NUR 113: SKILL 22-4 ADMINISTERING INTRAMUSCULAR INJECTIONS For this skill, I’m going to do a brief introduction, and then I will “dive” into the skill!

NOBODY LIKES RECEIVING AN INJECTION, SO LEARNING THE PROPER TECHNIQUE TO ADMINISTER ONE IS VITAL, TO KEEP THE PATIENT SAFE!

ADMINISTERING AN INTRAMUSCULAR INJECTION The intramuscular (IM) injection route deposits medication into deep muscle tissue, which has a rich blood supply, allowing medication to absorb faster than by the subcutaneous route. An IM injection requires a longer & larger-gauge needle to penetrate deep muscle tissue The viscosity of the medication, injection site, patient’s weight, and amount of adipose tissue influence needle size selection. Muscle is less sensitive to irritating and viscous medication. A normal, well-developed adult can safely tolerate 2 to 5 mL of medication in larger muscles such as the ventrogluteal.

INJECTION SITE When selecting an IM site, determine that the site is free of pain, infection, necrosis, bruising and abrasions. Also consider the location of underlying bones, nerves, and blood vessels and the volume of medication that you will administer. Because of the sciatic nerve location, the dorso-gluteal 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.

Let’s talk about injections! Administer IM injections so that the needle is perpendicular to the patient’s body and as close to a 90 degree angle as possible. Rotate IM injection sites to decrease the risk of hypertrophy. Emaciated or atrophied muscles absorb medications poorly; thus avoid their use when possible. The Z-track method, a technique for pulling the skin during an injection is recommended for IM injections. It prevents leakage of medication into subcutaneous tissues, seals medication in the muscle and minimizes irritation.

INJECTIONS – CONT’D To use the Z-track method, apply the appropriate size needle to they syringe and select an IM site, preferably in a large, deep muscle such as the ventrogluteal. Pull the overlying skin and subcutaneous tissue approximately 2.5 to 3.5 cm (1 to 1 ½ inches) laterally to the side with the ulnar side of the non-dominant hand. Hold the skin in this position until you have administered the injection. After cleaning a site, inject the needle deeply into the muscle. To reduce injection site discomfort, there is no longer any need to aspirate after the needle is injected when administering vaccines. It is the nurses’ responsibility to follow agency policy for aspirating after injecting the needle. Keep the needle inserted for 10 seconds to allow the medication to disperse evenly. Release the skin after withdrawing the needle. This leaves a zigzag path that seals the needle track wherever tissue planes slide across one another. The medication is sealed in the muscle tissue.

Z-TRACK METHOD

VENTROGLUTEAL SITE The ventro-gluteal muscle involves the gluteus medius and minimus and is a safe injection site for adults & children. To locate the ventrogluteal muscle, have a patient lie in either the supine or lateral position; place the heel of your hand over the greater trochanter of the patient’s hip with the wrist almost perpendicular to the femur. Use your right hand for the left hip and the left hand for the right hip. Point the thumb toward the patient’s groin; point the index finger to the anterior superior iliac spine; and extend the middle finger 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. To relax this muscle, patients lie on their side or back, flexing the knee and hip.

HOW DO YOU LOCATE THE VENTROGLUTEAL SITE? ANATOMICAL LANDMARKS: Place the heel of the hand over the greater trochanter of the patient’s hip. Use the right hand for left hip and left hand for the right hip. Point the thumb toward the patient’s groin, point the index finger to the anterior superior iliac spine and extend the middle finger back along the iliac crest toward the buttock. The index finger, middle finger, and the iliac crest form a V-shaped triangle, inject into the area outlined by the V.

VASTUS LATERALIS MUSCLE The vastus lateralis muscle is another injection site used in adults and is the preferred site for administration of biologics (e.g., immunizations) to infants, toddlers & children. The muscle is thick and well developed; it is located in the anterior lateral aspect of the thigh. It extends in an adult from a hand breadth above the knee to a hand breadth below the greater trochanter of the femur. Use the middle third of the muscle for injection. The width other muscle usually extends from the midline of the thigh to the midline of the outer side of the thigh.

