Administering Intramuscular Injection

Adm ini st ering In tramuscular Injection Def initi on An intramuscular injection is an injection given directly into the central area of a specific muscle. In this way, the bl oo d vesse ls supplying that muscle distribute the injected medication via the cardio vascular syst em. Pur pose Intramuscular injection is used for the delivery of certain drugs not recommended for other routes of administration, for instance intravenous, oral, or subcutaneous. The intramuscular route offers a faster rate of absorption than the subcutaneous route, and muscle tissue can often hold a larger volume of fluid without discomfort. In contrast, medication injected into muscle tissues is absorbed less rapidly and takes effect more slowly that medication that is injected intravenously. This is favorable for some medications. Preca ution s Careful consideration in deciding which injectable route is to be used for the prescribed medication is essential. The intramuscular route should not be used in cases where muscle size and condition is not adequate to support sufficient uptake of the drug. Intramuscular injection should be avoided if other routes of administration, especially oral, can be used to provide a comparable level of absorption and effect in any given individual's situation and condition. Intramuscular injections should not be given at a site where there is any indication of pain . Descri ption Intramuscular (IM) injections are given directly into the central area of selected muscles. There are a number of sites on the human body that are suitable for IM injections; however, there are three sites that are most commonly used in this procedure. De lt oid mus cl e The deltoid muscle located laterally on the upper arm can be used for intramuscular injections. Originating from the Acromion process of the scapula and inserting approximately one-third of the way down the humerus, the deltoid muscle can be used readily for IM injections if there is sufficient muscle mass to justify use of this site. The deltoid's close proximity to the radial nerve and radial artery means that careful consideration and palpation of the muscle is required to find a safe site for penetration of the needle. There are various methods for defining the boundaries of this muscle.

Vastus la teralis mus cl e The vastus lateralis muscle forms part of the quadriceps muscle group of the upper leg and can be found on the anteriolateral aspect of the thigh. This muscle is more commonly used as the site for IM injections as it is generally thick and well formed in individuals of all ages and is not located close to any major arteries or nerves. It is also readily accessed. The middle third of the muscle is used to define the injection site. This third can be determined by visually dividing the length of the muscle that originates on the greater trochanter of the femur and inserts on the upper border of the patella and tibial tuberosity through the patella ligament into thirds. Palpation of the muscle is required to determine if sufficient body and mass is present to undertake the procedure. Glut eus medius mus cle The gluteus medius muscle, which is also known as the ventrogluteal site, is the third commonly used site for IM injections. The correct area for injection can be determined in the following manner. Place the heel of the hand of the greater trochanter of the femur with fingers pointing towards the patient's head. The left hand is used for the right hip and vice versa. While keeping the palm of the hand over the greater trochanter and placing the index finger on the anterior superior iliac spine, stretch the middle finger dorsally palpating for the iliac crest and then press lightly below this point. The triangle formed by the iliac crest, the third finger and index finger forms the area suitable for intramuscular injection. Determining which site is most appropriate will depend upon the patient's muscle density at each site, the type and nature of medication you wish to administer, and of course the patient's preferred site for injections. Preparation Before ad mini st ering med ication , a health care practitioner verify the medication order for accuracy and prepare the medication from the vial or ampule. •

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First, ensure you have identified the patient and assist them into a position which is comfortable and practical for access to the injection site you have chosen. Locate the correct area for injection using the above guidelines or those taught during medical training. Clean the site with an alcohol swab or other cleansing agent. Prepare the syringe by removing the needle cover, inverting the syringe, and expelling any excess air. Approximately 0.1–0.2 ml of air should be left in the syringe so that the air in the top of the syringe chamber, when the syr in ge and need le are pointing down, forces the entire amount of medication to be delivered. This also prevents medication residue from being left in the needle, where it can leak into the subcutaneous and dermal layers when the syringe and needle are removed from the muscle.

