Transcript intramuscular injections

By
Greg Dix
Begin
Introduction
Welcome to this interactive learning pack on injection technique.
You are required to complete this package before attending the
practical skill session, it should take you approximately 60
minutes. There will be a knowledge test at the beginning of the
practical session to review your learning.
GOOD LUCK!
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Learning Outcomes
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Discuss the usage of commonly used needles and syringes
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Identify the differences between the intramuscular and
subcutaneous routes
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Identify and locate the anatomical sites for intramuscular and
subcutaneous injections
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Describe the procedure for preparation and administration of
intramuscular and subcutaneous injections
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Describe the method used to administer intramuscular injections
using the Z-track technique
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Contents Page (
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Needles
Syringes
Intramuscular Injections
Quiz (IM)
Subcutaneous Injections
Quiz (SC)
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Types of Needle
Needles come in a variety of colours and sizes. For intramuscular
injections (in adults) a green needle should be used, unless the
patient is extremely thin, with little muscle mass. In such cases a
blue needle would be the needle of choice. However each patient
should be assessed individually. Very rarely are children given
intramuscular injections.
An orange needle should be used for subcutaneous injections,
although some drugs by this route are already assembled in prewrapped syringes with needles attached.
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21g (Green)
23g (Blue)
25g (Orange
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Types of Syringes
Syringes come in a variety of sizes from 1ml to 50 mls, however for
injection purposes you will only use the following four:
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1ml
2ml
5ml
Insulin Syringe
Depending on the amount of fluid to be injected, would influence your
choice as to what size syringe to use. For example, if you are injected
2mls of fluid you would use a 2ml syringe, rather than a 5 ml syringe.
Please note that insulin syringes are marked in international
units and not millilitres!
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Intramuscular Injections
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The Intramuscular route is used to deposit a drug into the muscle
layer, which lies beneath the subcutaneous tissue. The rate of
absorption is quicker by this route than via the subcutaneous
route, because of the rich blood supply within the muscle fibres
Skin
Subcutaneous Layer
Muscle Layer
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Intramuscular Injections…
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If two drugs are to be administered, check compatibility. If the drugs are
incompatible, separate syringes and sites must be used for each drug
The intramuscular route may be contraindicated for some patients. For
example, those with blood clotting disorders.
The local code of practice for drug administration and the standards for the
administration of medications (NMC 2002)http://www.nmc-uk.org must be
adhered to at all times.
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Intramuscular Injections
Sites
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There are five sites commonly used for
intramuscular injections:
Deltoid
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Dorsogluteal
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Rectus Femoris
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Vastas Lateralis
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Ventrogluteal
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Locating the deltoid site
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This is located by drawing an
imaginary horizontal line, 2-3 finger
breadths (2.5-5cms) below the lower
edge of the acromion process.
The injection should be given into an
imaginary triangle, whose base is the
central half of this horizontal line and
whose apex is formed inverted on the
midpoint of the lateral aspect of the
arm in line with the axilla
Due to the small area of this site, the
number and volume of injections (not
usually more than 1ml) which can be
given into this site is limited. For
example, vaccines which are usually
small in volume are often given in the
deltoid muscle
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www.drugguide.com/muscleinjection.asp
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Locating the dorsogluteal site
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Often referred to as the upper outer
quadrant, the method of dividing the
buttock into four equal areas by
drawing imaginary lines, to bisect it
vertically and horizontally has been
utilised by many nurses over the years
to locate this injection site.
This site is better located by palpating
the greater trochanter and posterior
iliac spine, then injecting laterally and
superior to the midpoint of an
imaginary line joining these points
The presence of major nerves and
blood vessels, and the relatively slow
uptake of medication from this site
(because of a thick layer of adipose
tissue) makes this site less favourable.
Please check hospital policy prior
to using this site
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www.drugguide.com/muscleinjection.asp
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Locating the rectus femoris site
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Located midway between the
patella (knee) and superior iliac
crest on the mid-anterior aspect of
the thigh.
The uptake of drugs from this
region is slower than from the
arm, but faster than from the
buttocks.
This site is often utilised by
patients who administer their own
medication, as it is readily
available in the sitting or lying
position.
Injections into this site may cause
considerable discomfort
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Rectus
femoris
(Workman 1999)
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Locating the vastus lateralis site
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This is located on the lateral aspect of
the thigh between the greater
trochanter of the femur and the lateral
femoral condyle of the knee. Divide
into thirds with the middle third being
the injection site.
One of the advantages of this site is
that it is easy to access, but most
importantly there are no major blood
vessels or significant nerve structures
in the vicinity of the site.
