Back to Basics
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`I1
`The ght Way
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`This research-based protocol might change the way you give intramuscular injections.
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`By Suzanne C. Beyea, MS, PhD, . nd Leslie H. Nicoll, MS, MBA, PhD
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`0 you remember the fiist time you gave a
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`patient a “shot”? Were you nervous and
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`hesitant? Administering medications by
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`intramuscular (IM) injection is often the
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`first invasive skill that nursing students learn.
`What many of us don’t recall, however, is that
`even this most basic skill has a solid research base.
`
`Researchers have studied IM sites, syringes, needles,
`and medication volumes. They’ve also studied inter-
`ventions that can reduce pain and discomfort.
`We asked over 200 nurses if they were aware of
`this research base. Most said they were not. Frankly,
`neither were we. So we decided to explore the litera-
`ture, going back to the 19205. We found over 90
`studies related to IM injections. Using this literature
`and research base, we developed the following pro-
`tocol for IM injections.
`
`Preparing the medication
`Preparing an IM injection is as important as adminis-
`tering it. Whenever possible, use a filter needle to
`draw up medication from an ampule or vial. Hold
`the container pointed down. Don’t use the last few *
`drops in the container; some have been found to
`contain foreign substances, such as glass and rubber
`particles, that you might draw up into the syringe.
`To
`pain caused by tracking a medication
`through subcutaneous tissue, change to a dry, sterile
`needle before giving the injection. If you’re using a
`prefilled syringe to draw up medication from a vial or
`ampule, instill the complete dose (from both the pre-
`filled syringe and the vial or ampule) into another sy-
`ringe. This ensures that you’ll be using a sharp, clean
`
`Suzanne C. Beyea is an associate professor at Saint Anselm
`College. Manchester, NH. Leslie H. Nicoll is a research associ-
`ate at the Muskie Institute, University ofSouthern Maine,
`Portland.
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`RYUJIOTANI
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`34
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`needle. (Inserting a needle through the rubber top of a
`vial can dull the needle or remove the needle coating
`that helps it glide through the skin.) If you’re using a
`prefilled unit-dose syringe, check that no medication
`has dripped onto the needle. If it has, wipe the needle
`with a dry, sterile pad before the injection.
`
`size syringe
`choosing the ri
`What size syringe sho d you use? Try to match it as
`closely as possible to the volume you’ll be injecting.
`Less than 0.5 mL requires a low—dose syringe that
`most closely approximates the required close. A fine-
`ly graduated syringe (a tuberculin syringe, for exam-
`ple) will help ensure that the correct dose is adminis-
`tered.
`Research on the maximum volume to be drawn
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`up for a single injection is still inconclusive. The best
`recommendation seems to be this: For a large muscle
`such as the gluteus medius, use no more than 4 mL
`for adults and 1 to 2 mL for children and persons
`with less developed muscles; for the deltoid, use no
`more than 0.5 to 1 mL. Of course, you’ll want to
`discomfort and tissue damage by adminis-
`tering a large dose slowly.
`Needle gauge and length depend on the consisten-
`cy of the solution and how far the needle must be in-
`jected to reach the muscle. For most solutions, a 21-
`or 23-gauge needle is small enough to minimize tis-
`sue injury and subcutaneous leakage, yet large
`enough to allow easy passage. Needle length de-
`pends on the injection site. The ventrogluteal (VG)
`area has the most consistent depth of subcutaneous
`tissue; in adults, the adipose layer is always less than
`3.75 cm. Generally, use a 1.5-inch needle for adults
`and a 1-inch needle for children. Sites with less sub-
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`cutaneous fat, such as the deltoid or vastus lateralis,
`may require a 1-inch needle.
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`AJN /fanuary 1996 / Vol. 96, No. 1
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`Selecting the injection site
`We suggest the VG as the primary site for anyone over seven
`months old. The underlying muscle is well developed, and the
`site is free of nerves and blood vessels. Research shows that in-
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`juries~—including fibrosis, nerve damage, abscess, tissue necro-
`sis, muscle contraction, gangrene, and pain——have been asst»
`ciated with all the common IM sites (dorsogluteal, deltoid, and
`vastus lateralis, for example) except the VG site.
`There are, of course, contraindications for using the VG
`site: muscle contraction, damage in the area, and administra-
`tion of hepatitis—B vaccine. With adults, use the deltoid to ad-
`minister hepatitis-B vaccine; with infants under seven months,
`use the vastus lateralis.
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`To identify the VG site, position the palm of your right
`hand on the left greater trochanter so your index finger points
`toward the anterior superior iliac spine. (Use your left hand on
`the right greater trochanter.) Now spread your middle finger
`to form a V. The injection site is in the middle of the V.
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`Preparing the patient
`As with any injection site, carefully assess it by observation
`and palpation. If the site is indurated, inflamed, or damaged,
`choose another site. If all injection sites show evidence of tis-
`sue damage, consider an alternate route.
`If the VG site appears acceptable, position your patient so
`that the muscle at the site relaxes by following these steps:
`- 0 For patients lying on their side, have them flex the knee,
`then pivot the leg forward from the hip approximately 20° so
`it can rest on the bed.
