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Considerations for Site and Needle Selection

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Preparation

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Administration

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Summary

Preparing and Administering Intramuscular Injections

Source: Madeline Lassche, MSNEd, RN and Katie Baraki, MSN, RN, College of Nursing, University of Utah, UT

Intramuscular (IM) injections deposit medications deep into the muscle tissue. Since muscle fibers are well perfused, this route of administration provides quick uptake of the medication and allows for the administration of relatively large volumes. Skeletal muscles have fewer pain-sensing nerves than subcutaneous tissue, which allows for the less painful administration of irritating drugs (e.g., chlorpromazine, an anti-psychotic). IM injections are recommended for patients unable to take oral medications and for uncooperative patients. Some examples of medications that are commonly delivered by IM injections include antibiotics, hormones, and vaccinations.

As in any other route of administration, the nurse must consider if the medication is appropriate, given the patient's medical conditions, allergies, and current clinical status. In addition, specifically for IM injections, it is important to assess the patient's muscle mass to determine the appropriate needle size. Also, if the patient has already received this injection, it is necessary to verify the injection site that was previously used and to ensure that the previous dose did not result in any adverse reactions.

The sites that are most commonly utilized for IM injections include the deltoid muscle of the shoulder; the vastus lateralis of the thigh; and the ventrogluteal, gluteus medius, or dorsogluteal muscles of the hip. It is best to avoid administering IM injections into the dorsogluteal muscle, because this location is associated with an increased risk of hitting a blood vessel, nerve, or bone.

This video will focus on the essential steps that every nurse should follow in order to correctly prepare and administer an IM injection.

1. Similar to any other route of administration, preparing and administering IM medications requires the nurse to be knowledgeable about the patient's medical history, medication allergies, and preferences, as well as on the previous administration times, adverse effects, and purpose of the medication. All this information can be obtained through discussion with the patient and by reviewing the Medication Administration Record (MAR) at the patient bedside.

2. In the case of IM injections, you should be particularly aware of the patient's preference for an injection site and administration process (i.e., whether the patient prefers a particular site and whether he/she prefers you to count down to administration or to swiftly administer the medication).

3. Select the most appropriate site for IM injection depending, upon the type of medication being delivered.

Injections sites in the hip area, such as the gluteal muscles, are preferred for the administration of larger volumes of medications, while small volumes can be given to the arm, in the deltoid muscle. The deltoid site is mostly commonly used for immunizations. However, up to 1 mL of any medication may be administrated to this muscle (the maximum volume should never exceed 2 mL). The gluteal site is commonly used to administer antibiotics, or any medication with a volume exceeding 2 mL but less than 3 mL for an adult. Many providers consider the ventrogluteal muscle to be the preferred site for IM injections, due to the large muscle mass and the increased absorption when volumes larger than 2 mL are injected in the area.
Infants should receive all IM medications in the vastus lateralis because it is the largest muscle at that developmental age.
Avoid administering IM injections into the dorsogluteal muscle, because this location is associate with an increased risk of hitting a blood vessel, nerve, or bone.

4. Adherence to the five "rights"-right patient, right medication, right dose, right route, right time-at the three checkpoints of the safe medication administration process is imperative to prevent patient injury and harm. To learn about these five "rights" in detail, please refer to the video entitled "Safety Checks for Acquiring Medications from a Medication Dispensing Device." Remember to wash or sanitize your hands before and after each patient encounter. Vigorous friction for at least 20 s should be applied while washing the hands with soap and warm water or while applying hand sanitizer.

5. Upon entering the medication preparation area (this area may be in a secured room or in a secured portion of the nurses' station), complete the first safety check of the five "rights" of medication administration. Refer to the "Safety Checks for Acquiring Medications from a Medication Dispensing Device" video.

Preparing the IM injection

IM injection preparations are commonly provided in vials or ampules for withdrawal to a syringe. Before withdrawing, it is important that a nurse calculates the volume of the medication to be administered, according to the concentration provided on the container.

