demonstrated by clair merriman, head of professional

Deltoid site (upper arm)

Vastus lateralis site (lateral thigh)

Dorsogluteal site (buttock)

Ventrogluteal site (hip)

Choice of site for intramuscular injection

Epidermis

Dermis

Subcutaneous tissue

Muscle

Blood vessels

Anatomy of the skin

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Injection AdministrationAdults

Intramuscular injection using the vastus lateralis site Demonstrated by Clair Merriman, Head of Professional Practice Skills,

and Kathleen Greenway, Senior Lecturer in Adult Nursing, Oxford Brookes University, Oxford ©2019 Clinical Skills Limited. All rights reserved

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

The administration of an intramuscular injection is an essential nursing skill, which is used with varying frequency in the different nursing disciplines. It is a clinical procedure taught during preregistration training and there is an expectation by the public and the Nursing and Midwifery Council that healthcare professionals who undertake it attain and maintain an appropriate level of competence in this skill (NMC, 2018; Greenway et al., 2006). Unsafe injection practices can have a significant impact on patient outcomes, causing nerve damage, abscesses and pain, and resulting in potential litigation. In overweight/obese individuals and at sites with thicker subcutaneous fat, use of inappropriate needle sizes can lead to accidental subcutaneous injection (White et al., 2018; Larkin et al., 2018). Choice of needle length and injection site in obese or very thin patients is crucial for ensuring optimal medicine absorption (Larkin et al., 2018; Doyle & McCutcheon, 2015). Healthcare professionals who administer any injection, not only intramuscularly, must be trained in managing anaphylaxis.

Reasons why an intramuscular injection may be required include:• Rapid action is required; • The medicine is altered by intestinal secretions; • The medicine is not absorbed by the alimentary tract (e.g., as in Crohn’s disease, ulcerative colitis, bowel cancer);• The patient cannot take oral medicines (e.g., due to swallowing difficulties, following mouth/oesophageal surgery, or if they are nil by mouth);• The medicine is unavailable in an oral form; • When long-term release of a medicine is required (absorption can last for 2–5 weeks if desired, using an oil-based, slow-release preparation, as in depot injections).

Contraindications for intramuscular injections include potential infection, damage to nerves, poor blood supply or oedema to the injection site and surrounding tissue and an increased risk of bleeding, particularly if the patient is receiving anticoagulant therapy or has a clotting disorder.

The use of needles to draw up medication and administer the injection poses a potential risk of needlestick injury to the healthcare professional (RCN, 2013). Although many existing UK laws (for example, the Health and Safety at Work etc. Act 1974) require employers to ensure the health, safety and welfare of employees, European Directive 2010/32/EU requires all European Union member states to implement measures designed to provide healthcare workers with further protection from sharps injuries (Health and Safety Executive, 2013; RCN, 2013; European Council, 2010). The date for implementation in the UK was May 2013. One of the key requirements of the directive is that employers must eliminate the unnecessary use of sharps by implementing changes in practice and providing medical devices incorporating safety-engineered protection mechanisms. Many such safety devices are available, but your choice of equipment will depend on what is available, as dictated by local policy. It is your responsibility to ensure that you receive a full demonstration of how to use the device and that you are competent to use it.

These pages show use of a blunt fill needle or blunt fill needle with filter for drawing up the medication, and a particular type of safety needle, which has a cover on a pivot, for administering the injection. Ensure that a sharps disposal container is to hand, as close as possible to the area where the sharp is being used (HSE, 2013). This procedure shows how to give an intramuscular injection at the vastus lateralis site. (Also see other intramuscular injection procedures.)

With an intramuscular injection, the needle passes through subcutaneous tissue in order to penetrate the skeletal muscle, where there is a rich blood supply that will allow the medication to be absorbed quickly and effectively, and fewer pain receptors so minimising the pain felt by the patient. The rate of absorption is quicker than with oral medicine administration or subcutaneous injection, but slower than with intravenous injection. It is suitable for a wide range of medicines, provided that these are not irritant to the soft tissue.

The four sites commonly used for intramuscular injection are the deltoid muscle, the ventrogluteal muscle, the vastus lateralis muscle and the dorsogluteal muscle. The healthcare professional should use their clinical judgement, incorporating evidence-based practice, to select an appropriate site and should consider the inherent risks, e.g., sciatic nerve damage is a recognised complication of intramuscular injection at the dorsogluteal site (Shepherd, 2018; Greenway, 2014). The viscosity of the medication, the volume of medication to be injected and the amount of subcutaneous tissue at the injection site will all influence site selection. It is important to be guided by the licensing of the medication, e.g., most oil-based depot antipsychotic medications are licensed for administration into gluteal sites only (Feetam & White, 2016).

Greater trochanter of femur

Sciatic nerve

Femoral arteryand vein

Vastus lateralis

Injection site

Patella

Select syringes and needles of an appropriate size for the volume of themedication being injected and for the patient’s age and body mass index(BMI), muscle mass and subcutaneous fat at the injection site (Shepherd, 2018; Larkin et al., 2018).

Advantages of the vastus lateralis site:

• This muscle is easy to access, especially for self-administration;

• There are few major blood vessels in the area.

Disadvantages of the vastus lateralis site:

• Can be painful and leave discomfort;

• The depth of the subcutaneous tissue varies between individuals.

AS REQUIRED PRESCRIPTIONS

DRUG (APPROVED NAME)

Dose Max. Route Start Date Frequency

Signature Valid Period Pharm.

Additional Instructions/Indication

Date

Time

Dose

Given by

Route





Date

Time

Dose

Given by

Route

DRUG (APPROVED NAME) Date

PROCHLORPERAZINE

I2.5mg IM

8 hourly prn

2/4/19

Injection Administration

Adults

Intramuscular injection using the vastus lateralis site

The vastus lateralis site and its advantages and disadvantages

Wash your hands Explain the procedure to the patient and gain consent

Check the medication administration record Size of needle

The vastus lateralis is located on the anterior lateral aspect of the thigh in the quadriceps muscle (Ogston-Tuck, 2014). In adults, it extends from a hand’s breadth above the knee to a hand’s breadth below the greater trochanter of the femur. At this site, the normal volume for effective absorption is 1–3 mL (Feetam & White, 2019).

Decontaminate your hands with soap and water, drying with disposablepaper towels afterwards, or use an alcohol-based hand sanitiser if your handsare visibly clean (Loveday et al., 2014). Also see clinicalskills.net procedure,“Routine hand hygiene”.

Before beginning, explain the procedure to the patient and gain verbal consent (NMC, 2018). Maintain the patient’s privacy and dignity during the procedure. If the patient is receiving regular intramuscular injections, ask if they have a preferred site for their injection. However, be mindful of the need to rotate injection sites to reduce the risk of infection and irritation to the site.

Page 2 of 6


Before administering any prescribed medicine, look at the person's medication administration record (MAR) and check that you have the right person, medicine, dose, date and time of administration, route and method of administration. Check that the prescription is valid and legible, and has been signed by the prescriber. Check the MAR for allergies and confirm these with the patient (RPS/RCN, 2019). Check whether the medication is licensed for administration at a particular site only (Feetam & White, 2016).

Needle Needlelength gauge

16 mm ( ") 25–27G

16–25 mm 22–25G( "–1")

25–38 mm(1"–1 ") 19–25G(use 38 mm for adults >90 kg)

Location of injection

Vastus lateralis muscle

Deltoid muscle, ventroglutealsite, dorsogluteal site (not recommended for <3 years),vastus lateralis muscle

Deltoid muscle, ventrogluteal site (may be best for cachectic adults), dorsogluteal site (avoid in obese adults), vastus lateralis muscle

Infants

Children (>18 months to 18 years)

Adult >18 years

(Dougherty & Lister, 2015; BD, 2012; Craven & Hirnle, 2003)

58/

58/

12/

1ml

1321

.01

PROC

HLOR

PERA

ZINE

Inje

ctio

n B.

P.

2

.5

2

1

.5

1

0

.5

skin cleansing swabsIsopropyl Alcohol 70%External Use onlyR Registered TrademarkBSN medical gambit0-22771 Hamburg Germany

REF No. 72383-01 BSN

2

Cutisoft wipes

A 2-mL syringe, with 5 x 0.5-mL graduations, is shown here


PROCHLORPERAZINE

12.5mg IM

8 hourly prn

2/4/19

WARNING DO NOT FILL ABOVE THE LINE

CONTAMINATED SHARPS ONLY

TO BE INCINERATEDDANGER

Protouch

Protouch

350Ambidextrous

Examination Gloves

100PCS

Ref:Size Large

350AmbidextrousExamination Gloves Ref:

Size Large

100PCS



2

Cutisoft wipes

Safety needle of appropriate size (see table on page 2)

Blunt fill needle

Gauze swab (to cover puncture site)

Sterile swab (when opening ampoule)

2 pairs of gloves and apron

Sharps bin

Medicine for injection

Receiver

2.5

2

1.5

1

0.5

Alcohol swab (for skin cleansing according to local policy)

1ml

1321

.01

PROC

HLOR

PERA

ZINE

Inje

ctio

n B.

P.

LOT 0411040

2020 -10

REF 30714

Appropriately sized syringe

Medication administration record

Prepare the injection Snap open the ampoule

Wash your hands and assemble equipment. Check that equipment packaging is intact and not past its expiry date. Clean a tray or trolley according to local policy. Before beginning the procedure, decontaminate your hands again, and put on an apron and gloves as required.

If using a glass ampoule, flick it to ensure that all medication drains from the stem (inset). Covering the neck of the ampoule with a sterile swab, break off its top, by snapping it along the score line at its neck (or use an ampoule breaker, if available, following the manufacturer’s instructions). Check whether there are particles of glass in the liquid; if present, use a new ampoule.

Injections should be drawn up in a clean area using an aseptic non-touch technique (Rowley & Clare, 2009). Attach a blunt fill needle to the syringe. Use one with a filter if drawing up from a glass ampoule, to minimise the risk of drawing particles of glass into the syringe (Carraretto et al., 2011).

Medication administration record

Healthcare professionals must adhere to local policies on use of gloves. First decontaminate your hands. You may not need to wear gloves when preparing medication for injection—refer to the medicine information leaflet and local policy. Gloves must be worn for invasive procedures, and all activities assessed as carrying a risk of exposure to blood, body fluids, or to sharp or contaminated instruments (NICE, 2017). When giving injections, the healthcare professional may be at risk of exposure to all of these, so the use of gloves should follow a risk assessment that identifies exposure to body fluids as a risk to the person administering the injection (RCN, 2016).

Healthcare professionals must also adhere to local policies on skin preparation. Skin decontamination is widely debated: many authors recommend cleaning the skin before an intramuscular injection (Dougherty & Lister, 2015; Ogston-Tuck, 2014) but the Green Book (PHE, 2013) advises that skin cleansing is not necessary in socially clean patients and only visibly dirty skin needs to be washed with soap and water. If alcohol swabs are used, the site must be left to dry (alcohol can deactivate medication).

Use of gloves Skin preparation

Adults


Page 3 of 6



Gather equipment

2.5

2

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2

Cutisoft wipes

2.5

2

1.5

1

0.5

Tap syringe to remove air bubbles

Tap the side of the syringe to allow any air bubbles to rise to the top.


DANGER

2.5

2

1.5

1

0.5

2.5

2

1.5

1

0.5



2

Cutisoft wipes

Draw up the medicine Remove and dispose of the needle

Remove the needle from the syringe and dispose of it into a sharps bin. Draw up the prescribed medication from the ampoule.

Using a non-touch technique, attach a new needle. Use a 21G safety needle (often green), as this is the needle of choice for an intramuscular injection. If you use a shorter needle, the medication will not reach the target muscle (Greenway, 2004). Oil-based solutions or highly viscous medications can be administered with a needle such as an 18G, 19G or 20G (Nicoll & Hesby, 2002).

Attach a new needle

PROCHLORPERAZINE

12.5 mg

2.5

2

1.5

1

0.5

Expel air and any excess medication Label the syringe

If giving more than one medicine by injection, label the syringes according to local policy. Ensure that the label does not obscure the plunger and markings on the syringe. Remove gloves and wash your hands.