HOW DO YOU LOCATE THE VASTUS LATERALIS MUSCLE? Preferred site for infant immunizations Common site for IM self-injections ANATOMICAL LANDMARKS: Handbreadth below the greater trochanter and handbreadth above the knee on the anterior lateral aspect of the thigh. Inject into the outer middle third of the muscle.

DELTOID MUSCLE 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. Use this site for small medication volumes (2mL or less) Carefully assess the condition of the deltoid muscle; consult medication references for suitability of medication; and carefully locate the injection site using anatomic landmarks

HOW DO YOU LOCATE THE DELTOID MUSCLE? Locate the deltoid muscle by fully exposing the patient’s upper arm and shoulder and asking him or her to relax the arm at the side or by supporting the patient’s arm and flexing the elbow. Do not roll up any tight-fitting sleeve. Allow the patient to sit, stand, or lie down. Palpate the lower edge of the acromion process, which forms the base of a triangle in the line with the midpoint of the lateral aspect of the upper arm. The injection site is in the center of the triangle, about 3 to 5 cm (1 to 2 inches) below the acromion process. You locate the apex of the triangle by placing four fingers across the deltoid muscle with the top finger along the acromion process. The injection site is three fingers widths below the acromion process

THE DELTOID MUSCLE Deltoid: Use only if muscle is well developed Limit to 0.5 – 1.0 mL of fluid Maximum needle length 1 inch. ANATOMICAL LANDMARKS: Palpate the lower edge of the acromion process and the anterior axillary fold. Draw an inverted triangle between the two with the base at the top. Inject into the center of the triangle, approximately 1 to 2 inches below the acromion process

RECTUS FEMORIS Rectus Femoris: ANATOMICAL LANDMARKS: Discomfort is common Use only in adults Common site for IM self-injections ANATOMICAL LANDMARKS: Handbreadth below the greater trochanter and handbreadth above the knee on the anterior aspect of the thigh. Inject into the center of the anterior middle aspect of the muscle.

ASSESSMENT: Skill 22-4: Administering Intramuscular injections 1. Check accuracy & completeness of each MAR or computer printout with prescriber’s written medication order. Check patient’s name, medication name and dosage, route of administration, and time of administration. Recopy of reprint any portion of the MAR that is difficult to read. 2. Assess patient’s medical and medication history. 3. Assess patient’s history of allergies; known type of allergies & normal allergic reaction. 4. Review medication reference information for medication action, purpose, normal dose, side effects, time of peak onset, and nursing implications. 5. Observe patient’s previous verbal and nonverbal responses toward injection. 86. Assess for contraindications to IM injections such as muscle atrophy, reduced blood flow, or circulatory shock. 7. Assess patient’s symptoms before initiating medication therapy.

IMPLEMENTATION Prepare medications for one patient at a time using aseptic technique. Keep all pages of MARs or computer printouts for one patient together or look at only one patient’s electronic MAR at a time. Check label of medication carefully with MAR or computer printout 2 times and when preparing the medication. Take medication to the patient at the correct time. Medications that require exact timing include stat, first-time or loading doses, and one time doses. Give time critical scheduled medications at exact times ordered (no later than 30 minutes before or after schedules dose). Give non-time critical scheduled medications within a range of 1 tor 2 hours of scheduled dose. During administration, apply six rights of medication administration

IMPLEMENTATION – CONT’D Close room curtain or door. Identify patient using two identifiers (i.e., name & birthday or name and account number) according to agency policy. Compare identifiers in MAR / Medical record with information on patient’s identification bracelet and / or ask patient to state name. At patient’s bedside again compare MAR or computer printout with names of medications on medication labels and patient name. Ask patient if they have any allergies.