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When ready to inject, spread the skin using the fingers of the non-dominant hand. Holding the syringe with the thumb and forefinger of the dominant hand, pierce the skin and enter the muscle. This process should be done quickly with sufficient control so as to lessen the discomfort of the patient. If there is little muscle mass, particularly in infants or the elderly, then you may need to pinch the muscle to provide more volume of tissue in which to inject. Aspirate at the injection site (while syringe and needle are within the muscle) by holding the barrel of the syringe with the non-dominant hand and pulling back on the syringe plunger with the dominant hand. If blo od appears in the syringe, it is an indication that a blood vessel may have been punctured. The needle and syringe should be immediately withdrawn and a new injection prepared. If no blood is aspirated, continue by slowly injecting the medication at a constant rate until all medication has been delivered. Withdraw the needle and syringe quickly to minimize discomfort. The site may be briefly massaged, depending on the medication given. Some medication manufacturers advise against massaging the site after injection, as it reduces the effect and intention of the medication by dispersing it too readily or over too large an area. Manufacturers' recommendations should be checked. Discard the used syringe and needle intact as soon as possible in an appropriate disposal receptacle. Check the site at least once more a short time after the injection to ensure that no bleeding, swelling or any other signs of reaction to the medication are present. Monitor the patient for other signs of side effects, especially if it is the first time the patient is receiving the medication. Document all injections given and any other relevant information.

Af ter care Monitor for signs of localized redness, swelling, bleeding, or inflammation at injection site. Observe the patient for at least 15 minutes following the injection for signs of reaction to the drug.

Administering Subcutaneous Injection Def initi on A subcutaneous injection is a method of drug administration. Up to 2 ml of a drug solution can be injected directly beneath the skin. The drug becomes effective within 20 minutes. Pur pose Subcutaneous injection is the method used to administer drugs when a small amount of fluid is to be injected, the patient is unable to take the drug orally, or the drug is destroyed by intestinal secretions. Preca ution s If the drug to be administered is harmful to superficial tissues, it should be administered intramuscularly or intravenously. It is useful to remember the following when administering any medication: the right patient, the right medicine, the right route, the right dose, the right site, and the right time. Descri ption With the subcutaneous route, a small thin needle is inserted beneath the skin and the drug injected slowly. The drug moves from the small bl oo d ves sel s into the bloodstream. Subcutaneous injections are usually given in the abdomen, upper arm, or the upper leg. Preparation The hands should be washed, and gloves may be worn during the procedure. A syr in ge and needle should be prepared. If a sterile, multiple-dose vial is used, the rubber-capped bottle should be rubbed with an antiseptic swab. The needle is then inserted through the center of the cap and some air from the syringe inserted to equalize the pressure in the container. Slightly more of the required amount of drug is then removed. Holding the syringe vertically at eye level, the syringe piston is pushed carefully to the exact measurement line. If a small individual vial containing the correct amount of drug is used, the outside should be wiped with an antiseptic swab and held in the swab while the top is removed. The needle is then inserted into the vial, taking care that the tip of the needle does not scratch against the sides of the vial, thereby becoming blunt. A syringe and needle containing the drug should be placed on a tray with sterile cotton swabs, cleaning disinfectant, and adhesive tape. If the patient is unfamiliar with the procedure, the nurse should explain what he or she is about to do and that

the patient is to receive medication prescribed for them. The dose on the patient's prescription sheet should be checked prior to administration. A screen should be drawn around the patient to avoid any personal embarassment. The injection site is then rubbed vigorously with a swab and disinfectant to cleanse the area and increase the blo od supply. A small piece of skin and subcutaneous tissue is pinched between the thumb and forefinger, and the needle inserted quickly at a 45-degree angle. Certain drugs such as heparin are given at a 90-degree angle rather than at 45 degrees. It is important to ensure that the needle is not in a vein. Therefore the syringe should be aspirated a little by pulling back on the piston. If blood is present, the needle should be re-injected, and the piston withdrawn slightly once more. The skin is then released and the syringe piston pushed down steadily and slowly. A sterile cotton swab should be pressed over the injection site as the needle is quickly withdrawn, and the swab is taped to the skin for a few minutes, if required. Af ter care Monitor the patient's reaction and provide reassurance if required. Dispose of all waste products carefully, and place the syringe and needle in a puncture-resistant receptacle. Wash the hands. For patients requiring frequent injections, the site is changed each time.