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`0 For patients in the supine position, have them flex the
`knee on the side where they’ll receive the injection (for exam-
`ple, the right knee for an injection on the right side).
`0 For patients in the prone position, have them “toe—in” to
`internally rotate the femur.
`Although it’s possible to access the VG site while the patient
`is standing, this poses an obvious safety risk for both the pa-
`tient and yourself.
`Prior to injection, cleanse a circular area, two to three inches
`in diameter, with a 70% alcohol wipe. Wait at least 30 sec-
`onds to let the alcohol dry so it won’t be introduced into sub-
`cutaneous tissue during the injection, which can cause irrita-
`tion of the tissue.
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`How to administer the injection
`Do not use an air bubble in the syringe. A holdover from the
`days of reusable syringes, this can affect the medication
`dosage by 5% to 100%. Modern disposable syringes are cali-
`brated to give the correct dose without an air bubble.
`Which injection technique should you use? Nursing text-
`books describe two methods: spreading the skin between your
`fingers, and pulling the skin down or to one side (the Z—track
`technique). Spreading the skin increases the risk of medication
`leaking into the needle track and the subcutaneous tissue. The
`Z—track technique virtually eliminates this risk; it also pro-
`duces fewer complications and less discomfort, making it the
`technique of choice.
`\When administering an IM injection, insert the needle quick-
`ly and smoothly, using a dartlike motion and steady pressure,
`at a 90° angle to the iliac crest, in the middle of the V you
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`A]N/january 1996/ Vol. 96, No. 1
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`formed with your fingers. After insertion, aspirate for five to
`10 seconds. That may seem like a long time, but when the
`needle is in a small, low-flow blood vessel, it takes a while for
`the blood to appear. If no blood appears, inject the medica-
`tion slowly—approximately 10 seconds per mL. This slow,
`steady rate promotes comfort and allows time for the tissues
`to expand and begin absorbing the solution.
`After you’Ve injected the solution, wait 10 seconds so that
`the medication can diffuse through the muscle. Then smooth-
`ly withdraw the needle at the same angle of insertion. Once
`the needle is out, use a dry, sterile sponge to apply gentle pres-
`sure at the site. Don’t massage the site; this could cause tissue
`irritation.
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`Encourage the patient to perfonn leg exercises, such as flex-
`ion and extension, to help the muscle absorb the medication.
`Inspect the injection site within two to four hours. When you
`administer the next injection, check the former site for red-
`ness, swelling, pain, or other evidence of tissue damage. These
`findings are not normal or to be expected. They should be
`documented according to your agency’s policy and communi-
`cated in a timely manner to the primary physician for further
`evaluation and treatment measures.
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`More research is needed
`
`The research on IM injections is still continuing. An important
`area for study is the volume that various muscles can safely
`and comfortably absorb. For example, researchers have
`found various absorption rates for different muscles, but no
`one has documented the rate of absorption in the gluteal
`medius (target muscle of the VG site) or compared it with oth-
`er muscles. More research also needs to be done on interven-
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`tions for complications from IM injections. Although more
`than 200 adverse effects have been documented in the litera-
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`ture, no one has explored the efficacy of various interventions
`in minimizing these complications after they occur and in pro-
`moting healing.
`Nurses have always wanted to provide a level of care that
`ensures the fewest possible negative outcomes. Today, this
`means studying the research that has a direct influence on clin-
`ical practice. Next time you give an IM injection, follow the
`protocol outlined here. Your technique will be solidly ground-
`ed in research. CI
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`SELECTED REFERENCES
`
`Beecroft, I’. C., and Redick, S. A. Possible complications of intramuscular injections
`on the pediatric unit. Pediatr.Nurs. 15(4):333—336, 376, ]uly—-Aug. 1989.
`Beyea, S. C., and Nicoll, L. H. Administration of medications via the intramuscular
`route: An integrative review of the literature and research—based protocol for the
`procedure. Appl.Nurs.Res. 8(1):23-33, Feb. 1995.
`Cockshott, W. P., et al. Intramuscular or intralipomatous injections? N.Engl.].Mea'.
`307(6):356—358, Aug, 1982.
`Farley, H. F., et al. Will that [M needle reach the muscle? Am.].Nurs. 86(12):1327-
`1328, Dec. 1986.
`Keen, M. F. Comparison of intramuscular injection techniques to reduce site
`discomfort and lesions. Nurs.Res. 35(4):207—210,]uly—Aug. 1986.
`Keen, M. F. Get on the right track with Z-track injections. Nursing 20(8):59, Aug.
`1990.
`
`Newton, M., et al. Reviewing the “big three” injection techniques. Nursing 72(2):
`34-41, Feb. 1992.
`Rettig, F. M., and Southby, J. R. Using different body positions to reduce discomfort
`from dorsogluteal injection. Nurs.Res. 31(4)-.219—221,]uly—Aug. 1982.
`Zenk, K. E. Beware of overdose. Nursing 3:28-29, Mar. 1993.
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