPLIES

Click here for a list of supplies.

CHILD AND FAMILY EDUCATION

  • Provide individualized, developmentally appropriate education to the family and child based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Provide the family and child with appropriate verbal and written information about the medication, including its purpose and the reason for the IM route.
  • Instruct the family regarding the potential adverse effects of the medication.
  • Explain to the child and family the step-by-step procedure for IM medication administration.
  • Explain that the child may feel pain and anxiety during the procedure. Collaborate with the child and family to develop a plan for pain management.
  • Explain which strategies (e.g., breastfeeding, local anesthetic use, distraction), may be used to minimize the child’s pain and anxiety during the procedure.
  • Explain how the family can participate during the procedure.
  • Explain how the child can assist by holding still.
  • Provide the family and child with self-management techniques (e.g., acetaminophen for fever and cool compresses for pain). Tell them when and how to notify the practitioner about a problem.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Child and Family Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the child and family.
  3. Verify the correct child using two identifiers.
  4. Review the child’s history for reactions or allergies to medications, foods, or environmental allergens.
  5. Assess the child for specific contraindications to receiving the medication and advise the practitioner accordingly.
  6. Assess the child’s developmental level and ability to interact.
  7. Assess the child’s and family’s experiences with IM medication administration.
  8. Assess the child’s and family’s understanding of the reasons for and the risks and benefits of the procedure.
  9. Assess the child’s muscle mass and skin condition.
  10. Assess the family for ways they can assist in the procedure.
  11. Determine the child’s desire for the family to be present during the procedure.
  12. Determine the family’s desire to be present during the procedure.

Preparation

  1. Obtain consent, when appropriate.
    Ensure that parental or legal guardian consent is obtained for immunizations per the organization’s practice.
  2. Select an appropriate injection site based on the child’s age and muscle mass, the medication volume, and the viscosity of the medication (Figure 1)Figure 1 (Figure 2)Figure 2 (Table 1)Table 1.
    Tissue or nerve damage, scar tissue, poor muscle mass or tone, and lack of accessibility may be contraindications to using a particular site.
  3. Apply a topical anesthetic as ordered. Follow the manufacturer’s instructions for application and time to peak effect.
  4. Consider consulting a child life specialist if available.
  5. Obtain the medication and verify the expiration date.
  6. Inspect the medication for particulates, discoloration, or other loss of integrity.
    Do not use any medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe; otherwise, this may lead to harmful reactions.
  7. Review medication information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, common side effects, and nursing implications, if needed.

PROCEDURE

  1. Perform hand hygiene.
  2. Verify the correct child using two identifiers.
  3. Explain the procedure to the child and family and ensure that they agree to treatment.
  4. Check the accuracy and completeness of the medication administration record (MAR) with the practitioner’s original order.
  5. Ensure the six rights of medication safety: right medication, right dose, right time, right route, right patient, and right documentation. Use a bar code system or compare the MAR to the child’s armband.
  6. Mix and draw up the exact volume of medication. Use a filter needle if drawing the medication from a glass ampule.
    Rationale: A filter needle prevents glass and large particles from being drawn into the syringe.
  7. Attach an appropriate-size needle to the syringe (Table 1)Table 1.
  8. Label all medications and medication containers. The only exceptions are medications still in their original container or medications administered immediately by the person who prepared them.4
  9. Provide privacy, as needed.
  10. Position the child and initiate developmentally appropriate distraction measures. Have the family of an infant begin breastfeeding or feeding breast milk. For an infant who is unable to breastfeed or for an infant who does not breastfeed, consider nonnutritive sucking, sucrose, and warmth.3
    Position the child to relax the muscle. Placing the child’s hand on the hip relaxes the deltoid muscle. For the vastus lateralis site, the child can sit on an adult’s lap. Some distraction techniques involve books, cell phones, tablets, music, videos, pictures, bubbles, and toys.
  11. Don gloves.
  12. Cleanse the area with an antiseptic solution and allow the skin to dry.
  13. Administer the injection.
    1. Nonvaccine administration
      1. Stretch the skin or pull it laterally at the injection site to achieve flattening (Z-track) or use the bunching technique.
        Rationale: Stretching the skin increases the likelihood of administering the medication into the muscle. Pulling the skin to the side (Z-track) method should be used with medications that are irritating to the tissue. 1 Bunching is useful when there is little muscle tissue. Initial research has shown that applying manual pressure before the injection decreases pain in a small population of children. 6
      2. Insert the needle at a 90-degree angle to the skin, using a steady, smooth motion.5
      3. After the needle pierces the skin, use the thumb and forefinger of the nondominant hand to hold the syringe barrel while still pulling on the skin. Move the dominant hand to the end of the plunger. Avoid moving the syringe.
      4. Pull back on the plunger. If no blood appears after 5 to 10 seconds,1 inject the medication over several seconds.
        Rationale: Injecting the medication over several seconds allows the muscle to stretch and accommodate the volume with less leakage into the subcutaneous tissue.
    2. Vaccine administration
      1. Stretch the skin or pull it laterally (Z-track) at the injection site to achieve flattening or use the bunching technique.
        Rationale: Stretching the skin increases the likelihood of administering the medication into the muscle. The Z-track method should be used with medications that are irritating to the tissue. 1 Initial research has shown that applying manual pressure before the injection decreases pain in a small population of children. 6
      2. Insert the needle at a 90-degree angle to the skin, using a steady, smooth motion.5
      3. Inject the vaccine into the tissue.
        Because the recommended sites do not contain large vessels, aspiration is not necessary when vaccines are administered. 2
        Vaccines take less time to inject than medications, such as penicillin, because vaccines are thinner and have less volume.
  14. Remove the needle and syringe quickly and smoothly. Activate the needle safety device per the manufacturer’s instructions.
  15. Apply pressure at the injection site.
    Do not massage the site. Use gauze, not an alcohol wipe, to prevent skin irritation.
  16. Assess the injection site for complications and apply an adhesive bandage.
    If the child is an infant or toddler, a bandage can become a choking hazard. If one is applied, explain to the family that it must be removed before the child is left alone.
  17. Praise the child for positive behavior and allow the child to express his or her feelings after the procedure.
  18. Discard supplies, remove gloves, and perform hand hygiene.
  19. Document the procedure in the child’s record.

