Intramuscular Injection (IM)

• Injection is instilling medication into body tissues for systemic absorption.
• Injections should be prepared and administered under an aseptic technique.
• Site selection is important for nurses to avoid tissue or nerve damage.
• Types of injections include: intramuscular (IM), subcutaneous (SQ, SC), intradermal (ID), and intravenous (IV).

Intramuscular Injection (IM)

• IM injection means injecting a drug into a muscle at a 90° angle to the skin.
• The muscle's vascularity allows for rapid drug absorption.
• Objectives of IM injections:
  • Rapid action compared to the oral route, with aqueous solutions absorbed in 10-30 minutes.
  • Larger volumes (up to 4ml) can be administered in well-developed adult muscles.
  • Suitable for irritant medications or strong-effect medications.
  • Used when there's a contraindication to the oral route, such as in unconscious patients or those undergoing oral surgery.
• Disadvantages of IM injections:
  • Can be painful and carries a risk of nerve or tissue injury.
• Contraindications include muscle atrophy, reduced blood flow, circulatory shock, and coagulation disorders.
• Intramuscular site selection criteria:
  • The site should be free from inflammation, necrosis, bruises, abrasions, or tenderness.
  • It should be suitable for the volume of medication to be given.
  • It should be free from lumps or nodules on palpation, which may indicate inadequate absorption.

Sites for Intramuscular Injection

• Ventrogluteal muscle:
  • Involves the gluteus medius and minimus.
  • Locate by pointing the thumb towards the patient’s groin and index finger over the anterior superior iliac spine, extending the middle finger back along the iliac crest towards the buttock.
  • Inject in the center of the V shape formed by the index and middle finger.
  • Advantages: Deep and safe (away from major nerves and blood vessels), and has a consistent layer of adipose tissue.
  • Proper site can be located using the left hand if the patient lies on their left side, and the right hand if they lie on their right side.
  • Position: On either side with the knee bent, supine, or prone.
• Dorsogluteal muscle:
  • Located in the upper outer quadrant of the buttock.
  • Divide the buttock into 4 quadrants and inject in the upper outer quadrant, lateral and slightly superior to the midpoint of a line drawn from the greater trochanter to the posterior superior iliac spine.
  • Disadvantage: Risk of injuring the sciatic nerve and major blood vessels. No longer commonly used.
  • Position: Prone with toes pointing inward, or on either side with the upper leg flexed in front of the lower leg.
• Vastus lateralis:
  • Located on the anterior lateral aspect of the thigh.
  • Extends in an adult from a hand breadth above the knee to a hand breadth below the greater trochanter of the femur.
  • The middle third of the muscle is the best site.
  • It is thick, well-developed, but has small nerve endings, resulting in discomfort after injection.
  • Position: Supine with knee flexed, or sitting.
• Rectus femoris:
  • Located on the anterior aspect of the thigh.
  • Injection site is in the middle third of the anterior aspect of the thigh.
  • Used for small injections.
  • Position: Supine with knee flexed or sitting.
• Deltoid:
  • In the upper arm, forming a triangle with its base at the acromion process.
  • Place four fingers width with the top finger along the acromion process and inject within 3 fingers width in the center of the muscle.
  • Not well developed in many adults, so used when other sites are inaccessible by cast or dressing.
  • Only for small doses (0.5-1ml).
  • Avoid injection in the middle or lower 1/3 of the upper arm, because it might injure the radial nerve.
  • Hepatitis vaccines should be given in this muscle only.
  • Position: Sitting or lying down with the arm relaxed and the elbow flexed, exposing the upper arm and shoulder.

Equipment Needed for Injections

• Syringes (choose the suitable size).
• Needles (needles vary in length and sizes).
• Medication cards.
• Ampoule or vial of medication.
• Solvent (e.g., normal saline or sterile water) if needed.
• Alcohol sponge.
• Dry sponge.
• Tray.
• Container for disposing of waste product (paper bag).

Steps for Preparation

• Wash hands (to prevent cross-infection).
• Prepare needed equipment and supplies (to save time and effort).
• Check each medication card against the label on each ampoule or vial (ensures that the right drug and dosage are prepared).

Preparing Injection from Ampule

• Tap the top of the ampule lightly and quickly with a finger until the fluid leaves the neck to dislodge fluid collected above the neck.
• Place a small dry sponge around the neck of the ampule (protects your finger from glass edges).
• Snap the neck quickly and firmly away from your hands (prevents shattering glass towards your finger or face).
• Draw up medication quickly while holding the ampule upside down, inserting the needle into the center of the opening.
• Prevent the needle tip or shaft from touching the rim of the ampule, as a broken rim is considered contaminated.
• Aspirate medication into the syringe by gently pulling back on the plunger (withdrawal creates negative pressure within the syringe barrel).
• Keep needle tip below the surface of the liquid to prevent aspiration of air bubbles.
• To expel air bubbles, hold the syringe vertically with the needle pointing up, tap the side of the syringe to cause bubbles to rise, draw back slightly on the plunger, and push the plunger upward to eject air.
• If the syringe contains excess fluid, hold it vertically with the needle tip up and slowly eject the excess fluid to ensure the proper dose.
• Cover the needle with a sheath or change it if indicated to prevent contamination and needle stick. Changing needle is needed if medication is on needle shaft.
• Dispose of soiled supplies properly to control the transmission of infection.

