Best practice in intramuscular injections

BEST PRACTICE IN

INTRAMUSCULAR INJECTIONS

Monina Hernandez Gesmundo, RNOctober 12, 2011

Auckland, New Zealand

NINE DOT DILEMMA

Draw 4 lines to connect all the nine dots without lifting your pen from the paper.

ANSWER:

Draw 4 lines to connect all the nine dots without lifting your pen from the paper.

THINKING OUT OF THE BOX IS IMPORTANT IN NURSING PRACTICE … AND SO WITH STICKING TO EVIDENCE-

BASED PRACTICE.

OBJECTIVES:After the brief presentation, the participants

will be able to:A. Define evidence-based practiceB. Identify different sites used for

intramuscular injectionsC. Select the best practice site for IM

injectionsD. Describe essential steps for safely

administering IM injections E. Implement evidence-based practice in IM

injection

WHAT IS EVIDENCE-BASED PRACTICE?

EBP is “the conscientious, explicit and judicious use of current evidence in making decisions about the care of individual or groups of patients … This practice requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research, available resources, and our patient’s unique values and circumstances.” –Sacketts as cited in Salmond, 2007

Practice based on evidenceEvidence based on:

ResearchInput from patientsCase studies and case reportsExpert opinion

INTRAMUSCULAR INJECTION SITES

WHAT NURSING TEXTBOOKS SAYDORSOGLUTEAL SITE

- used in adults and children with well-developed gluteal muscles (Berman et al 2008)- avoided in children <3 unless child has been walking for > 1 year

Client’s Position: prone, with toes pointing inward OR side-lying, with upper knee flexed

Procedure:• palpate posterior superior iliac spine• draw an imaginary line to the greater trochanter of femur• site is lateral and superior to this line to avoid the sciatic nerve

WHAT NURSING TEXTBOOKS SAYVENTROGLUTEAL SITE

- gluteus medius site- suitable for children > 1 year and adults- less fats, no large nerves/blood vessels; sealed off by bone (Berman et al 2008)

Client’s Position: Side lying, flexed knee

Procedure:

• place heel of hand (right hand for left hip, left hand for right hip)on client’s greater trochanter, fingers towards head• with index finger on client’s anterior superior iliac spine, stretch middle finger dorsally• inject at the triangle formed by index finger, third finger and iliac crest

WHAT NURSING TEXTBOOKS SAYVASTUS LATERALIS SITE

- IM site of choice for infants < 1 yr (Berman et al, 2008)- no major blood vessels/nerves

Client’s Position: supine or sitting

Procedure:• divide area between greater trochanter of femur and lateral femoral condyle into thirds• middle third is the injection site

WHAT NURSING TEXTBOOKS SAY

DELTOID SITE

- used in adults due to rapid absorption- < 1 ml only because of small size- close to radial nerve and radial artery (Berman et al, 2008)

Client’s Position: sitting

Procedure:

• place four fingers across deltoid muscle, with first finger at acromion process • top of axilla marks the lower border • site is approximately 2 inches below the acromion process

WHAT IS THE BEST PRACTICE IN INTRAMUSCULAR INJECTIONS?

WHAT RESEARCH SAYS DORSOGLUTEAL SITE

Presence of major nerves and blood vessels, slow uptake of medication, thick layer of adipose tissue (Small, 2004 as cited in Cocoman, A & Murray, J., 2010)

Difficult to palpate due to thick layer of adipose fat – from 1 cm to 9 cm (Lachman,1963 as cited in Cocoman, A & Murray, J., 2010)


Turkish study with 59 women and 60 men with BMI >25kg/m2, only 98% of women and 37% of men received a true IM; recommends that a needle > 1.5 inches be used in women with BMI >25kg/m2 (Zayback et al, 2007 as cited in Cocoman, A & Murray, J., 2010)


CT scans conducted by Haramati, et al in 1994 in 338 patients, found that 20% had calcified granulomas in the buttocks

Damage to the sciatic nerve has been documented in several legal cases with financial awards (Small, 2004 as cited in in Greenway, K., Merriman,C. & Statham, D., 2006)

WHAT RESEARCH SAYS VENTROGLUTEAL SITE

Findings by Nisbett in 2006 (as cited in Greenway, K., Merriman,C. & Statham, D., 2006) show:

IM SiteMean thickness of subcutaneous

fat

Probability of penetrating muscle using 21G needle

(35mm length)

Ventrogluteal site 19 mm 74%

Dorsogluteal site 32 mm 57%

SYSTEMATIC REVIEW OF LITERATURE

- conducted in Australia in 2005 by Wynaden, D., Landborough, I. & Chapman, R. showed that:

A. INJECTION SITE:

Abscess, induration, erythema, wheals, pain, hematoma, bleeding and paralysis are largely attributed to site and technique

Deltoid - causes immediate and post-injection discomfort (Wink, 1992)

Dorsogluteal site - last choice due to damage to sciatic nerve and superior gluteal artery (Perry & Potter, 2004)

Ventrogluteal - safest site for administering IM injections (Greenway, 2004; Perry & Potter, 2004); with no documented evidence of complications (Beecroft & Redick, 1989; Beecroft & Kongelbeck, 1994)

