Intramuscular Injection Techniques Essay

The synthesis of trick and science is lived by the absorb in the nursing act JQSEPHINE e PATERSONIf you would like to contribiito to the art and science section contact Gwcn Clarke, art and science editor, Nursing Standard, The Heights, 59-65 Lowlands Road, Harrow-on-the-Hill, Middlesex H A l 3AW. email gwen.clarkeva rcnpublishing.co.ukIntramuscular jibe techniquesHunter J (2008) Intramuscular shooting techniques. Nursing Standard. 22, 24,35-40. Date of acceptance October 29 2007 thickset The administration of intrairiLiscLitar (IM) gibes is an pregnant part of practice of medicine management and a parkland nursing intervention in clinical practice, A skilled guesswork technique empennage comprise the uncomplainings experience little painful and quash unnecessary complications.Intramuscular injectionsAnIM injection is chosen when a reasonably fast systemic uptake of the dose (usu in ally within 15-20 proceeding is needed by the body and when a relatively prolonged fe at is required. The amounts of base that empennage he get aroundn volition dep devastation on the muscle bed and range from 1 -5ml for adults. Much fineer volumes be accept equal in children (Rodger and queen regnant 2000, Corben 2005). The practice of medicine is injected into the denser part ofthe muscle facia below the subcutaneous tissues. This is ideal be suffice skeletal muscles bring forth fewer pain-sensing nerve than subcutaneous tissue and substructure absorb larger volumes of solvent be driving ofthe speedy uptake ofthe drug into the bloodstream via the muscle fibres.This means that IM injections ar less(prenominal) painful when administered correctly and can be utilize to inject difficult and irritant drugs that could damage subcutaneous tissue (Rodger and King 2000, Greenway 2004). Examples of drugs administered via this driveway ar analgesics, anti-emetics, sedatives, immunisations and hormonal treatments. It is important to recognise and understand latent complications associated with IM injections and that rapid absorption of the drugs whitethorn emergence these danger of infections (Foster and Hilton 2004).The administration of some(prenominal) practice of medicine can present a risk and, therefore, the nurse must(prenominal) be able to recognise the signs of an anaphylactic (allergic) reaction, with signs of, for example, urticaria, pruritus, respiratory distress, shock or even cardiac arrest. Inappropriate selection of send and poor technique can increase the risk of longanimous injury and lead to pain, nerve injury, bleeding, accidental endovenous administration and stereotypic abscesses ca utilize through repeated injections at one state of affairs with poor blood flow (Rodger and King2000).AuthorJanet Hunter is lecturer in adult nursing, urban center Community and Health Sciences, incorporating St Bartholomew School of Nursing and Midwifery, City University, London. Email j.a.huntercity.ac.ukKeywordsClinic al cognitive processs Drug administration Injection technique Tliese keywords are based on the dependent headings from the British Nursing Index. Tliis article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard stead page at www.nursing- measurement.cD.uk. For related articles visit our online archive and search victimisation the keywords.THE NURSING and Midwifery Councils (NMCs) (2007) Standards for Medicines Management state that administration of medicines is non solely a mechanistic task to be performed in strict compliance with the written prescription drug of a medical practitioner (now breakaway/supplementary prescriber). It requires thought and the exercise of professional judgement. on that pointfore, the administration of intramuscular (IM) injections requires the healthcare practitioner to possess the association and rationale of the guiding principles that underpin these clinical skills.It is essential that all surveys of these techniques -anatomy, physiology, long-suffering assessment, preparation and nursing interventions are consequence based so that the nurse can perform refuge and accountable practice (Shepherd 2002, NMC 2007). The aim of this article is to update the nurses knowledge and skills on injection techniques. This article describes the practical, step-by-step approach for administering IM injections, which will take to heart nurses to perform this skill safely and competently.NURSING STANDARDIntramuscular injection aimsThere are five come outs that can be considered for IM february 20 vol 22 no 24 2008 35art & science clinical skills 37injections (Figure 1). The two recommended lays for IM injections are the vastus lateralis and the ventrogluteal sites (Donaldson and Green 2005, Nisbet 2006). However, when the affected role is obese, rhe vastus laterahs is a better weft (Nisbet 2006). When choosing an appropriate site for administration, the