Preparing Injection from Vial

• Remove the metal cap covering the top of the unused vial and expose the rubber seal.
• The metal cap prevents contamination of the rubber seal.
• Wipe off the surface of the rubber seal with alcohol sponge to disinfect, especially if the vial has been previously opened.
• Take syringe and remove the needle cap. Pull back on plunger to draw an amount of air into the syringe equivalent to the volume to be aspirated which facilitates aspiration of medication.
• Insert the needle tip, with the bevel pointing up, through the center of the rubber seal, as the center is thinner and easier to penetrate.
• Inject air into the vial while holding onto the plunger, as the plunger may be forced backward by air pressure within the vial.
• Invert the vial while keeping a firm hold on the syringe and plunger, holding the vial between the thumb and middle fingers of the non-dominant hand.
• Grasp the end of the syringe barrel and plunger with the thumb and forefinger of the dominant hand, for easy manipulation of the plunger.
• Inverting the vial allows the fluid to settle in the lower half of the container.
• Keep the tip of the needle below the fluid level to prevent aspiration of air.
• Allow air pressure to fill the syringe gradually with medication. Pull back slightly on the plunger if necessary and to create positive pressure within the vial.
• Tap the side of the syringe barrel carefully to dislodge air bubbles.
• Eject air remaining at the top of the syringe into the vial accumulation of air displace medication.
• After the correct dose is obtained, remove the needle from the vial by pulling rather than barrel causing separation from barrel.
• Remove remaining air from the syringe by holding it upright allows fluid to setlle in bottom of the barrel which prevents loss of medication.
• Cover the needle to prevent contamination and prepare a powdered drug

Preparing a Powdered Drug

• Draw up the amount of solvent recommended on the vial's label.
• Inject the solvent into the vial in the same manner as before.
• Gently shake the vial to dissolve the powder.
• Draw up the dissolved medication.
• For a multi-dose vial, add a label that includes the date of mixing, concentration of drug per ml, your initials, and ensures that future doses will be prepared correctly.

Final Steps

• Dispose of soiled supplies (to maintain medical asepsis).
• Check fluid level in syringe (ensures accurate dose is prepared).
• Clean and dry work area (to reduce transmission of microorganisms).
• Wash hands (to prevent cross infection).

Intramuscular (IM) Administration Technique

• Assemble the needed equipment.
• Explain the procedure to the patient (to relieve fear and gain cooperation).
• Provide for privacy and locate the site of choice.
• Have the patient assume a position appropriate for the selected site.
• Clean the site with an alcohol sponge, using a circular motion and moving from the center to the outer edge as pathogens are killed and prevent injecting alcohol into tissue.
• Remove the needle sheath by pulling it straight off.
• Spread the skin at the site using your non-dominant hand for obese patients, and collect the skin for thin patients to minimize discomfort.
• Hold the syringe in your dominant hand between the thumb and forefingers. Quickly dart the needle into the tissue at a 90-degree angle as a quick injection is less painful.
• As soon as the needle is in place, move your non-dominant hand to hold the lower end of the syringe. Slide your dominant hand to the tip of the barrel.
• Aspirate by slowly pulling back on the plunger to ensure the needle is not in a blood vessel and verify the correct site.
• If no blood is aspirated, inject the medication slowly (to minimize discomfort and allow time for the medication to disperse in the tissues).
• Remove the needle quickly at the same angle as you inserted it (to reduce discomfort).
• Press the site with a dry sponge.
• If the drug should be rapidly absorbed, massage the site for 1 to 2 minutes.
• Do not massage if the medication you just injected would cause tissue trauma or pain, or if it will be absorbed too quickly.
• Discard the needle and syringe according to the hospital's policy as it prevents needle stick and transmission of diseases.
• Assist the patient to a comfortable position and wash hands.
• Chart the time, medication, dose, the injection site, your name, and the patient's response for legal documentation.