SYSTEMATIC REVIEW OF LITERATURE BY WYNADEN, D., LANDBOROUGH, I. & CHAPMAN, R., 2005

B. EQUIPMENT

Generally, gauge 23(32mm) to gauge 21(38mm) (Chiodini, 2001; Newton, et al, 1992)

If client is > 91kg, use gauge 20 (50mm) (Beyea & Nicholl, 1996; Keen, 1990)

Regardless of method of choice, needle length should be appropriate for the site and client’s BMI (Belanger-Annable, 1985; Calnan, 2001; Cockshott et al, 1982; Haramati et al, 1994; Keen, 1983,1989; Lenz, 1983; McConnell, 1982; Murphy, 1991; Zuckeman, 2000)


C. MEDICATION VOLUME

Deltoid – 0.5ml to 1 ml (Murphy, 1991; Rodger & King, 2000)

Ventrogluteal – up to 5ml (Murphy, 1991; Rodger & King, 2000)

If pH or tonicity of medication is different than body fluids, choose larger muscle sites (Murphy, 1991)


D. MEDICATION FORMULATION

Pain can be associated with buffers, co-solvents, antimicrobials, preservatives (Brazeau et al, 1998)

Read literature supplied with medication to consider drug formulation


E. TECHNIQUES TO REDUCE DISCOMFORT

pressure to site for 10 seconds prior to injection (Barnhill et al, 1996; Chung, et al, 2002)

pinch-grasp technique (Locsin, 1985)

thumping technique (Hasan, 2001)

Others include: give client appropriate information; RN should be calm and confident; use drawing-up needle; use smallest diameter needle; stretch skin; pierce skin quickly; distract client; inject medication slowly (Brentnell,1990; Beavis, 1999; Campbell, 1995; Dickerson, 1992; Rodger & King, 2000; Workman, 1999)

PINCH-GRASP TECHNIQUE

Z-track technique: for highly irritating, viscous solutions; reduces leakage, pain and irritation to prevent seepage of medication

IM injection at a 90 degree angleA) skin pulled to the sideB) skin released

Note: When skin returns to its normal position after needle is withdrawn, a seal is formed over the site



G. SKIN CLEANSING Disinfect a circular area of 2.5cm to 7.5cm

with alcohol wipe for 30 seconds and allow to dry for 30 seconds (Newton & Newton, 1977; Beyea & Nicoll, 1996; Workman, 1999)

H. ASPIRATING FOR BLOOD Aspirate for blood for 5 to 10 seconds; if

blood appears, withdraw the needle and repeat the process using sterile equipment (Beyea & Nicoll, 1996; McConnell, 1982; Workman, 1999)


I. ANGLE AND VELOCITY OF NEEDLE Less emphasis on the velocity of the needle

piercing the skin, but more on starting with the needle closer to the skin to minimize needle stick injury and missing the target (Katsma & Katsma, 2000)

J. BODY POSITIONING Dorsogluteal site: femur-pointing inward (toes

pointing inward) relaxes the gluteus maximus (Kruszewski et al, 1979; Rettig & Southby, 1982)

SUMMARY Assess BMI:

- Generally, use 32mm (23G) to 38 mm (21G) needle- If client > 91 kgs, use 38 mm (21G) or 50mm (20G) needle

Use drawing up needle Select appropriate site and proper position Cleanse site for 30 seconds with alcohol wipe and allow to dry for

30 seconds Use Z-track technique Position needle close to skin Insert needle quickly and smoothly at 72-90 degree-angle Aspirate for blood If no blood is aspirated, inject medication slowly (1ml per

second); if blood is aspirated, withdraw needle and recommence with sterile equipment.

Withdraw needle smoothly and quickly Apply gentle pressure to site for 30 seconds Assess site for abnormal reaction and ensure patient comfort.

BEST PRACTICE CHALLENGE

THINKING OUT OF THE BOX IS IMPORTANT IN NURSING PRACTICE … AND SO WITH STICKING TO EVIDENCE-

BASED PRACTICE.

REFERENCES: Berman, A., Snyder, S., Kozier, B. & Erb, G. (2008). Fundamentals

of nursing (8th ed). New Jersey: Pearson Education, Inc. Cocoman, A. & Murray, J. (2010). Recognzing the evidence and

changing practice on injection sites. British Journal of Nursing, 19(18), 1170-1174.

Floyd, S. & Meyer, A. (2007). Intramuscular injections – what’s best practice. Kai Tiaki Nursing, 13(6), 20-22.

Greenway, K., Merriman,C. & Statham, D. (2006). Using the ventrogluteal site for intramuscular injections. Learning Disability Practice, 9(8), 34-37.

Henkelman, W.J. (2011). Evidence-based practice and injection techniques. Nevada RN formation, 20.

Salmond, S. W. (2007). Advancing evidence-based practice: a primer. Orthopedic Nursing, 26(2), 114-123.

Wynaden, D., Landborough, I. & Chapman, R. (2005). Establishing best practice guidelines for administration of intramuscular injections in the adult: A systematic review of the literature. Contemporary Nurse, 20(2), 267-277.

Health & Medicine

Best practice in intramuscular injections