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Dec.29.2020View related content

Medication Administration: Intramuscular Injection - CE

ALERT

Follow instructions for SARS-COV2 vaccine administration provided on Elsevier’s Vaccination Hub https://elsevier.health/en-US/preview/sars-cov2-vaccine or Clinical Key for Nursing https://www.clinicalkey.com/nursing/#!/content/drug_monograph/6-s2.0-5295.

Intramuscular (IM) injections have been associated with adverse effects and pain, and this route of medication injection should be used as a last resort. Consider contacting the practitioner for an alternative, preferred route of medication administration.

Take steps to eliminate interruptions and distractions during medication preparation.

OVERVIEW

The IM injection route deposits medication into deep muscle tissue, which has a rich blood supply, allowing medication to be absorbed faster than it would be by the subcutaneous route. This rich blood supply, however, increases the risk for injecting drugs directly into blood vessels. Any factor that interferes with local tissue blood flow affects the rate and extent of drug absorption.

An IM injection may require a longer and larger-gauge needle to penetrate deep muscle tissue. The needle is inserted at a 90-degree angle; this varies from the angle used for subcutaneous and intradermal injections (Figure 1)Figure 1.2 The appropriate needle length is determined by the patient’s weight and age and the amount of adipose tissue in the chosen injection site (Table 1)Table 1. The needle must be long enough to reach the muscle tissue, but not too long to present the risk of hitting underlying neurovascular structures or bone.2

Needle gauge is determined by the medication to be administered, the size of the muscle, amount of fatty tissue at the site, and administration technique.2 Immunizations should be administered using a needle with a gauge range of 22 to 25.2 Vaccines are generally not highly viscous and will flow easily through a smaller gauge needle.

IM injections should be administered so that the needle is perpendicular to the patient’s body or as close to a 90-degree angle as possible.2 IM injection sites should also be rotated to decrease the risk for hypertrophy. When possible, IM injections should be avoided in muscles that are emaciated or atrophied because these muscles absorb medication poorly.

Aspiration before injection and slow injection of the medication is not supported by research for vaccine administration.1 The vastus lateralis and deltoid muscle are the only two sites recommended for vaccine administration because these sites do not contain large vessels that are within reach of the needle.2 For all other medications there is no evidence to support abandoning the practice of aspiration before administration. More research is needed to investigate the practice of aspiration before administering an IM injection with medications other than vaccines.10,11 The recommended route and site for each vaccine is included in the manufacturer’s instructions for use.2

Muscle tissue is less sensitive than subcutaneous tissue to irritating and viscous medications. Smaller muscles absorb smaller volumes. For a well-developed adult, no more than 5 ml of medication should be administered in a single IM injection because the muscle tissue does not absorb it well.9 For “deep” IM injections, the recommended volume ranges from 2 to 5 ml.9 If the patient’s available muscle tissue is limited and the dorsogluteal muscle must be used, volumes of up to 4 ml can be administered into this site.9 The ventrogluteal muscle can accommodate up to 2.5 ml, with a maximum volume of 3 ml.9 The rectus femoris and vastus lateralis remain the recommended sites for volumes up to 5 ml in adults.9 A maximum of 2 ml is recommended for older adults and thin patients.9

The Z-track method can be used (except with infant vaccination where skin is compressed) provided that the overlying tissue can be displaced. This technique, pulling the skin laterally before injection, prevents medication leakage into subcutaneous tissue, seals medication in the muscle, and minimizes irritation.7 To use the Z-track method in an adult, the appropriate-size needle is attached to the syringe, and an IM site is selected. The overlying skin and subcutaneous tissues are pulled to the side with the ulnar side of the nondominant hand. The skin is held in this position until the injection has been administered. After cleansing the site, the needle is injected deep into the muscle and the medication is injected slowly. After the needle is withdrawn, the skin is released. The displacement of the skin and muscle layer closes off the needle track when the skin is released (Figure 2)Figure 2.