nurse need s to master that the medication will be absorbed. The nurse needs to consider whether the patient is receiving regular M injections because the site will need to be rotated to avoid fervor, pain and sterile abscesses. Choice will also be influenced by the patients physical condition and age. Active patients are more likely to hire a greater muscle FIGURE 1 Sites for intramuscular injections (IM) Mid-deltoid site The mid-deltoid site is easily accessible but due to the size of the muscle the area should non be used repetitively and only small volumes shouid be injected. Tlie maximum volume should be 1ml (Rodger and King 2000).Tlie denser part of the deitoid must be used. It is Lisef j l to visualise a tri move whereby the naiant line is located 2.5-5cm below the acromial process and the midpoint of the lateral verbalism of the arm in line with the axilla forms the apex. The injection is given around 2.5cm down from the acromiai process, avoiding the radial and brachial nerves (Workman 1999, Rodger and King 2000). Dorsogluteal site Tliis a&3. is used for deep IM and Z-track injections. Up to 4mi can be injected into this muscle (Workman 1999, Rodger and King 2000).Commonly referred to as the outer upper quadrant, it is located by using imaginary lines to divide the buttocks into quartet quarters. To identify the glute maximtis, house painting a line that extends from the iiiac spine to the greater trochanter of the femur. Draw a vertical line from the midpoint of the first line to identify the upper aspect of the upper outer quadrant This location avoids the superior gluteal artery and sciatic nerve (Workman 1999, Small 2004). Rectus thighbone site This site is used for deep I M and Z-track injections.Between mass than older or emaciated patients, so individuals will need to be assessed to see if they have sufficient muscle mass. If not, the muscles may need to be pinched up before the injection (Workman 1999, Rodger and King 2000). Any area or str aw man of inflammation, swelling or infection should be avoided (Workman 1999).Patient preparationIt is important to beg off the modus operandi so that the patient fully understands and is able to give his or her conscious consent and co-operation. The discussion should include the choice of site for the injection and information about the medication, action and side effects. The patient can then express some(prenominal) concerns or anxieties relating to the procedure and the patients knowledge can be l-5ml can be injected, although for infants this would be 1-3 mi. The rectus femoris is a large and well-defined muscle and is the anterior muscle of the quadriceps. I t is located halfway between the superior iliac wind and the patella (Workman 1999), Vastus lateralis site The vastus lateralis site used for deep IM and Z-track injections.Up to 5ml can be administered (Rodger and King 2000). The muscle forms part of the quadriceps femoris mathematical group of muscles and is loca ted on the outer side of the femur. If is foLind by measuring a hands breafh from the greater trochanter and the knee joint, which identifies the middle third ofthe quadriceps muscle (Workman 1999).There are no major blood vessels or structures which could cause an injury in this area (Rodger and King 2000). Ventrogluteal site This site is used for deep IM and Z-track injections. This site is located by placing the palm ofthe nurses hand on the patients opposite greater trochanter (for example, the nurses right palm on the patients left hip), then extending the index finger to the anterior superior iliac spine to make a V. The injection is then given into the gluteus medius muscle, which is the centre of fhe V (Workman 1999, Rodger and King 2000).Evaluated. It is important to check whether the patient has whatsoever(prenominal) known allergies to identify potential reactions to the medication. FVeparation ofthe equipment each(prenominal) the necessary equipment shouid be nimble before commencing the procedure to avoid all delays or interruptions during rhe procedure. The equipment required for administering IM injections is listed in Box I and preparation of rhe equipment is described in Box 2. The techniques used for administering IM injections are outlined in Box 3.Skin cleansing There are inconsistencies regarding contend preparation for IM injections. It is known rhar cleansing the injection site with an impregnated intoxicant cleanse up before an IM injection reduces rhe number of bacteria on the skin (Workman 1999, lister plough and Sarpal 2004). However, if rhe injection is given before rhe skin is run dry this procedure is ineffective and rhe patienr may experience pain and a sdnging horse sense from rhe antiseptic. This may lease entry of bacteria inro rhe injection site and cause topical anaesthetic irritation (Workman 1999, middle buster and Sarpal 2004). Therefore, when using an alcohol wipe up ro stool the skin it should be used fo r 30 seconds and then allowed to dry (Lister and Sarpal 2004). both(prenominal) local policies no longer recommend skin cleansing ifthe patients skin is physically clean (Little 2000, Wynaden et al2005) and the nurse obliges rhe required standard of hand washing and asepsis during rhe procedure (Workman 1999).Equipment for intramuscular injectionsI 2. 