Administering an Intradermal Injection Def initi on Intradermal injections are injections given to a patient in which the goal is to empty the contents of the syringe between the layers of the skin. Pur pose Intradermal injection is often used for conducting skin aller gy tests and testing for antibody formation. Preca ution s This is a painful procedure and is used only with small amounts of solution. The nurse should ensure that the needle is inserted into the epidermis, not subcutaneously, as absorption would be reduced. It is imperative that the following information is reviewed prior to administration of any medication: the right patient, the right medicine, the right route, the right dose, the right site, and the right time. Because this method of injection is often used in allergy testing, it is important that latex-free syringes are used. Descri ption With the intradermal injection, a small thin needle of 25 or 27 gauge and 3/8 to 3/4 inch (1-2 cm) is inserted into the skin parallel with the forearm, with the bevel facing upward. These injections are normally given in the inner palm-side surface of the forearm, with the exception of the human diploid cell rabies vaccine, which is given in the deltoid muscle. Preparation After washing his or her hands, the nurse should put on latex-free gloves to complete the procedure. A sterile syringe and a needle should be prepared. If a sterile multiple-dose vial is used, the rubber-capped bottle should be rubbed with an antiseptic swab. The needle is then inserted through the center of the cap, and some air from the syringe inserted to equalize the pressure in the container. Slightly more of the required amount of drug is should then be removed. The syringe should be held vertically at eye level, then the syringe piston should be pushed carefully to the exact measurement line. If a small individual vial containing the correct amount of drug is used, the outside should be wiped with an antiseptic swab and held in the swab while the top is snapped off. The needle is then inserted into the vial, taking

care that the tip of the needle does not scratch against the sides of the vial, thereby becoming blunt. The syr in ge and needle containing the drug should be placed on a tray with sterile cotton swabs and cleaning disinfectant. If the patient is unfamiliar with the procedure, the nurse should explain what he or she is about to do, and let the patient know that the medication was prescribed by the doctor. As with all drugs prescribed for a patient, the dose on the patient's prescription sheet should be checked prior to administration. A screen should be drawn around the patient to ensure privacy. The injection site is then rubbed vigorously with a swab, and disinfectant applied to cleanse the area and increase the bl oo d supply. With the bevel of the needle facing upwards, the needle is inserted into the skin, parallel with the forearm. The syringe piston should then be pushed in steadily and slowly, releasing the solution into the layers of the skin. This will cause the layers of the skin to rise slightly. Af ter care Monitor the patient's reaction and provide reassurance, if required. Dispose of all waste products carefully and place the syringe and needle in a puncture-resistant receptacle.

Administering an Intramuscular Injection 1. 2. 3. 4. 5. 6.

Assemble equipment and check physician’s order. Explain procedure to patient. Perform hand hygiene. If necessary, withdraw medication from ampule or vial. Do not add air to syringe. Identify the patient carefully. There are three ways to do this. a. Check the name on the patient’s identification badge. b. Ask the patient his or her name. c. Verify the patient’s identification with a staff member who knows the patient. 7. Provide for privacy. Have patient assume a position for the site selected. a. Ventrogluteal – Patient may lie on back or side with hip and knee flexed. b. Vastus lateralis – Patient may lie on the back or may assume a sitting position. c. Deltoid – Patient may sit or lie with arm relaxed. d. Dorsogluteal – Patient may lie prone with toes pointing inward or on side with upper leg flexed and placed in front of lower leg. 8. Locate site of choice (vastus lateralis, ventrogluteal, deltoid, dorsogluteal) and ensure that the area is not tender and is free of lumps or nodules. Don disposable gloves. 9. Clean area thoroughly with alcohol swab, using friction. Allow alcohol to dry. 10.Remove needle cap by pulling it straight off. 11.Displace skin in a Z-track manner or spread skin at the site using your nondominant hand. 12.Hold syringe in your dominant hand between thumb and forefinger. Quickly dart needle into the tissue at 72- to 90- degree angel. 13.As soon as needle is in place, move your nondominant hand to hold lower end of syringe. Slide your dominant hand to tip of barrel. 14.Aspirate slowly (for at least 5 seconds), pulling back on plunger to determine whether the needle is in a blood vessel. If blood is aspirated, discard needle, syringe and inject in another site. 15.If no blood is aspirated, inject solution slowly (10 seconds per mL of medication). 16.Remove needle slowly and steadily. Release displaced tissue if Z-track technique was used. 17. Apply gentle pressure at site with small sponge. 18.Do not recap used needle. Discard needle and syringe in appropriate receptacle. 19.Assist patient to a position of comfort. Encourage patient to exercise extremity used for injection if possible. 20.Remove gloves and dispose of them properly. Perform hand hygiene.