Injection Sites

For IM injections, the nurse selects a site that is free of pain, infection, necrosis, bruising, and abrasions. The location of underlying bones, nerves, and blood vessels and the volume of medication to be administered are also considered. Because of the sciatic nerve location, the dorsogluteal muscle is not recommended as an injection site. If a needle hits the sciatic nerve, the patient may experience partial or permanent paralysis of the leg.9

Ventrogluteal Site

The ventrogluteal site involves the gluteus medius and minimus muscles and is a safe injection site for adults and children.6 This site provides the greatest thickness of gluteal muscle, is free of penetrating nerves and blood vessels, and has a narrower layer of fat.9

The dorsogluteal site is closer to neurovascular structures than the ventrogluteal site and is not a recommended site for injection. However, the thickness of the muscle in the dorsogluteal region is greater than muscle in the ventrogluteal region. Selected site for IM injections is based on clinical assessment of the patient.3

To locate the ventrogluteal site, the heel of the hand is placed over the greater trochanter of the patient’s hip with the wrist almost perpendicular to the femur. The right hand is used for the left hip, and the left hand for the right hip. The thumb is pointed toward the patient’s groin, with the index finger pointing to the anterior superior iliac spine, and the middle finger is extended back along the iliac crest toward the buttock. The index finger, the middle finger, and the iliac crest form a V-shaped triangle. The injection site is the center of the triangle (Figure 3)Figure 3. To relax this site, the patient lies on his or her side or back, flexing the knee and hip.

Vastus Lateralis Muscle

The vastus lateralis muscle is another injection site used in adults. The muscle is thick and well developed and is located on the anterior lateral aspect of the thigh. It extends, in an adult, from a handbreadth above the knee to a handbreadth below the greater trochanter of the femur (Figure 4)Figure 4. The middle third of the muscle is used for injection. To help relax the muscle, the patient is asked to lie flat, supine, with the knee slightly flexed and foot externally rotated or to assume a sitting position.

Deltoid Muscle

Although the deltoid site is easily accessible, the muscle is not well developed in many adults. There is potential for injury because the axillary, radial, brachial, and ulnar nerves and the brachial artery lie within the upper arm under the triceps and along the humerus (Figure 5A)Figure 5A (Figure 5B)Figure 5B. This site is used for small medication volumes and administration of routine immunizations in children older than 2 years with acceptable muscle mass and development.2 If the deltoid site is used, no more than 2 ml of medication should be administered at one time.9 The deltoid muscle is the recommended site for regular vaccinations in adults.2

The deltoid muscle is located by fully exposing the patient’s upper arm and shoulder and asking the patient to relax the arm at his or her side or by supporting the patient’s arm and flexing the elbow. Next, the lower edge of the acromion process, which forms the base of a triangle in line with the midpoint of the lateral aspect of the upper arm, is palpated, and the injection site is found in the center of the triangle (Figure 5A)Figure 5A.

Rarely, an adverse reaction occurs after immunizations. Reactions may include anaphylaxis, anaphylactic shock, and neurologic deficits.1 Vaccine adverse event reporting is monitored by the Centers for Disease Control and Prevention.

If the patient expresses concern regarding the accuracy of a medication, the medication should not be given. The patient’s concern should be explored, the practitioner notified, and the order verified.

SUPPLIES

Click here for a list of supplies.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Explain the procedure for an IM injection, including the purpose of the injection and the reason for using the IM route.
  • Explain the risks related to the procedure, including hematoma formation, nerve injury, and allergic reaction to the medication.
  • Instruct the patient regarding the potential side effects of the medication.
  • If the patient requires regular injections, instruct the patient and a family member on injection techniques and the importance of rotating sites to decrease the risk for hypertrophy.
  • Have the patient perform several return demonstrations of medication preparation to validate learning.
  • Instruct the patient and a family member to observe injection sites for complications and to report complications to the practitioner immediately.
  • Instruct the patient and a family member to observe for effectiveness of the medication and adverse reactions and to report ineffectiveness of the medication and adverse reactions to the practitioner.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Assess the patient for specific contraindications to receiving IM injections and advise the practitioner accordingly. Assess for factors such as muscle atrophy, reduced blood flow, skin condition, and circulatory shock.
  5. Assess the patient’s symptoms before initiating medication therapy.
  6. Assess the patient’s knowledge regarding the medication to be received.
  7. Assess the patient’s history of allergies, including any drug allergies, type of allergens, and normal allergic reaction.
  8. Review the patient’s previous verbal and nonverbal responses to injections.
  9. Assess baseline vital signs and the patient’s medical and medication history.