6. In the medication preparation area, prepare the IM injection according to the MAR, nurse drug guide, best practices, and institutional policies/procedures. Remove the medication from the box and removing the vial top.

Scrub the medication vial with an alcohol prep pad for 20 s, with friction and intent, while watching a wall clock or watch.
Using aseptic technique, attach a blunt-tipped needle to a syringe, remove the cap, and withdraw the appropriate amount of medication for injection. Note the viscosity of the liquid while withdrawing the medication from the vial. This will help to determine the size of needle needed for the injection.
1. Hold the vial at eye-level and the needle tip below the level of medication to ensure that the correct amount of liquid is withdrawn and that air bubbles are avoided.
If at any time during medication withdrawal, the needle hub, needle cap, or syringe connection point is contaminated from contact with the hands or countertop, obtain new supplies and restart the medication preparation procedure.
Engage the blunt-tipped needle safety device or replace the cap using the scoop method (i.e., placing the needle cup on a flat surface and sliding the needle into it) to avoid accidental needle sticks. Discard the blunt-tipped needle in an approved sharps container. Maintain the sterility of the syringe containing the medication.
Attach an appropriately sized needle for IM injection to the syringe using aseptic technique. The gauge of the needle should be between 18 and 25 and the length between 5/8 and 1½ inches. Needle selection is dependent upon the age of the patient, administration site, volume of fluid, amount of muscle and adipose tissue, and viscosity of the solution.
1. Large-bore needles (18 and 20 gauge) are appropriate for thick, viscous medications, while small-bore needles (22 and 25 gauge) are appropriate for thinner medications and for infants.
2. Long needles (1 and 1½ inches) are most often used for patients with large amounts of adipose tissue covering the muscle site, in order to reach the muscle tissue, or for deep muscles, such as the ventrogluteal muscle. Shorter needle lengths (5/8 and ½ inch) are appropriate for thin patients and for pediatric patients to avoid needle sticks into bone.
3. If injecting medication into the deltoid muscle of an adult, the volume of solution should not exceed 1 mL.
4. If injecting into the vastus lateralis, ventrogluteal, gluteus medius, or dorsogluteal muscles of an adult, the volume should not exceed 3 mL.
5. If administering an IM injection into a child under age 2, the maximum amount that should be administered is 1 mL.
6. Label the syringe with the medication name and dosage amount and then discard the packaging materials in a trash receptacle. Note that some institutions may require more information, depending upon to their medication labeling policies.

7. In the medication preparation area, complete the second safety check using the five "rights" of medication administration. Refer to the "Safety Checks for Acquiring Medications from a Medication Dispensing Device" video.

8. In addition to the medication to be administered, be sure to obtain all supplies needed for injection before entering the patient's room. These include an alcohol prep wipe, non-sterile gloves, and an adhesive bandage or a cotton ball and silk/paper tape.

Administration

9. Wash hands when entering the patient room and complete the third and final medication safety check, adhering to the five "rights" of medication administration. Refer to the "Preparing and Administering Oral and Liquid Medications" video.

Prepare the patient and administer the IM medication

10. As with any medication administration, remind the patient of the medication purpose, any adverse reactions, and administration procedure.

11. Remove bed linens and the patient's gown or clothing to access the selected injection site. Perform injection site selection, as described in step 3, with the deltoid muscle preferred for small volumes and the ventrogluteal for large volumes in adults.

When delivering small volumes, such as immunizations, to the deltoid muscle, locate the acromial process at the top of the shoulder as your landmark. Mark two fingerbreadths down from the acromial process and envision an inverted triangle. Needle insertion should be at the center of the inverted triangle.
When delivering larger-volume injections, such as antibiotics, into the ventrogluteal muscle, have the patient lie comfortably on his/her side, with the selected hip exposed. Find the greater trochanter and iliac crest as landmarks. Place the palm of your hand, with the thumb pointing to the front of the patient, on the greater trochanter. Point the index finger at the anterior iliac crest and then spread the middle finger towards the back of the patient, forming a "V." The needle injection site is located between the knuckles of the index and middle fingers.

12. Clean gloves should be donned at this time. Make sure to assess if the patient has a latex allergy, or use non-latex gloves to avoid allergic reactions.

According to the CDC, it is unnecessary to clean the injection area with an alcohol prep pad, unless the skin is visibly soiled or dirty.

13. The z-track technique for IM administration should always be used. The z-track technique prevents medication from leaking into the subcutaneous tissue. Hold the syringe in your dominant hand, and with your non-dominant hand, remove the needle cap.

Using the non-dominant hand, pull the skin taut between the thumb and forefinger, pushing the adipose tissue approximately 1 inch away from the muscle.
Insert the needle at a 90° angle. Hold the syringe between the thumb and index finger of the dominant hand and insert it into the muscle using a quick, purposeful motion.
1. VARIATION: When administering some IM medications (this does not include vaccinations) into the ventrogluteal, gluteus medius, or dorsogluteal muscles, it is recommended to aspirate for blood return. This prevents the accidental administration of medication into a blood vessel. This is not necessary for the deltoid or vastus lateralis muscles, because they do not contain large blood vessels.
2. To aspirate, hold the syringe between the thumb and middle finger and gently push up on the plunger with the forefinger. If you see a blood return in the syringe, remove the needle from the site and begin the process again, selecting a different IM administration site.
Using the thumb or index finger of the dominant hand, press the plunger slowly to inject the medication at a rate of 1 mL per 10 s. You may stabilize the syringe in the skin with the fingers of the non-dominant hand. Using the dominant hand, push down on the plunger with the index finger or thumb.

14. As with any injection, remove the needle smoothly, along the line of insertion; engage the safety device with the thumb of the dominant hand; and immediately place the needle and syringe directly into a "sharps" container.

15. If blood is present after injection, apply an adhesive bandage or cotton ball with silk/paper tape.

16. Replace all clothing and bed linens according to patient preference.

17. Finally, dispose gloves and waste into a garbage receptacle and wash hands with soap and water for at least 20 s, applying vigorous friction.

18. As with any medication, document the medication administration date, time, and location of in the electronic MAR.

Variation: Immunizations may require additional documentation, depending upon facility policy.

19. Prior to leaving the room, remind the patient about any side effects/adverse effects associated with IM injections, such as pain at the site, redness, bruising, or swelling. These should be immediately reported to the nurse.

20. Leave the patient room and wash hands with soap and water for at least 20 s, applying vigorous friction.

This video demonstrates the preparation and administration of IM medications. According to best practices, IM medications should be administered in the deltoid muscle for immunizations or medications less than 1 mL but not exceeding 2 mL. Large volumes (i.e., more than 2 mL but less than 3 mL) should be administered in the ventrogludeal muscle; this site is used for antibiotics. Common errors in IM medication administration include administering large volumes to the deltoid muscle or using the gluteal muscle, causing the medication and needle to hit a nerve, bone, or adipose tissue. Another common error is using long needle lengths in patients with small amounts of muscle tissue, also increasing the chances of hitting bone tissue and causing osteomyelitis. As with any injection, failure to create a taut surface and hesitating with the injection may result in needle tip contamination, and recapping a used needle may lead to a needle-stick injury. Therefore, strict adherence to safe needle practices should always be enforced.

Institute of Medicine. To Err is Human: Building a Safer Healthcare System. Academic Press. Washington, DC. (2000).
Centers for Disease Control and Prevention. http://www.cdc.gov/. (2017).

Transcript

Intramuscular, or IM, injection is a safe and effective alternate route commonly used to deliver medications, which includes antibiotics, hormones, and vaccinations. An intramuscular injection deposit medications deep into the muscle tissue. Since muscle fibers are well perfused, this route of administration provides quick uptake of the medication and allows administration of relatively large volumes.

