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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.
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).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). 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).
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
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). To relax this site, the patient lies on his or her side or back, flexing the knee and hip.
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). 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.
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 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).
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.
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Rationale: Actual weight should be verified or measured. Stated, estimated, or historical weight should not be used.
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.
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.
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.
Rationale: Injection sites should be free of abnormalities that interfere with drug absorption (e.g., bruising, signs associated with infection).
Rationale: Sites used repeatedly become hardened from lipohypertrophy (increased growth in fatty tissue).
Rationale: A comfortable position reduces strain on the muscle and minimizes injection discomfort.
Rationale: Injection into the correct anatomic site prevents injury to nerves, bone, and blood vessels.
Rationale: A vapocoolant spray decreases pain at the injection site.
Rationale: The swab or gauze remains readily accessible for use when withdrawing the needle.
Rationale: Pulling the cap straight off prevents the needle from touching the sides of the cap, thus preventing contamination.
Rationale: A quick, smooth injection requires proper manipulation of the syringe parts.
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.
Rationale: Smooth manipulation of the syringe reduces discomfort from needle movement. Skin remains pulled until after medication is injected to ensure Z-track administration.
Rationale: Grasping the muscle body helps ensure that the medication reaches the muscle mass.
Rationale: Aspiration of blood into the syringe indicates possible placement into a vein.
Rationale: The vastus lateralis and deltoid muscle are the only two sites recommended for vaccine administration.
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.
Rationale: Massage damages underlying tissue.
Dyspnea, wheezing, and circulatory collapse are signs of severe anaphylactic reaction.
Rationale: Discarding the uncapped needle helps prevent injury to the patient and staff. Recapping needles increases the risk for a needlestick injury.
Report profuse bleeding, hematoma, loss of function, and signs and symptoms of infection.
Report rash, seizures, and difficulty breathing.
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 http://www.ismp.org/Newsletters/acutecare/showarticle.aspx?id=37 (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 http://www.who.int/infection-prevention/tools/injections/GuidingPrinciple-injection-device-security.pdf (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.
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