Preparation

  1. Verify the practitioner’s order.
  2. Verify the patient’s actual admission weight in kilograms. Reweigh the patient if appropriate.4
    Rationale: Actual weight should be verified or measured. Stated, estimated, or historical weight should not be used. 4
  3. Understand drug reference information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, common side effects, and nursing implications, if needed.
  4. Obtain the medication and verify the expiration date.
  5. 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.
  6. Assemble appropriate-size needles, syringes, and other administration supplies.

PROCEDURE

  1. Perform hand hygiene.
  2. Verify the correct patient using two identifiers.
  3. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  4. Check 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 patient’s armband.
  6. Label all medications, medication containers, and other solutions that are both on and off the sterile field. 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
    Medications or other solutions in unlabeled containers are unidentifiable. Errors, sometimes tragic, have resulted from medications and other solutions removed from their original containers and placed into unlabeled containers. This unsafe practice neglects basic principles of medication management safety, yet has been routine in many organizations. 5
  7. Take the medication to the patient at the right time according to the six rights of medication safety and perform hand hygiene.
  8. Provide privacy for the patient.
  9. Compare the patient’s name and one other identifier (e.g., organization identification number) with the MAR. Ask the patient to state his or her name as an additional identifier.
    Rationale: This identification comparison and verification comply with The Joint Commission requirements to improve medication safety. In most acute care settings, the patient’s name and identification number on armband and the MAR are used to correctly identify patients. 5
  10. Compare the medication label with the MAR one final time at the patient’s bedside.
  11. Perform hand hygiene and don gloves.
  12. Keep a sheet or gown draped over body parts not requiring exposure.
  13. Select the appropriate site for injection based on the patient’s age, muscle tissue mass, and medication volume and viscosity.
    1. Inspect the skin surface over sites for bruises, inflammation, or edema.
      Rationale: Injection sites should be free of abnormalities that interfere with drug absorption (e.g., bruising, signs associated with infection).
    2. Note the integrity and size of the muscle. Palpate for tenderness or hardness and avoid hardened areas. If the patient receives frequent injections, rotate sites.
      Rationale: Sites used repeatedly become hardened from lipohypertrophy (increased growth in fatty tissue).
  14. Assist the patient to a comfortable position that is appropriate for the chosen injection site (e.g., sitting, or lying flat, on side, or prone).
    Rationale: A comfortable position reduces strain on the muscle and minimizes injection discomfort.
  15. Locate the injection site again using anatomic landmarks. The ventrogluteal site is a safe injection site for adults and children receiving irritating or viscous solutions and is the site of choice for administering IM injections to adults.9 In addition, this site provides the greatest thickness of gluteal muscle, is free of penetrating nerves and blood vessels, and has a narrower layer of fat.9
    Rationale: Injection into the correct anatomic site prevents injury to nerves, bone, and blood vessels.
  16. Cleanse the site with alcohol or an antiseptic swab, per the organization’s practice. Allow the skin to dry completely. Optional: Use a vapocoolant spray (e.g., ethyl chloride) for pain relief just before injection.
    Rationale: A vapocoolant spray decreases pain at the injection site.
  17. Hold a clean swab or dry gauze between the third and fourth fingers of the nondominant hand.
    Rationale: The swab or gauze remains readily accessible for use when withdrawing the needle.
  18. Remove the needle cap by pulling it straight off.
    Rationale: Pulling the cap straight off prevents the needle from touching the sides of the cap, thus preventing contamination.
  19. 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.
  20. Administer the injection.
    1. Z-track method
      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.2
        Rationale: The Z-track technique creates a zigzag path through tissues that seals the needle track to avoid leaking of medication. A quick, dartlike injection reduces discomfort. Z-track injections may be used for all IM injections. 9
      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 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. 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.
      6. Smoothly, quickly, and steadily withdraw the needle and release the skin. Apply a dry cotton ball or gauze with light pressure for several seconds over the site.
    2. Vaccine administration
      1. Use the vastus lateralis or deltoid muscle.2
        Rationale: The vastus lateralis and deltoid muscle are the only two sites recommended for vaccine administration. 2
      2. Spread the skin taught between the thumb and forefinger over the selected muscle or grasp the tissue and bunch up the muscle (commonly used for children or older adult patients).
      3. Inject the vaccine into the tissue and withdraw the needle.2
        Rationale: The vastus lateralis and deltoid muscle sites do not contain large vessels that are within reach of the needle so aspiration is not necessary. 2
  21. Apply gentle pressure to the site; do not massage. Assess the site and apply a bandage if needed.
    Rationale: Massage damages underlying tissue.
  22. Assist the patient to a comfortable position.
  23. Stay with the patient for several minutes and observe for any allergic reactions.
    Dyspnea, wheezing, and circulatory collapse are signs of severe anaphylactic reaction.
  24. Discard the uncapped needle (or needle enclosed in safety shield) and the attached syringe into a puncture-proof and leakproof receptacle.
    Rationale: Discarding the uncapped needle helps prevent injury to the patient and staff. Recapping needles increases the risk for a needlestick injury. 8
  25. Discard supplies, remove gloves, and perform hand hygiene.
  26. Document the procedure in the patient’s record.