IMPLEMENTATION – CONT’D Discuss purpose of each medication, action, and possible adverse effects. Allow patient to ask any questions. Tell patient that injection will cause a slight burning or sting. Perform hand hygiene and apply clean gloves. Keep sheet or gown draped over body parts not requiring exposure. Select appropriate site. Note integrity and size of muscle. Palpate for tenderness or hardness. Avoid these areas. If patient receives frequent injections, rotate sites. Use ventrogluteal if possible. Help patient to a comfortable position. Position patient depending on chosen site (e.g., sit, lie flat, on side, or prone).

IMPLEMENTATION – CONT’D Clinical Decision Point: Ensure that medical condition (e.g., circulatory shock) does not contraindicate patient’s position for injection. Relocate site using anatomic landmarks. Clean site with antiseptic swab. Apply swab at center of site and rotate outward in circular direction for about 5 cm (2 inches). A. Optional: Apply EMLA cream on injection site at least 1 hour before IM injection or use vapocoolant spray (e.g., ethyl chloride) just before injection Before doing this, must check hospital policy regarding this.

IMPLEMENTAION – CONT’D Hold swab or gauze between third and fourth fingers of nondominant hand. Remove needle cap or sheath by pulling it straight off. Hold syringe between thumb and forefinger of dominant hand; hold as dart, palm down. Administer injection: A. Position ulnar side of non-dominant hand just below site and pull skin laterally approximately 2.5 to 3.5 cm (1 to 1 ½ inches). Hold position until medication is injected. With dominant hand inject needle quickly at a 90 degree angle into muscle.

IMPLEMENTATION – CONT’D B. Option: If patient’s muscle mass is small, grasp body of muscle between thumb and forefingers. C. After needle pierces skin, still pulling on skin with non-dominant hand, grasp lower end of syringe barrel with fingers of non-dominant hand to stabilize it. Move dominant hand to end of plunger. Avoid moving syringe. D. Pull back on plunger 5 to 10 seconds. If no blood appears, inject medication slowly at the rate of 10 sec/mL. Clinical Decision Point: If blood appears in syringe, remove needle dispose of medication and syringe properly, and prepare another dose of medication for injection. E. Wait 10 seconds, smoothly and steadily withdraw needle, release skin, and apply gauze gently over site. This allows time for the medication to absorb into muscle before removing syringe. Dry gauze minimizes discomfort associated with alcohol on non intact skin.

IMPLEMENTATION – CONT’D Apply gentle pressure to site. Do not massage site. Apply bandage, if needed. Help patient to a comfortable position. Discard uncapped needle or needle enclosed in a safety shield and attached syringe into puncture and leak proof receptacle. Remove gloves and perform hand hygiene. Stay with the patient for several minutes and observe for any allergic reaction.

EVALUATION 1. Return to room 15 to 30 minutes and ask if patient feels any acute pain, burning, numbness, or tingling at injection site. Inspect site; note any bruising or induration. Apply warm compress to site. Observe patient’s response to medication at times that correlate with onset, peak, and duration of medication. Ask the patient to explain the purpose and effects of the medication they received.

UNEXPECTED OUTCOMES – what we don’t want to happen! Patient complains of localized pain or continued burning at injection site, indicating potential injury to nerve or vessels During injection, blood is aspirated. Patient displays adverse reaction with signs of urticarial, eczema, pruritus, wheezing & dyspnea.

RECORDING & REPORTING Immediately after administration, record medication, dose, route, site, time & date given on MAR. Correctly sign MAR according to agency policy. Record patient teaching, validation of understanding and patient’s response to medication in nurse’s notes and electronic health record (EHR). Report any undesirable effects from medication to patient’s healthcare provider and document adverse effects in record.

JUST A FEW SPECIAL CONSIDERATIONS: Pediatric: Children can be very anxious or fearful of needles. Help with proper positioning and holding the child is sometimes necessary. Distractions such as blowing bubbles and pressure at the injection site before giving the injection can help alleviate anxiety. Gerontologic: Older patients may have decreased muscle mass, which reduces drug absorption from IM injections. In addition, older adults may have loss of muscle tone and strength that impairs mobility, placing them at high risk for falls from guarding an injection site.