This video will focus on the essential steps that every nurse should follow in order to correctly prepare and administer an intramuscular injection

Before delving into the protocol, let's review the common intramuscular injection sites and considerations associated with site and needle selection. The sites that are most commonly utilized for IM injections include the shoulder's deltoid muscle; the thigh's vastus lateralis; and the hip's ventrogluteal, gluteus medius, or dorsogluteal muscles. The deltoid site is most commonly used for immunizations. However, only up to 1 mL of any medication may be administrated in this muscle. The gluteal site is commonly used to administer antibiotics, or any medication, when the volume exceeds 2 mL but is less than 3 mL for an adult.

Infants should receive all intramuscular medications in the vastus lateralis because it is the largest muscle at that developmental age. If administering an intramuscular injection into a child under age 2, the maximum amount that should be administered is 1 mL.

It is recommended to avoid administering intramuscular injections into the dorsogluteal muscle, because this location has an increased risk of hitting a blood vessel, nerve, or bone.

Needle selection is dependent upon the age of the patient, administration site, volume of fluid, amount of muscle and adipose tissue, and viscosity of the solution. Large bore needles-18 and 20 gauge-are appropriate for thick, viscous medications, while small bore needles-22 and 25 gauge-are appropriate for thinner medications and infants. Long needles-1 to 1½ inch-are most often used for patients with large amounts of adipose tissue covering the muscle site, or for deep muscles, such as the ventrogluteal muscle, whereas shorter needle lengths-5/8th to ½ inch-are appropriate for thin patients and pediatric patients to avoid needle sticks into the bone.

Let's begin by reviewing the necessary preparation steps.

First, review the patient's medical history. It is important to have a working knowledge of the patient's preferences, allergies, and medication administration times. This information can be obtained by asking the patient and reviewing their Medication Administration Record, or MAR. It is also important to have an understanding of the medication being delivered to the patient. Medication information, like indication and adverse effects, can be obtained by referencing online databases. Next, keeping in mind the factors discussed in the previous section, select the most appropriate site for intramuscular injection.

Remember, adherence to the five "rights"-right patient, right medication, right dose, right route, right time-at three checkpoints of the safe medication administration process is imperative to prevent patient injury and harm. In order to learn about these five "rights" in detail, refer to another video in this collection.

Remember to wash or sanitize your hands before and after each patient encounter. Vigorous friction for at least 20 seconds should be applied while washing hands with soap and warm water or while applying hand sanitizer.

Once the injection site is selected, obtain the patient's medication from the medication preparation area. Recall, adherence to the five "rights" at this first safety checkpoint of acquiring medication is critical. In the preparation area, first calculate the volume of medication needed for the correct patient dose. The calculated volume must be based on the concentration of the provided medication. For example, if the ordered dose is 2 milligrams and the vial concentration is 5 milligrams per milliliter, then the amount of volume to that you need to withdraw can be obtained by using the method of cross-multiplication, which is 0.4 milliliters in this case.

Then, remove the medication, which is a vial or an ampule, from the box and remove the vial top. Scrub the medication vial with an alcohol prep pad for 20 seconds, with friction and intent, while watching a wall clock or watch. Next, using aseptic technique, attach a blunt-tip needle to the syringe, remove the needle cap, and withdraw the appropriate amount of medication needed for injection. Note the viscosity of the medication being withdrawn from the vial. This will help determine the needle size needed for the patient's IM injection. Hold the vial at eye-level and the needle tip below the level of medication to ensure the correct amount of liquid is withdrawn and air bubbles are avoided. If at any time during medication withdrawal, the needle hub, needle cap, or syringe connection point is contaminated from contact with hands or countertop, obtain new supplies and restart the medication preparation procedure. Next, slowly remove the needle from the medication. Then discard the blunt-tipped needle in an approved sharps container, while maintaining the sterility of the syringe containing the medication.

Now, attach the appropriate-sized needle to the syringe. Needle selection was discussed in the previous section of this video. Next, label the syringe with the medication name, dose, and any other information required by your institution's labeling policy. Then, complete the second safety check, adhering to the 5 "rights" of medication administration. After the second safety check is complete, gather the necessary supplies, including alcohol prep wipes, non-sterile gloves, adhesive bandages or a cotton ball and silk/paper tape. Then, discard any remaining trash appropriately and proceed to the patient's room.