MONITORING AND CARE

  1. Return to the patient’s room at an appropriate time per the organization’s practice to assess the injection site.
    Report profuse bleeding, hematoma, loss of function, and signs and symptoms of infection.
  2. Monitor the patient 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.
    Report rash, seizures, and difficulty breathing.
  3. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

  • Correct medication administration according to the six rights of medication safety.
  • Patient experiences no pain or only mild burning at injection site.
  • Patient achieves desired effect of medication with no adverse reactions, signs of allergies, or undesired effects.
  • Patient demonstrates acceptable level of comfort after injection.
  • Patient explains purpose, dosage, and effects of medication.

UNEXPECTED OUTCOMES

  • Incorrect medication administration according to the six rights of medication safety.
  • Patient complains of localized pain, bleeding, or continued burning at injection site, indicating potential injury to nerve or vessels.
  • Medication is administered in subcutaneous tissue.
  • Patient displays adverse reaction to the medication, with signs of urticaria, eczema, pruritus, wheezing, or dyspnea.
  • Other adverse effects occur: hematoma or abscess; infection; fibrosis of the muscle, tissue damage because of patient movement during injection; glass particles injected into muscle as a result of not using a filter needle; permanent damage to sciatic nerve resulting in paralysis, fibrosis, or abscess.
  • Patient experiences unmanaged pain.

DOCUMENTATION

  • Medication name, dose, route, site, time, and date of administration (with MAR correctly signed)
  • Patient’s response to medication, including any adverse reactions
  • Unexpected outcomes and related nursing interventions
  • Education
  • Comfort assessment and any interventions performed
  • Patient’s weight in kilograms per the organization’s practice

PEDIATRIC CONSIDERATIONS

  • Children can be very anxious or fearful of needles. Assistance is sometimes necessary to hold the child and position him or her properly. Distraction, such as blowing bubbles and applying pressure at the injection site before giving the injection, may help alleviate the child’s anxiety.
  • If possible, a topical analgesic should be applied to the injection site with sufficient time allowed for peak action before the IM injection. A vapocoolant spray (e.g., ethyl chloride) may also be used just before injection to decrease pain. The nurse should collaborate with the practitioner to reduce pain before injection.
  • The vastus lateralis muscle is the preferred site for administration of immunizations to newborns, infants, toddlers, and children through 2 years old.2 The deltoid muscle is the acceptable site for administration of routine immunizations in children 3 to 18 years old who have acceptable muscle mass and development.2
  • The nurse should consider applying a colorful adhesive bandage or sticker to the injection site.

OLDER ADULT CONSIDERATIONS

  • Older adult patients may have decreased muscle mass, which reduces drug absorption from IM injections.
  • Older adults may have loss of muscle tone and strength that impairs mobility, placing them at high risk for falls as a result of guarding an injection site.

HOME CARE CONSIDERATIONS

  • The nurse should consider contacting the practitioner about alternative methods of medication administration when there is tissue atrophy and poor absorption associated with IM injections.
  • Self-administration of an IM injection is difficult. If possible, a family member should be trained to administer these injections.
  • Adult patients who require frequent injections should be instructed to apply a topical analgesic to the injection site before administration.
  • Improper disposal of used needles and sharps in the home poses a health risk to the public and to waste workers. Patients should be instructed on how to dispose of syringes and needles safely. Options for safe sharps disposal at home include allowing patients to transport their own sharps containers from home to collection sites (e.g., practitioner’s office, hospital, pharmacy), mailing their used syringes to a collection site (mail-back programs), participating in syringe exchange programs, or using special devices that destroy the needle on the syringe, rendering it safe for disposal. Needles should be stored in Food and Drug Administration-approved containers or in containers that are in compliance with community guidelines. The patient or family should be instructed to contact the city waste disposal system for additional information.12