MONITORING AND CARE

  1. Monitor the child’s tolerance of the procedure.
  2. Assess for the intended response to medication.
  3. Monitor the child for adverse and allergic reactions to the medication. Recognize and immediately treat dyspnea, wheezing, and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization’s practice for emergency response.
    Reportable conditions: Adverse medication, medication-to-medication interaction, or allergic or anaphylactic reaction
  4. Monitor the injection site for tissue injury.
    Reportable conditions: Profuse bleeding, hematoma, loss of function, signs and symptoms of infection
  5. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

  • Medication administration according to the six rights of medication safety
  • Signs of intended response to medication
  • No adverse reactions
  • Minimal discomfort
  • Child and family able to state the purpose and side effects of the medication

UNEXPECTED OUTCOMES

  • Medication administration not according to the six rights of medication safety
  • No sign of intended response to medication
  • Adverse reaction to the medication
  • Pain with administration
  • Child or family cannot state the purpose and side effects of the medication

DOCUMENTATION

  • Consent, if required
  • Name of the medication, dose, volume, injection site, time of administration, and name of person administering it
  • Child’s response to the medication, including adverse reactions
  • Pain assessment and interventions provided
  • Unexpected outcomes and related interventions
  • Child and family education

REFERENCESReturn to text

  1. Brown, T.L. (2017). Chapter 20: Pediatric variations of nursing interventions. In Hockenberry, M.J., Wilson, D., Rodgers, C.C. (Eds.), Wong’s essentials of pediatric nursing (10th ed., pp. 575-635). St. Louis: Elsevier.
  2. Centers for Disease Control and Prevention (CDC). (2015). Vaccine administration. In Epidemiology and prevention of vaccine-preventable diseases (13th ed., pp. 79-106). Washington, DC: Public Health Foundation. Retrieved September 18, 2019, from https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/vac-admin.pdf (Level D)
  3. Gray, L. and others. (2015). Sucrose and warmth for analgesia in healthy newborns: An RCT. Pediatrics, 135(3), e607-e614. doi:10.1542/peds.2014-1073 (Level B)
  4. Joint Commission, The. (2019). National patient safety goals: Hospital accreditation program. Retrieved September 18, 2019, from https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2019.pdf (Level D)
  5. Rishovd, A. (2014). Pediatric intramuscular injections: Guidelines for best practice. MCN: The American Journal of Maternal/Child Nursing, 39(2), 107-112. doi:10.1097/NMC.0000000000000009
  6. Taddio, A. and others. (2015). Reducing pain during vaccine injections: Clinical practice guideline. CMAJ: Canadian Medical Association Journal, 187(13), 975-982. doi:10.1503/cmaj.150391 (Level D)

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AACN Levels of Evidence

  • Level A - Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment
  • Level B - Well-designed, controlled studies, with results that consistently support a specific action, intervention, or treatment
  • Level C - Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results
  • Level D - Peer-reviewed professional organizational standards with clinical studies to support recommendations
  • Level E - Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations
  • Level M - Manufacturer's recommendations only