Medication Administration: Intramuscular Injection (Pediatric) - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

Take steps to avoid interruptions and distractions when getting medications ready.

OVERVIEW

The purpose of intramuscular (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.

The injection site affects how much fluid can be given and how quickly the medication will be absorbed. The best sites for IM injections are the vastus lateralis (anterolateral thigh) for infants and toddlers and the deltoid muscle for pediatric patients 3 years and older.^{undefined#ref6">6} Selection of the injection site is based on the patient’s age, muscle mass, medication volume, and medication viscosity.

Topical anesthesia or tactile stimulation should be considered to decrease pain at the injection site. 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 patient receiving an IM injection. A child life specialist should be enlisted to support the patient, if available.

Because the recommended sites for pediatric IM injections for vaccines have no large blood vessels, the practice of aspiration for immunization or toxoids is unnecessary.² However, there is no clear evidence supporting or contraindicating aspiration for medications other than vaccines or toxoids.

If the patient and family express worry about the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• Explain to the patient and family the importance of managing medication information to identify and resolve discrepancies.⁵
• Teach the family about the potential side effects and adverse reactions to the medication.
• Explain that the patient may feel pain and anxiety during the procedure. Collaborate with the patient and family to develop a plan for pain management.
• Explain how the family can participate during the procedure.
• Explain how the patient can assist by holding still.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Determine if the patient has health literacy needs or requires tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety.
2. Review the patient’s previous experience and knowledge of IM medication administration and understanding of the care to be provided.
3. Review the patient’s history for reactions or allergies to medications, foods, or environmental allergens.
4. Determine if the patient has specific contraindications to receiving the medication and notify the practitioner as needed.
5. Assess the patient’s developmental level and ability to interact.
6. Assess the patient’s muscle mass and skin condition.
7. Find out the patient’s and the family’s desires for the family to be present.

Preparation

1. Verify the patient’s daily weight in kilograms.⁴
2. Select an injection site based on the patient’s age and muscle mass, the medication volume, and the viscosity of the medication (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. Get, update, and compare information about the medications the patient is currently taking with those ordered to identify and resolve discrepancies.⁵
5. Get the medication, check against the practitioner’s order, verify the expiration date, and check that the medication and container are clean and intact.
6. Request the participation of a child life specialist, if available.

PROCEDURE

1. Check the rights of medication safety.
2. Provide privacy, as needed.
3. Position the patient and initiate developmentally-based 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 patient to relax the muscle. Placing the patient’s hand on the hip relaxes the deltoid muscle. For the vastus lateralis site, the patient can sit on an adult’s lap. Some distraction techniques involve books, cell phones, tablets, music, videos, pictures, bubbles, and toys.

4. Clean the area with an antiseptic solution and allow the skin to dry.
5. Hold the syringe between the thumb and forefinger of the dominant hand as if holding a dart, palm down.

   Rationale: A quick, smooth injection requires proper manipulation of the syringe parts.

   1. Administer the injection using the Z-track method, if indicated.
      1. Position the ulnar side of the nondominant hand just below the site and pull the skin laterally. Hold this position until the medication is injected.
      2. With the dominant hand, inject the needle quickly into the muscle at a 90-degree angle using a steady and smooth motion.¹

         Rationale: The Z-track technique creates a zigzag path through tissues that seals the needle track to avoid tracking medication. A quick, dart-like injection reduces discomfort. Z-track injections may be used for all IM injections.¹

      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.

         Rationale: Smooth manipulation of the syringe reduces discomfort from needle movement. Skin remains pulled until after medication is injected to be sure of Z-track administration.

      4. Optional: If the patient’s muscle mass is small, grasp the body of the muscle between the thumb and forefingers of the nondominant hand while still pulling the skin laterally.

         Rationale: Grasping the muscle body helps the medication reach the muscle mass.

      5. Smoothly, quickly, and steadily withdraw the needle and release the skin.

         Rationale: Using gauze instead of an alcohol wipe prevents skin irritation.

   2. If not using the Z-track method, follow these steps for injection.
      1. With the dominant hand, inject the needle quickly into the muscle at a 90-degree angle using a steady and smooth motion.¹
      2. 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.
      3. Optional: If the patient’s muscle mass is small, grasp the body of the muscle between the thumb and forefingers of the nondominant hand.

         Rationale: Grasping the muscle body helps the medication reach the muscle mass.

      4. Smoothly, quickly, and steadily withdraw the needle.

         Rationale: Using gauze instead of an alcohol wipe prevents skin irritation.

6. Apply a gauze pad with light pressure for several seconds over the site; do not massage.

   Rationale: Massaging can force the medication into the subcutaneous tissue causing tissue damage and unpredictable absorption.

7. Activate the needle safety device per the manufacturer’s instructions.
8. Assess the injection site for complications and apply an adhesive bandage.

   If the patient 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 patient is left alone.

9. Praise the patient for positive behavior.
10. Discard supplies, remove PPE, and perform hand hygiene.

    At the end of the procedure, be sure that all choking hazards are removed from the patient’s bedding.

MONITORING AND CARE

1. Monitor the patient’s tolerance of the procedure.
2. Assess for the intended response to medication.
3. Watch the patient for adverse and allergic reactions to the medication. If a reaction occurs, 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 administered per the rights of medication safety
• Signs of intended response to medication
• No adverse reactions
• Minimal discomfort
• Patient and family able to state the purpose and side effects of the medication

UNEXPECTED OUTCOMES

• Medication not administered per the rights of medication safety
• No sign of intended response to medication
• Adverse reaction to the medication
• Pain with administration
• Patient 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
• Patient’s response to the medication, including any adverse reactions
• Pain assessment and interventions provided
• Patient’s weight in kilograms
• Unexpected outcomes and related interventions
• Education

REFERENCES

1. Anderson, C.E., Herring, R.A. (2024). Chapter 22: Pediatric nursing interventions and skills. In M.J. Hockenberry, E.A. Duffy, K.D. Gibbs (Eds.), Wong’s nursing care of infants and children (12th ed., pp. 668-738). St. Louis: Elsevier.
2. Centers for Disease Control and Prevention (CDC). (2023). Vaccine recommendations and guidelines of the ACIP: Vaccine administration. Retrieved August 9, 2024, from https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html
3. Hellsten, M.B. (2024). Chapter 5: Pain assessment in children. In M.J. Hockenberry, E.A. Duffy, K.D. Gibbs (Eds.), Wong’s nursing care of infants and children (12th ed., pp. 131-166). St. Louis: Elsevier.
4. Institute for Safe Medication Practices (ISMP). (2024). Targeted medication safety best practices for hospitals. Retrieved August 9, 2024, from https://www.ismp.org/guidelines/best-practices-hospitals
5. Joint Commission, The. (2024). National Patient Safety Goals for the hospital program. Retrieved August 9, 2024, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_hap_jan2024.pdf
6. Wolicki, J., Miller, E. (2021). Chapter 6: Vaccine administration. In E. Hall and others (Eds.), Epidemiology and prevention of vaccine-preventable diseases (14th ed., pp. 69-96). Centers for Disease Control and Prevention (CDC). Washington, DC: Public Health Foundation. Retrieved August 9, 2024, from https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-6-vaccine-administration.html?CDC_AAref_Val=https://www.cdc.gov/vaccines/pubs/pinkbook/vac-admin.html

Clinical Review: Marlene L. Bokholdt, MS, RN, CPEN, TCRN

Published: September 2024