END OF SKILL I realize this skill is long and tedious, but, as a nurse, you will be giving injections throughout your career, so once you learn these skills, they will always be useful to you. Your book has provided a video for you and here is the link: http://bookstie.Elsevier.com/Perry-Potter/ClinicalSkills/video29.php Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques, 8 e – 22-4. Administering Intramuscular injection

ADMINISTRATION OF INJECTIONS For one of your handouts, you have a sheet named “ADMINISTRATION OF INJECTIONS” I will review this for you, but it would be easier if you looked at the sheet directly and memorized it from the sheet itself. I will review this in several slides, so, again, look at the sheet itself and carry it everywhere until you have learned it! When I was in nursing school, I would take my books and my notes everywhere! For example, when my boyfriend (who is my husband now), would run an errand, I would go with him and study, study, study!

TYPE: IM OR Z- TRACK IM Angle IM or Z-Track 90 degrees TYPE SITES SYRINGE TYPE NEEDLE Angle NURSING IMPLICATIONS IM or Z-Track Ventrogluteal IM 90 degrees Med Must state for IM use Preferred adult site GAUGE 20-25 3 mL maximum Vastus Lateralis LENGTH 1” – 3” Less than 2 mL for older adult, children, thin person Preferred for infants Change needle if med is irritating Rectus Femoris Z-Track: use 0.2 mL airlock Deltoid Aspirate Cannot use for Z-Track

INTRADERMAL Intradermal Types Sites Syringe type Needle Nursing Implications Intradermal Forearm Tuberculin Angle: 5-15 “ Med must state for intradermal use Upper Chest Gauge: 25-27 0.1 mL maximum with bevel up Back, beneath scapulae Length: ¼” – 5/8” Do not Aspirate If necessary use sites appropriate for subcutaneous Do not Massage Bleb must occur

SUBCUTANEOUS Subcutaneous Type Sites Syringe Type Needle Nursing Implications Subcutaneous Outer Aspect of Upper Arm Subcutaneous or Tuberculin Angle: 45-90 Degrees Med must state subcutaneous use Anterior Thigh Gauge: 25-30 2 mL Maximum Abdomen Length: 5/16” – 5/8” Do not massage Select site 2” away from the umbilicus, Do not aspirate (cont’d) between the costal margins & iliac crests and anterior to the mid-axillary line Do not release pinched skin until needle is removed

INSULIN Insulin Type Site Syringe Type Needle Nursing Implications Outer Aspect of Upper Arm Insulin Syringe Only Angle: 45-90 degrees Check Blood glucose level Anterior Thigh Gauge: 25-30 1 mL maximum Abdomen Length: 5/16” – 5/8” Do not aspirate Select site 2” away from the umbilicus, Do not massage (cont’d) between the costal margins and the iliac crests & anterior to the mid-axillary line Do not release pinched skin until needle is removed Rotate Sites

HEPARIN Heparin Type Site Syringe Type Needle Nursing Implications Lower Abdominal Fat Pad ONLY Subcutaneous or Tuberculin Angle 45-90 degrees Check INR, PT, PTT lab values Select site 2” away from the umbilicus, between the umbilicus and iliac crests (cont’d) Gauge: 25-26 1 mL maximum And anterior to the mix-axillary line Length: 3/8” – ½” Rotate Sites Do not Aspirate Do not Massage

END OF POWER POINT PRESENTATION This is the end of the power point presentation. This skill is long and it appears tedious. I have full faith in everyone and with continuous practice in the nursing skills lab, with a partner, there is not reason not to pass! Again, while this power point presentation is helpful, you will not pass this skill without practicing it in the Skills Lab. Mark the Anatomical Landmarks on your partner Talk out-lout when marking these Landmarks Tell your partner exactly what you are doing and name the landmarks, as you go along! Good Luck & Practice!