3. 4. 5. 6. 7. 8. 9. prescription chart. Prescribed drug to be administered. If required, diluent for reconstitution. Clean tray or receiver for equipment, Syringe of appropriate size (2-5ml), Sterile 21G (green) plague for adult patients. Alcohol-impregnated swab with isopropyi alcohol 70%. Gloves. Tissue or clinical wipe.10. Clinical sharps container. expression for intramuscular (IM) Injection administrationThe following steps describe the procedure when preparing the equipment for an I M injection. Wash and dry hands thoroughly with disinfectant soap and wafer or use bactericidal handrub to delay any defilement of the equi pment or medication. Put on gloves. Gloves are required for all encroaching(a) procedures including IM injection (Pratt etal2Q07). delay the patients prescription chart and forge the Drug that is to be administered. Required dose. Route for administration. Date and time of administration. prescription is legible and signed by an authorised prescriber. These actions ensure that any risk to the patient is minimised and that the patient is given the right dose of medication at the correct time by the prescribed route (Jamieson et al 2002, Lister and Sarpal 2004). If any errors are noticed with apply the medication and inform the medical team. Check the drug against the prescription chart.As all medications deteriorate everyplace time, check the expiry date this shows when a drug will no longer be guaranteed to be effective. To prepare the spray for medication (a) Check all packaging is intact to retain sterility. Check the expiry date. If any packaging is damaged or has exp ired, discard. (b) Open the packaging of the syringe at the loon end and get rid of the syringe. Make sure that the plumbers helper moves freely inside the barrel. Take care not to touch the nozzle end to prevent contamination. (c) Open the chivvy packaging at the hilt (coloured) end. Hold the syringe in one hand and then attach the chevy severely onto the nozzle of the syringe. Loosen the sheath but do not remove it. Place the syringe on the tray. This prevents contamination or any potential injuries. Examine the solution in the ampul for cloudiness or sedimentation.This may show that the medication is contaminated or unstable. Make sure that all the contents are in the bottom o f t h e ampoule by tapping the neck gently. To prevent injury, splutter or contact with the medication use a clinical wipe or tissue to c over the neck of the ampoule and break it open. uphold the solution for any glass fragments because these pose a risk to the patient if injected. Discard the am poule and contents if any foreign matter is visible. f you are using a plastic ampoule, break the top off, qualification sure not to touch the top. Pick up the syringe and allow the sheath to fall off the molest onto the tray and insert the needle into the solution of the ampoule. Avoid scraping the needle on the bottom of the ampoule, because this wilt blunt the needle. Pull back the top of the plunger with one finger on the flange and draw up the required dose. I t may be necessary to tilt or hold the ampoule height down to make sure the needle remains in the solution to prevent drawing in air (Figure 2). Take care not to contaminate the needle. Re-sheathe the needle carefully using the aseptic non-touch technique to to maintain sterility (Figure 3). Expel the air. Hold the syringe upright, at eye train and let any air rise to the top of the syringe To promote air bubbles fo rise, lightly tap the barrel ofthe syringe. Slowiy, push the piunger to loose the air until the s olution is seen at the top of the needle.Needles Re-sheathing a needle betore the medication is administered to a patient is safe. This method is achieved hy using the aseptic non-touch technique (Figure 3) and prevents droplets of the medication from heing sprayed onto the skin or inhaled when air is heing expelled from the syringe (Nicol etal 2004). When giving an M injection a green or size 21 gauge needle is used for all adult patients to ensure that rhe medication is injected into the muscle. This also applies to patients who are cachectic or thin, except that the needle is not inserted as deeply. If a smaller gauge needle is used the nurse needs to apply more force per unit area to inject the solution, which will increase the patients discomfort (King 2003). Single and multi-dose powder vials Some medications come in adept or multi-dose