This muscle, like the rectus femoris is
associated with the quadriceps femoris
group of muscles and has similar
absorptive properties
www.drugguide.com/muscleinjection.asp
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Ventrogluteal Site
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Located by the nurse placing the heel
of his/her opposing hand (i.e right
hand for left hip) on the patients
greater trochanter. The index finger of
the hand is placed on the patients
anterior superior iliac spine and the
middle finger stretched dorsally
towards but below the iliac crest. The
triangle formed by the index finger,
the third finger and the crest of the
ilium is the injection site
This site is free of penetrating nerves
and blood vessels and has attracted
significant attention in the nursing
literature. It is the opimum site for IM
injections.
The extent to which this muscle is
used in the United Kingdom is
unknown.
www.drugguide.com/muscleinjection.asp
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Preparing the Injection
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Injections should be drawn up in a
clean, designated area. Always
check that the packaging of all
equipment is intact prior to use
and check expiry date.
Check the drug to be administered
against the patients prescription
Wash hands. Prepare the
equipment- syringe and 21g/23g
needle (check hospital policy).
Check that the plunger of the
syringe moves freely in the
syringe barrel.
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Preparing the Injection
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The drug may be contained within
an ampoule or a vial. If drawing
up a drug from an ampoule, tap
the stem of the ampoule while
holding it vertically. Using a
snapping motion, break off the
top of the ampoule along the
scored line at its neck.
Draw up the drug into the syringe.
Holding the syringe with the
needle uppermost, tap the side of
the syringe to allow any air
bubbles to rise and expel the air
gently. Change the needle.
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Drawing up from a vial
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Preparing the patient
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Take the receiver and the
prepared drug and prescription
chart to the patient. Check the
patient’s identity with the
prescription chart and identity
band.
Ensure privacy, then assist the
patient into a comfortable position
and expose the site to be injected.
Clean skin as per hospital
protocol.
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Administering the Injection
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Stretch the skin to one side
around the injection site (Z-track
technique). Holding the barrel of
the syringe firmly between thumb
and index finger, plunge the
needle into the skin at an angle of
90 degrees leaving a third of the
needle exposed (just in case the
needle snaps).
Steady the barrel and pull back
gently on the plunger to observe if
blood is aspirated. If blood is
present discontinue the procedure
and reassure the patient. Dispose
of the drug and all equipment and
repeat as appropriate.
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Administering the Injection
cont…
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Inject the drug by pushing the plunger of the syringe using your
thumb, with a slow continuous movement. The fingers steady the
syringe and act as a counterforce.
Injecting slowly allows time for the tissue to be displaced and is less
painful. Inject solution at a rate of 1ml per 10 seconds.
Wait a few seconds to allow diffusion through the muscle, then
withdraw the needle. Apply pressure to the site if necessary.
Make the patient comfortable and dispose of sharps according to
hospital policy.
Never re-sheath the needle
Sign the patient’s prescription chart and document the time the
drug was given.
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Z – Track Technique
A
B
C
A) Using your non-dominant hand, pull the skin and subcutaneous tissue 2-3 cms
sidewards
B) Pierce the skin with a quick dart-like motion at 90 degree’s. Aspirate for blood, if
none, slowly inject the medication
C) Withdraw the needle and release the skin to create a disjointed pathway which locks
in the medication. Note – remember to use a long enough needle to reach the
target muscle so that the medication is not deposited into the subcutaneous tissue.
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(Rodger & King 2000)
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Complications of IM injections
Complications can occur at the site of the injection following IM drug
administration. For example, seepage of the injection solution
and/or bleeding from the injection site onto the skin, pain, irritation
and even skin lesions.
Such complications have been widely researched and one possible
cause being some degree of fault in the IM injection administration
technique itself.
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Quiz
The following quiz consists of a list of 8 multiple choice
questions pertaining to intramuscular injections. Please
click the mouse over the sound symbol for the answer
you believe to be the correct one. If you hear the sound
of a gun shot, then unfortunately, you have chosen the
incorrect answer. A round of applause indicates the
correct answer.
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Question 1
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What colour needle
would you normally
use to administer an
intramuscular
injection to an adult?
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A - Blue
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B - Green
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C - Orange
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Question 2
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When administering
an intramuscular
injection, a blue
needle is only used
when the patient is..
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A - Obese
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B - Thin
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C - A diabetic
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Question 3
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A 2ml syringe is used
for every
intramuscular
injection
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A - Yes
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B - No
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C - Doesn’t matter
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Question 4
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When administering
an IM injection, the
angle of the needle
should be at…
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A – 45 degrees
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B – 90 degrees
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C – 60 degrees
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Question 5
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The intramuscular
layer lies beneath
the..
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A – Subcutaneous
layer
B – Skin
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Question 6
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The rate of absorption
via the IM rate is
quicker than the SC
route because of…
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A – Rich blood supply
B – More nerve
endings
C – thick muscle
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Question 7
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The Z track technique
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A – Deposits the drug
into subcutaneous tissue
B – Deposits the drug
into the target muscle
C – Deposits the drug
into both the
subcutaneous tissue and
the target muscle
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Question 8
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The Dorsogluteal
muscle can be
found…
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A – Front of leg
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B – Buttocks
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C – Side of leg
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Subcutaneous Injections
Drugs that need to be absorbed steadily and slowly are given via the
subcutaneous route. A subcutaneous injection is administered beneath the
epidermis into the fat and connective tissue underlying the dermis.
Examples of drugs given via this route include insulin and low molecular
weight heparin. The majority of injections given to children is via this
route.
Skin
Subcutaneous Layer
Muscle Layer
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Subcutaneous Injection Sites
Rotation of the injection sites will
reduce the likelihood of local
reaction and improve absorption
of the drug:
•Abdomen
•Thigh
•Deltoid area
•Loins
www2.mc.duke.edu/ivf/injectio.htm
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Procedure for Administration
of SC injections
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Follow the same procedure for drawing up the drug as if you were
drawing up an IM injection. However remember that some drugs
are available in pre-filled syringes.
Expose the injection site and clean the skin according to hospital
policy. Grasp the skin to elevate the subcutaneous tissue.
A topical local anaesthetic can be applied to the injection site for
children. Distraction therapy may also be necessary.
SC injections are normally given at an angle of 45 degrees when
they are more than half an inch long (an orange needle)
If the needle is half an inch or less (pre-filled syringes), the needle
should then be inserted at an angle of 90 degrees.
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Procedure cont…1
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There is no need to pull back to aspirate as there is very little blood
supply in the subcutaneous layer.
Administer the injection at a rate of 1ml per 10 seconds.
Withdraw the needle and apply pressure to the site if necessary.
Make the patient comfortable and dispose of sharps according to
hospital policy.
Never re-sheath the needle
Sign the patient’s prescription chart and document the time the
drug was given.
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Complications of SC Injections
Complications can occur at the site of injection following SC
administration. For example:
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Excessive bruising, especially following heparin administration
Repeated cleaning of the injection site with alcohol swabs and/or
repeated use of the same site may result in hardening of the skin.
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Quiz
The following quiz consists of a list of 7 multiple choice
questions pertaining to subcutaneous injections. Please
click the mouse over the sound symbol for the answer
you believe to be the correct one. If you hear the sound
of a gun shot, then unfortunately, you have chosen the
incorrect answer. A round of applause indicates the
correct answer.
Previous
Next
Question 1
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What colour needle
would you normally
use to administer a
subcutaneous
injection
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A - Orange
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B - Blue
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C - Green
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Question 2
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An insulin syringe is
marked in…
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A - International mls
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B - International mgs
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C – International units
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Question 3
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When administering a
SC injection with a
needle less than half
an inch, the angle of
the needle should be..
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A – 90 degrees
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B – 45 degrees
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C – 30 degrees
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Question 4
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When administering a
SC injection with a
needle longer than half
an inch, the angle of
the needle should be…
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A – 60 degrees
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B – 45 degrees
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C – 90 degrees
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Question 5
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Aspirating for blood is
required prior to
administration of a
S/C drug..
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A - Sometimes
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B – Always
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C - Never
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Question 6
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A common site for a
SC injection is the…
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Abdomen
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Shoulder
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Calf
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Question 7
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Rotating SC sites
will…
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A – Decrease pain
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B – Reduce Swelling
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C – Prevent hardening
of the skin
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Further Reading
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It is recommended that you access the
resource file for articles upon injection
technique.
The articles in yellow bold on the following
page are those we recommend you read.
References
Beyea S; Nicoll LM (1996) Back to basics. Administering intramuscular injections the right way. American Journal of
Nursing. Vol 91. No 1. P 34-35
Greenway.K (2004) Using the Ventrogluteal Site for Intramuscular Injection. Nursing Standard. Vol18,
No 25. p.39-42.
King L (2003) Subcutaneous insulin injection technique. Nursing Standard. Vol 17. No 34. P45-52.
Pritchard AP; Mallett J (1994) Manual of clinical nursing procedures. Blackwell Scientific Publications. Oxford.
Rodger MA; King L (2000) Drawing up and administering intramuscular injections: a review of the
literature. Journal of Advanced Nursing. Vol 31. No 3. P 574-582.
Royal College of Paediatrics and Child Health (2002) Position Statement on Injection Technique.
London: Royal College of Paediatrics and Child Health.
Workman. B (1999) Safe Injection Techniques. Nursing Standard. Vol13. No.39 p47-53.
www.2.mc.duke.edu/ivf/injectio.htm - accessed 30/5/04
www.drugguide.com/muscleinjection.asp -accessed 30/5/04
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I hope you found this learning pack useful and
informative.
Thank -You
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