REFERENCES

  1. Centers for Disease Control and Prevention. (2015). Chapter 4: Vaccine safety. In J. Hamborsky, A. Kroger, C. Wolfe (Eds.), Epidemiology and prevention of vaccine-preventable diseases (13th ed., pp. 47-62). Washington, DC: Public Health Foundation. Retrieved March 24, 2020, from https://www.cdc.gov/vaccines/pubs/pinkbook/safety.html (Level VII)
  2. Centers for Disease Control and Prevention. (2015). Chapter 6: Vaccine administration. In J. Hamborsky, A. Kroger, C. Wolfe (Eds.), Epidemiology and prevention of vaccine preventable diseases (13th ed., pp. 79-106). Washington, DC: Public Health Foundation. Retrieved March 24, 2020, from https://www.cdc.gov/vaccines/pubs/pinkbook/vac-admin.html (Level VII)
  3. Coskun, H., Kilic, C., Senture, C. (2016). The evaluation of dorsogluteal and ventrogluteal injection sites: A cadaver study. Journal of Clinical Nursing, 25(7-8), 1112-1119. doi:10.1111/jocn.13171 (Level V)
  4. Institute for Safe Medication Practices (ISMP). (2020). Targeted medication safety best practices for hospitals. Retrieved April 28, 2020, from (Level VII)
  5. Joint Commission, The. (2020). National patient safety goals: Hospital accreditation program. Retrieved April 28, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/npsg_chapter_hap_jan2020.pdf (Level VII)
  6. Kara, D. Uzelli, D. Karaman, D. (2015). Using ventrogluteal site in intramuscular injections is a priority or an alternative? International Journal of Caring Sciences, 8(2), 507-513.
  7. Lilley, L.L., Rainforth Collins, S., Snyder, J.S. (Eds.). (2020). Chapter 9: Photo atlas of drug administration. In Pharmacology and the nursing process (9th ed., pp. 103-134). St. Louis: Elsevier.
  8. Occupational Safety and Health Administration (OSHA). (2001). Occupational exposure to bloodborne pathogens; needlestick and other sharps injuries; final rule. Federal Registers, 66, 5317-5325. Retrieved April 28, 2020, from https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=16265 (classic reference)* (Level VII)
  9. Ogston-Tuck, S. (2014). Intramuscular injection technique: An evidence-based approach. Nursing Standard, 29(4), 52-59. doi:10.7748/ns.29.4.52.e9183 (classic reference)*
  10. Sepah, Y. and others. (2014, revised 2017). Aspiration in injections: Should we continue or abandon the practice? (version 3). F1000Research, 3, 157. doi:10.12688/f1000research.1113.3
  11. Sisson, H. (2015). Aspirating during the intramuscular injection procedure: A systematic review. Journal of Clinical Nursing, 24(17-18), 2368-2375. doi:10.1111/jocn.12824 (Level I)
  12. U.S. Food and Drug Administration (FDA). (2018). Safely using sharps (needles and syringes) at home, at work and on travel. Retrieved April 28, 2020, from (Level VII)

ADDITIONAL READINGS

Centers for Disease Control and Prevention (CDC). (2017). Vaccine administration. Retrieved on April 28, 2020 from https://www.cdc.gov/vaccines/hcp/admin/admin-protocols.html

Institute for Safe Medication Practices (ISMP). (2012). Side tracks on the safety express. Interruptions lead to errors and unfinished… Wait, what was I doing? Retrieved April 28, 2020, from (classic reference*)

Kroger, A., Duchin, J., Vazquez, J. (2015). General best practice guidelines for immunization: best practices guidance of the advisory committee on immunization practices (ACIP). Retrieved on April 28, 2020, from https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html

World Health Organization (WHO). (2015). Guiding principles to ensure injection device security. Retrieved on April 28, 2020, from (classic reference)* (Level VII)

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Adapted from Perry, A.G., Potter, P.A., Ostendorf, W.R. (2018). Clinical nursing skills & techniques (9th ed.). St. Louis: Elsevier.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports