About Course
Intramuscular injections require a thorough and meticulous approach to patient assessment and injection technique. This short course reviews the evidence base for safe practice.
A framework for safe practice is included, identifying important points for safe technique, patient care and clinical decision making.
Course Content
Learning outcomes
This article, the second in a series of two, aims to address safe injection practice with particular reference to intramuscular techniques. Methods of minimising the particular risks to the patient of intramuscular injections are discussed and a framework to promote safer practice is provided. Good patient assessment is integral to any injection, and also a fundamental aspect of any nursing procedure – principles of this vital skill are presented. After reading this article and completing the time out activities you should be able to:
▶Describe the common injection sites for intramuscular injections and discuss the advantages and disadvantages of each.
▶List the risks associated with intramuscular injections.
▶List the main steps in injection technique that minimise potential adverse effects.
▶Discuss the principles of patient assessment to maximise the success of intramuscular injections.
Introduction
The first article in this series addressed best practice in injection technique with reference to subcutaneous injections. This article discusses the nurse’s role in providing safe and effective intramuscular injections. Intramuscular injections are used for administering medication that requires relatively quick absorption by the body but with reasonably prolonged action (Rodger and King 2000). A range of medicines can be administered intramuscularly in both the acute and community settings and in a range of disciplines.
The intramuscular injection technique has changed in recent years in response to changes in equipment, and evidence and research have influenced best practice in site selection and patient assessment (Engstrom et al 2000, Chung et al 2002, Chan et al 2003, Zaybak et al 2007, Hunter 2008).
Patient assessment and safe practice
There is a link between pain perception and gender differences (Ağac and Güneş 2011). Compared with men, women consistently report more pain from all intramuscular injections (Mitchell and Whitney 2001, Chan et al 2003), which might be attributed to the physiology of muscle and fatty tissues, where pain receptors are located – women have more subcutaneous tissue in the buttocks than men. Studies carried out by Zaybak et al (2007) identified that there is a marked difference in fatty tissue between men and women, and Nisbet (2006) concurs that BMI should be a consideration in the selection of needle size, injection site and pain reduction.
Assessing the patient is therefore vital to minimising pain and reducing the risks of intramuscular injections. However, an assessment of the patient, performed before the intramuscular injection is given, is often not performed in clinical practice. Spending time with a patient, providing information and gaining consent, is an ideal opportunity to perform this assessment. The patient’s underlying medical condition and previous experience are also important considerations.
Having a full discussion with the patient may affect their perception of pain and even reduce their experience of pain from intramuscular injections (Schechter et al 2007). An individualised assessment of the patient is recommended (Small 2004), and this should take into consideration the patient’s status, weight, skin integrity, noted lesions, and rash or other skin conditions that may have an effect on the site of injection. Recommendations for safe practice include:
▶Patient assessment and consent – this should be prioritised. A discussion with the patient offers the opportunity to gather relevant information to determine the equipment, site and volume for injection. Obtaining a patient’s history, understanding previous experience, determining weight and BMI, skin condition and overall condition will inform safe practice and good clinical decision making.
▶Medication for administration – understanding the pharmacological principles, along with the volume and therapeutic effect, of the drug can help in choosing and landmarking correct sites, injection rates and patient positioning. This can also help to reduce unnecessary risk and minimise pain.
▶Infection control – minimising risks to the patient by correct handwashing, use of sterile equipment and thorough skin assessment.
▶Patient positioning and landmarking of injection sites – this is necessary to minimise risk and maximise the benefits of treatment and comfort for the patient. It reflects individualised care and good clinical decision making.
Box 1 lists a proposed framework for safe practice for intramuscular injections.
Box 1
Framework for safe practice for intramuscular injections
▶Perform handwashing to minimise the risk of infection to the patient.
▶Check the patient’s identification as per hospital policy.
▶Prepare the patient and obtain consent.
▶Position the patient sitting or lying (prone if accessing the ventrogluteal site).
▶Know the drug, its formulation, indication, route, volume and side effects.