Gently expel the air and any excess medication, leaving exactly the right dose in the syringe. (Note that you need to be careful not to expel too much; if you do, you would need to remove the needle, reattach a new blunt fill needle, draw up more medication and reattach a fresh 21G needle.)


Adults


Page 4 of 6


Muscle

Skin

Subcutaneous tissue


CONTAMINATED SHARPS ONLY

TO BE INCINERATEDDANGER

PROCHLORPERAZINE

12.5mg IM

8 hourly prn

2/4/19



2

Cutisoft wipes

PROCHLORPERAZINE

12.5 mg

HYD

RO

XOCO

BALA

MIN

1mg

1mg

ever

y 3

mon

ths

IM

2/4/

12

HYDROXOCOBALAMIN

1mgPROCHLORPERAZINE

12.5mg

Take the syringe to the patient Confirm the patient’s identity

Greater trochanter Femur

Patient position Locate the vastus lateralis

Ensuring the patient’s privacy and dignity are maintained, ask the patient to adopt a supine position. Put on a clean pair of gloves as appropriate.

To locate the vastus lateralis muscle, palpate from a hand’s breadth above the knee to a hand’s breadth below the greater trochanter, on the anterior lateral aspect of the thigh.

Identify the injection site Z-tracking: (a) Stretch the skin

Assess the injection site for signs of inflammation, oedema, infection and skin lesions; if any of these are present, use an alternative site. If required by local policy, clean the injection site for 30 seconds with a swab saturated with 70% isopropyl alcohol, and allow to dry for 30 seconds. Stretch the skin 2–3 centimetres, using your thumb, as shown. This technique is known as Z-tracking; it reduces pain and leakage from the injection site (Ogston-Tuck, 2014; Nicoll & Hesby, 2002; Rodger & King, 2000).

Confirm the patient’s identity, both verbally and by checking the patient’s identity band against the medication administration record.

Take the prepared syringe, in an injection tray, to the patient together with the medication administration record. Make sure a sharps bin is to hand.


Adults


Page 5 of 6


The middle third of the muscle is your landmark for administering the injection. The width of the muscle is usually from the midline of the thigh to the midline of the thigh’s outer side (Perry & Potter, 2014).

0.5

1

1.5

2

2.5

PROCHLORPERAZINE

(b) Insert the needle (c) You do not need to check for flashback

Date

AS REQUIRED PRESCRIPTIONS





Date

Time

Dose

Given by

Route





Date

Time

Dose

Given by

Route




Date

Time

Dose Route

PROCHLORPERAZINE

I2.5mg IM

8 hourly prn

2/4/19 14.20

2/4/19

Documentation

Using a darting motion, insert the needle at a 90º angle as this gives optimum opportunity to reach the target muscle. Insert the full length of the needle; do not leave a gap between the skin and the hub (Malkin, 2008).

There is no need to pull back on the plunger and check for flashback of blood, as there is no risk of striking a blood vessel at this site (Sisson, 2015; Malkin, 2008).

Aftercare

90°


Adults


(d) Inject the medicine (e) Wait before removing the needle

While maintaining skin traction, inject slowly (approximately 1 millilitre per 10 seconds) (Beckton Dickson, 2003). It is important to inject slowly in order to reduce the pain of the injection, and to allow the muscle fibres to stretch to accommodate the fluid.

Wait 10 seconds before removing the needle (Ogston-Tuck, 2014). Once the needle is out, immediately release the retracted skin, as this allows the medication to disperse evenly, and activate the safety device on the needle (inset). Immediately dispose of the needle into the sharps bin.

Page 6 of 6


2.5

2

1.5

1

0.5

90°

Document on the medicines administration record that the medication has been administered. Advise the patient to contact their doctor if they experience any of the following potential complications: haematoma, persistent nodules, local irritation and, rarely, anaphylaxis. Evaluate the effectiveness of the injection and monitor the patient for possible side-effects.

Apply pressure with a dry gauze swab as needed. Assist the patient into a comfortable position. Dispose of equipment according to policy. Remove gloves; wash your hands (Loveday et al., 2014). Warn the patient that the injection site may be sore for 1 or 2 days, which is normal after an injection.


demonstrated by clair merriman, head of professional

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