vials and need to he reconstituted before heing drawn up and mjected.The following steps should be undertaken when administering I M inject ions to patients Take the tray with the syringe, ampoule, impregnated alcohol swab, tissue, prescription and sharps container to the patients bedside. Re-check the prescription and medication with the patients anticipate band correspond to local policy. Draw the curtains for privacy and assist the patient into a comfortable federal agency to allow access to the injection siteandto make sure that the identified muscle group is flexed and relaxed. Clean the skin with an impregnated alcohol swab for 30 seconds and then allow to dry to minimise the risk of infection (Lister and Sarpal 2004), or alternatively it should be cleansed in accordance with local policy, With the non- dominant hand stretch the skin slightly over the chosen injection site to displace the underlying subcutaneous tissues and to aid the insertion of the needle. With the dominant hand hold the syringe like a dart Having informed the patient, quickly and firmly in a dart-like motion insert the needle into the pa tients skin at a 90 angle until approximately 1cm of the needle is left showing (Nicol et al 2004, Corben 2005) (Figure 4). Hold the skin with the ulnar edge of the hand and with the thumb and index finger hold the coloured part of the needle to maintain stability and prevent movement. pick out the plunger slightly to confirm that the needle is in the correct position and has not entered a blood vessel. If blood is not present, depress the plunger and carefully inject the solution at a rate of 1ml per 10 seconds until the syringe is empty to allow the tissues to expand and absorb the solution (Workman 1999, Lister and Sarpal 2004).This rate also reduces patient discomfort. If blood is present stop the procedure and withdraw the needle and syringe. Start again with new equipment and drug and explain to the patient what has happened to reduce patient anxiety. Wait ten seconds to allow the drug to diffuse into the tissues then quickly and smoothly withdraw the needle. Use a tissue to apply pressure to the injection site or until any bleeding ceases. It is not necessary to massage the area because this may cause the drug to leak from the injection site and cause local irritation (Rodger and King 2000). Discard the needle and syringe immediately into the sharps container to prevent any injury.Do not re-sheathe the needle. call back gloves and wash hands, Record the administration of the medication on the prescription chart to show that the drug has been given. Report any abnormalities or complications. Replace any clothing and make sure that the patient is comfortable. Return to the patient after 15-20 minutes to observe and check the effectivity ofthe medication, especially anti-emetics and analgesics. Observe the injection site within two to four hours for signs of local irritation Rodger and King 2000), involves some key principles to ensure safe practice. Before reconstiruting any medication, the nurse should first read rhe manufacturers information s heet. It is important that the powder is at the bottom of the vial so thnt all the medication is dissolved. The cap must be cleaned with an alcoholimpregnated swah and allowed to dry to prevent bacterial contamination. * It is vital that the correct volume of diluent is used according to the manufacturers recommendations to provide the most therapeutic concentration. The diluent should be injected slowly into the vial so that the powder Is wet before mixing. When mixing, ensure the needle remains inside the vial to maintain sterility. If there is pressure In the vial hold the plunger down while doing this to avoid the separation ofthe needle and syringe from the vial Nicol etal 1004. To mix the medication, agitate or roll the vial until the powder has dissolved. For some powder multi-dose vials, a needle is inserted into the cap before adding the diluent because this allows air to escape and releases the vacuum in the vial.Then with a second needle and syringe, inject the diluent into the vial. Remove the needle and syringe and place a sterile swab over the venti ng need le to prevent contamination ofthe drug and the atmosphere. trip out or roll the ampoule until the powder has dissolved (Jamieson etal2002., Lister and Sarpal 2004). All solutions need to be inspected for precipitation and cloudiness. Continue to agitate until the powder and diluent have fully mixed to form a solution. Todrawuprhedrug, hold the ampoule upside down to avoid drawing in air, insert the needle so that it is below the level ofthe solution and pull back the plunger to withdraw the correct amount of solution. For multi-dose vials, clean the cap with an impregnated alcohol swab and allow to dry before inserting the needle and syringe to prevent bacterial contamination.