21.Chart administration of medication, including the site of administration. This may be documented on the CMAR. Evaluate patient response to medication within an appropriate time frame. Assess site, if possible, within 2 to 4 hours after administration.

Administering an Subcutaneous Injection Assemble equipment and check physician’s order. Explain procedure to patient. Perform hand hygiene. If necessary, withdraw medication from ampule or vial. Identify patient carefully. Close curtain to provide privacy. Don disposable gloves (optional). 6. Have patient assume a position appropriate for the most commonly used sites. a. Outer aspect of upper arm- Patient’s arm should be relaxed and at side of body. b. Anterior thighs- Patient may sit or lie with leg relaxed. c. Abdomen-Patient may lie in a semirecumbent position. 1. 2. 3. 4. 5.

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Locate site of choice (outer aspect of upper arm, abdomen, anterior aspect of thigh, upper back, upper ventral or dorsogluteal area). Ensure that area is not tender and is free of lumps or nodules.

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Clean area around injection site with an alcohol swab. Use a firm circular motion while moving outward from the injection site. Allow antiseptic to dry. Leave alcohol swab in a clean area for reuse when withdrawing the needle.

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Remove needle cap with nondominant hand, pulling it straight off.

10. Grasp and bunch area surrounding injection site or spread skin at site. 11. Hold syringe in dominant hand between thumb and forefinger. Inject needle quickly at an angle of 45 to 90 degrees, depending on amount and turgor of tissue and length of needle. 12. After needle is in place, release tissue. If you have a large skin fold pinched up, ensure that the needle stays in place as the skin is released. Immediately move your nondominant hand to steady the lower end of the syringe. Slide your dominant hand to the tip of the barrel. 13. Aspirate, if recommended, by pulling back gently on syringe plunger to determine whether needle is in the blood vessel. If blood appears, the needle should be withdrawn, the medication syringe and needle discarded, and a

new syringe with medication prepared. Do not aspirate when giving insulin or heparin. 14. If no blood appears, inject solution slowly. 15. Withdraw needle quickly at the same angle at which it was inserted. 16. Massage area gently with alcohol swab. (Do not massage a subcutaneous heparin or insulin injection site.) Apply a small bandage if needed. 17. Do not recap used needle. Discard needle and syringe in appropriate receptacle. 18. Assist patient to a position comfort. 19. Remove gloves, if worm, and dispose of them properly. Perform hand hygiene. 20. Chart administration of medication, including the site of administration. This charting can be done on CMAR. 21. Evaluate patient response to medication within an appropriate time frame.

Administering an Intradermal Injection 1. 2. 3. 4. 5.

Assemble equipment and check physician’s order. Explain procedure to patient. Perform hygiene. Don disposable gloves. If necessary, withdraw medication from ampule or vial. Select area on inner aspect of forearm that is not heavily pigmented or covered with hair. Upper chest or upper back beneath the scapulae also are sites for intradermal injections. 6. Cleanse the area with an alcohol swab by wiping with a firm circular motion and moving outward from the injection site. Allow skin to dry. If skin is oily, clean area with pledget moistened with acetone. 7. Use nondominant hand to spread skin taut over injection site. 8. Remove needle cap with nondominant hand by pulling it straight off. 9. Place needle almost flat against patient’s skin, bevel side up. Insert needle into skin so that point of needle can be seen through skin. Insert needle only about ? inch. 10.Slowly inject agent while watching for a small wheal or blister to appear. If none appears, withdraw needle slightly. 11.Withdraw needle quickly at the same angle it was inserted. 12.Do not massage area after removing needle.

13.Do not recap used needle. Discard needle and syringe in the appropriate receptacle. 14.Assist patient into a position of comfort. 15.Remove gloves and dispose of them properly. Perform hand hygiene. 16.Chart administration of medication as well as the site of administration. Charting may be documented on CMAR, including location. Some agencies recommend circling the injection site with ink. 17. Observe the area foe sign of reaction at ordered intervals, usually at 24- to 72- periods. Inform the patient of this inspection.