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

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Use the intramuscular (IM) injection route in pediatric patients only when it is the recommended route for a prescribed medication.

Take steps to eliminate interruptions and distractions during medication preparation.

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.

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 pediatric patients 3 years and older.⁶ Selection of the injection site is based on the patient’s age, muscle mass, medication volume, and medication viscosity.

Local 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, aspiration is routinely used and is recommended when medications other than vaccines or toxoids are administered.

If the patient and 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

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Assess the patient’s and family’s learning readiness.
• Explain to the patient and family the importance of managing medication information to identify and resolve discrepancies.⁵
• Provide the patient and family with written information on the medication the patient should be taking,⁵ including its purpose and the reason for the IM route.
• Instruct the family regarding the potential adverse effects of the medication.
• Explain to the patient and family the step-by-step procedure for IM medication administration.
• 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 which strategies (e.g., breastfeeding, local anesthetic use, distraction) may be used to minimize the patient’s pain and anxiety during the procedure.
• Explain how the family can participate during the procedure.
• Explain how the patient can assist by holding still.
• Provide the family and patient with self-management techniques following IM medication administration (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

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient and family.
3. Verify the correct patient using two identifiers.
4. Review the patient’s history for reactions or allergies to medications, foods, or environmental allergens.
5. Assess the patient for specific contraindications to receiving the medication and advise the practitioner accordingly.
6. Assess the patient’s developmental level and ability to interact.
7. Assess the patient’s and family’s experiences with IM medication administration.
8. Assess the patient’s and family’s understanding of the reasons for and the risks and benefits of the procedure.
9. Assess the patient’s muscle mass and skin condition.
10. Assess the family for ways they can assist in the procedure.
11. Determine the patient’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. Verify the patient’s daily weight in kilograms. Stated, estimated, or historical weight should not be used.⁴
2. Obtain consent, when appropriate.

   Ensure that parental or legal guardian consent is obtained for immunizations per the organization’s practice.

3. Obtain, update, and compare information about the medication the patient is currently taking with that of the medications ordered for the patient to identify and resolve discrepancies.⁵
4. Select an appropriate 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.

5. Apply a topical anesthetic as ordered. Follow the manufacturer’s instructions for application and time to peak effect.
6. Consider consulting a child life specialist if available.
7. Obtain the medication, check the practitioner’s order, verify the expiration date, and inspect the medication for particulates, discoloration, or other loss of integrity.

   Do not use medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe.

8. Review medication reference information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, and common side effects and implications.

PROCEDURE

1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient 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 rights of medication safety.
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).
8. Label all medications, medication containers, and other solutions. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them.⁵
9. Provide privacy, as needed.
10. Position the patient 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 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.

11. Perform hand hygiene and don gloves.
12. Cleanse the area with an antiseptic solution and allow the skin to dry.
13. 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 appropriate.
       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 ensure 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 ensure that the medication reaches the muscle mass.

       5. Per the organization’s practice, pull back on the plunger. If no blood appears, inject the medication. If blood appears in the syringe, remove the needle, discard the medication, obtain a new syringe, and try again.

          Rationale: Aspiration of blood into the syringe indicates possible placement into a vein.

          Rationale: There is no definitive research to recommend eliminating aspiration other than for vaccination and toxoids.¹

       6. 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 ensure that the medication reaches the muscle mass.

       4. Per the organization’s practice, pull back on the plunger. If no blood appears, inject the medication. If blood appears in the syringe, remove the needle, discard the medication, obtain a new syringe, and try again.

          Rationale: Aspiration of blood into the syringe indicates possible placement into a vein.

          Rationale: There is no definitive research to recommend eliminating aspiration other than for vaccination and toxoids.

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

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

14. Apply a gauze 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.

15. Activate the needle safety device per the manufacturer’s instructions.
16. 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.

17. Praise the patient for positive behavior and allow the patient to express any feelings after the procedure.
18. Discard supplies, remove PPE, and perform hand hygiene.

    At the completion of the procedure, ensure that all choking hazards (e.g., syringe caps, medication caps, alcohol wrappers, bandages) are removed from the patient’s linens and placed in the appropriate receptacle.

19. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Monitor the patient’s tolerance of the procedure.
2. Assess for the intended response to medication.
3. Monitor the patient for adverse and allergic reactions to the medication. Recognize and immediately treat respiratory distress 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 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

• Comprehensive list of current medications and those recently discontinued
• 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 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. (2022). Chapter 20: Pediatric nursing interventions and skills. In M.J. Hockenberry, C.C. Rodgers, D. Wilson (Eds.), Wong’s essentials of pediatric nursing (11th ed., pp. 551-618). St. Louis: Elsevier.
2. Centers for Disease Control and Prevention (CDC). (2023). Vaccine recommendations and guidelines of the ACIP: Vaccine administration. Retrieved May 11, 2023, from https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html (Level VII)
3. Hellsten, M. (2022). Chapter 5: Pain assessment and management in children. In M.J. Hockenberry, C.C. Rodgers, D. Wilson (Eds.), Wong’s essentials of pediatric nursing (11th ed., pp. 114-147). St. Louis: Elsevier.
4. Institute for Safe Medication Practices (ISMP). (2022). 2022-2023 Targeted medication safety best practices for hospitals. Retrieved May 11, 2023, from https://www.ismp.org/guidelines/best-practices-hospitals (Level VII)
5. Joint Commission, The. (2023). National Patient Safety Goals for the hospital program. Retrieved May 11, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jan2023.pdf (Level VII)
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 May 11, 2023, from https://www.cdc.gov/vaccines/pubs/pinkbook/vac-admin.html (Level VII)

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