Now, let's learn how to perform IM injection. Upon entering the patient's room, wash your hands thoroughly for 10-20 seconds, as described previously, and complete the third and final medication safety check, adhering to the 5 "rights" of medication administration. As with any medication administration, remind the patient of the medication purpose, any adverse reactions, and go over the administration procedure. Next, remove bed linens and the patient's gown or clothing to access the selected injection muscle. Then locate the injection site.

If the deltoid has been selected as the injection muscle, locate the injection site by first locating the acromion process at the top of the shoulder. Then make a "V" with the index and middle fingers on the patient's shoulder, with the tips of each finger touching the bottom of the acromion process. The deltoid injection site is in the middle of the "V."

If the ventrogluteal muscle has been selected as the injection muscle, instruct your patient to lay on their side, exposing the selected hip. Locate the greater trochanter and the iliac crest. Place the palm of the hand on the patient's hip, with the thumb on the patient's greater trochanter. Point the index finger at the patient's anterior iliac crest. Then spread the middle finger toward the back of the patient, forming a "V." The needle injection site is located between the knuckles of the index and middle fingers.

Once the injection site has been located, don a pair of non-sterile gloves. If the patient has a latex allergy, be sure to use non-latex gloves to avoid allergic reactions. According to the CDC, it is unnecessary to clean the injection area with an alcohol prep pad, unless the skin is visibly soiled or dirty.

Next, obtain the prepared syringe. Hold the syringe between the thumb and index finger of your dominant hand and remove the needle cap with your non-dominant hand. Then, using your non-dominant hand, pull the patient's skin taut between the thumb and forefinger, pushing the adipose tissue approximately 1 inch away from the muscle. In one quick motion, insert the needle at a 90° angle into the patient's muscle. This is called the "z-track technique," which prevents the medication from leaking into the subcutaneous tissue.

Slowly press the syringe plunger down with the thumb or index finger to inject the medication into the patient. The medication should be administered at a rate of 1 milliliter per 10 seconds. The syringe needle may be stabilized into the patient's skin with the non-dominant hand. When the medication administration is complete, slowly remove the needle from the patient. Engage the needle safety device with the thumb and immediately discard the syringe and needle into the sharps container.

If blood is observed at the injection site, apply an adhesive bandage or cotton ball with silk/paper tape over the area. Then help the patient adjust their gown and bed linens. Next, remove the non-sterile gloves and immediately discard them, along with any other trash. Then thoroughly wash your hands for 10-20 seconds.

Finally, complete the required documentation in the patient's electronic MAR. Be sure to document the medication administration time, date, location, and any other facility-required information. Before leaving the patient's room, instruct the patient to immediately report any unusual reactions to the medication, such as injection site pain, redness, or swelling, to the nursing staff. Then exit the patient's room and thoroughly wash your hands again.

"Selecting the injection site for the administration of IM medications is very important. Immunizations and medication doses between 1-2 milliliters should be administered in the deltoid muscle. Medication doses between 2-3 milliliters should be administered in the ventrogluteal muscle."

"Common IM injection errors include administering large medication volumes into the deltoid muscle and selecting long needles in patients with small amounts of muscle tissue. These errors can lead to a needle hitting a nerve, adipose tissue, or bone, which may cause osteomyelitis"

"As with any injection, improper technique when recapping a needle may lead to a "needle stick" injury, and failure to create a taut surface or hesitating with the injection may result in needle-tip contamination. Therefore, all nurses must adherence to safe needle practices to safely and effectively administer IM injections."

You've just watched a JoVE video on the preparation and administration of IM injections. You should have a better understanding of IM injection sites and factors involved in site and needle selection, and you should also be aware of the critical protocol steps for safe and effective delivery of IM medications. As always, thanks for watching!

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