▶Two-needle technique – change needles after preparation and before administration (so they are clean, sharp and dry).
▶Select needle size based on patient gender, weight and body mass index, condition, site, drug and volume.
▶Make the ventrogluteal site the first choice wherever possible for deep intramuscular injections.
▶Assess the skin and the patient’s condition.
▶Use the Z-track method: smooth/stretch the skin.
▶Rotate sites for frequent injections and document to this effect.
▶Inject at 90°, dart-like, to the hub of the needle and inject at 1mL per second.
▶Wait at least ten seconds before withdrawing the needle.
▶Do not massage or rub the site afterwards unless otherwise indicated.
▶Reassess for therapeutic effect and any side effects.
▶Document accurately and appropriately.
Risks of intramuscular injections
Intramuscular injections have the potential to cause adverse events for the patient as a result of poor practice (National Patient Safety Agency (NPSA) 2007). Unnecessary complications can arise from poor technique, lack of understanding, and lack of skill and confidence on the nurse’s part. A skilled injection technique can make the patient’s experience less painful (Floyd and Meyer 2007, Ağac and Güneş 2011). Sciatic nerve injury can be caused by erroneous injections, resulting in discomfort, morbidity and lasting disability, and may lead to negligence claims (Small 2004).
Complications of poorly performed intramuscular injections include bleeding (Plotkin et al 2008), abscess, cellulitis, tissue necrosis, granuloma, muscle fibrosis, contractures, haematoma and injury to blood vessels, bones and peripheral nerves (Small 2004). There is a risk of pain (Schechter et al 2007, Malkin 2008) and in some cases tendonitis. Infection is also a risk (Plotkin et al 2008).
Evidence suggests that a range of factors are associated with painful intramuscular injections: patient anxiety, patient position, drug volume and speed of delivery, injection technique, injection site and size of the needle bore and length (Chung et al 2002, Alavi 2007, Malkin 2008). An important factor associated with increased patient discomfort is the technique used by clinicians (Ağac and Güneş 2011).
Knowledge and skill are required to prevent complications and minimise risk to patients. Nurses should understand the relevant anatomy and the proximate anatomical structures so that they are able to identify landmarks and site boundaries safely and confidently (Small 2004). Small (2004) states the administration technique should be meticulous. A skilled injection technique can make the patient’s experience less painful and avoid unnecessary complications (Ağac and Güneş 2011).
Pain
Pain can be minimised by good technique and confidence on the part of the nurse. Injecting slowly, using the smallest diameter of needle size and entering the skin quickly are strategies to reduce pain (Campbell 1995, Workman 1999, Rodger and King 2000, Schechter et al 2007). Manual pressure on the injection site for ten seconds before needle insertion has been advocated and shown to reduce pain (Chung et al 2002). Ensuring the needle tip is sharp and free from residue by adopting a ‘two-needle’ approach (drawing up with one needle and injecting with another) has also been shown to reduce pain and discomfort (Rock 2000). This is further supported in the literature (Workman 1999, Engstrom et al 2000, Rodger and King 2000, Nicoll and Hesby 2002, Wynaden et al 2006, Floyd and Meyer 2007, Ismail et al 2007).
Pain can also be reduced by using a longer needle and choosing the ventrogluteal over the dorsogluteal site (Cook and Murtagh 2003, King 2003, Nisbet 2006, Zaybak et al 2007). An understanding of pain theories can help nurses to appreciate and understand how minimising pain is central to the patient experience. As previously stated, applying manual pressure to the site can reduce pain (Schechter et al 2007, Malkin 2008). This serves as a distraction technique and as emotional interference with the perception of pain (Chung et al 2002, Alavi 2007, Ogston-Tuck 2011).
Reflective Activity
Consider the medications you administer intramuscularly in your practice, and choose one on which to reflect. Where do you administer this medication and how do you identify the site of injection?
Injection Technique
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Injection site
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Volume of injection
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Reflective Activity 2
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Landmarking for intramuscular Injection
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Best Practice
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Equipment
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Skin preparation
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Patient positioning
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Injection rate
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Injecting