Z-Track Technique

• Z-track or zigzag technique is used to administer medications that are highly irritant to subcutaneous tissues, for example, iron-dextran injection (Imferon).
• A lock of 0.2 ml to 0.3 ml is created after the medication is prepared in the syringe.
• A clean needle is attached to the syringe to prevent medication on the needle into superficial tissues.
• A needle should be a minimum of 1 to 1.5 inches long. For obese persons, the needle may require being 3 inches to there be no danger of injecting the medication into the subcutaneous tissue.
• The dorsogluteal or vastus lateralis sites can be used for this procedure.
• The skin is pulled to one side about 1 inch laterally or downward and held in this position with the non-dominant hand.
• The needle is inserted and aspirated for blood.
• The solution is injected.
• The needle is allowed to remain in place for 10 seconds after injecting medication to prevent seepage of the solution into the needle tract.
• The needle is withdrawn and the displaced tissue is allowed to return to its normal position.
• Guidelines for IM injection:
  • Select a needle of the smallest gauge that is appropriate for the site and solution to be injected.
  • Ensure the needle is free of medication that may irritate superficial tissues as the needle is inserted.
  • Inject the medication into relaxed musculature.
  • Do not inject areas that feel hard on palpation or tender to the patient.
  • Do not administer more solution in one injection than is recommended for the site.
  • Rotate the sites when the patient is to receive repeated injections.
  • Injections in the same site may cause undue discomfort, irritation, or abscess in tissues.
• Never recap the needle when discarding it.

Subcutaneous Injections

• It is depositing medication into the loose connective tissue underling the dermis.
• In S.C injection drugs are absorbed more slowly mainly through the capillaries so they give prolonged effect.
• The subcutaneous tissue is sensitive to irritating solutions and large volumes of medications.
• If large volumes of medication are given, it will be collected within the tissues and cause sterile abscesses, which appear as hardened, painful lumps.
• Factors affecting the rate of absorption:
  • Absorption of medications is affected by anything affecting blood flow to the tissues:
    • Physical exercise.
    • Local application of hot or cold compresses.
    • Conditions as occlusive vascular disease impair client's blood flow and delay absorption.
• Advantages of subcutaneous injection:
  • Allows slower, more sustained drug administration.
  • Minimal tissue damage and trauma.
  • Carries a low risk of striking large blood vessels and nerves.
• Contraindications of subcutaneous injection:
  • Site that is inflamed, edematous, scarred, or covered by mole, birthmark, or other lesion.
  • In patients with impaired coagulation mechanisms.
• Sites of subcutaneous injections should be free from infectious skin lesions, scars, bony prominences and large underling muscles or nerve:
  • The outer aspect of the upper arms (the patient's arm should be relaxed and at the side of the body).
  • The anterior aspect of the thighs (the patient may sit or lie with the leg relaxed).
  • The abdomen from below the costal margins to the iliac crests (the patient may lie in the recumbent position).
  • The abdomen location is around the umbilicus, and using the umbilicus as a site is important for vascularity reasons.
  • Other sites include the scapular area of the upper back (patient may be prone or on side or in a sitting position) and upper ventral or dorsogluteal areas.

Equipment needed for S.C injection

• Medication.
• Medication card.
• A sterile syringe (1-3 ml) with a 25-27G needle.
• Antiseptic swab and disposable gloves.

Intradermal Injections

• Indication of intradermal injections: It is often used for diagnostic testing and allergy tests. Such as tuberclin test; test site for hardness after 48 to 72 hrs or an allergy test where the test site's result can be read if there is a change in color, rash, itching after 20 to 30 min.
• Because little systemic absorption of the intradermal injection agent takes place, this type of injection produces a local effect.
• Advantage of intradermal Injections is it tests allergy in patient, or to giving him injection or vaccine before patient enters anaphylactic reaction.
• No effect on patient and let simple reaction if the patient have allergy.
• In minimal cases, may lead to skin allergy and erythema of a disadvantage.
• Sites of Intradermal injections: Injection should be easy access with lack of hair and lightly pigmented:
  • The inner aspect of the fore arms (pt's arm should be relaxed and at the side of the body, common site used).
  • The outer aspect of the upper arm.
  • Area of the back located between the scapulae. -Upper Chest
• Intradermal injection is administrated in small volumes usually 0.5 ml or less using 10-15 degree angle.
• Equipment: -Medication -Medication card
  • A sterile tuberculin syringe or hypodermic syringe and needle -Antiseptic swab -Disposable gloves -Pen for marking

Intradermal Injection Steps

• Check physician order before assessment of injection.
• Washing hands that prevent cross of infection that facilitates organization and efficiency.
• Draw up correct dose of medication from ampule or vial to reduce anxiety and gain cooperation.
• Explain the procedure to the patient to provide privacy to prevent infection.
• Apply antiseptic solution by swabbing at center of site and rotating outwards in circular direction for about 5 cm.
• Then proceed to hold and use the 3 and 4 fingers of non dominant hand and the use non-dominant hand to stretch skin over the injection site with or thumb.
• If using a cap/covering remove the needle as you would do for a pencil.
• Then the following injection procedure can be carried out: place the needle and inject 0.3ml. then withdraw.
• Then circle the test site with a marking pen and instruct the patient not to scratch it and to refrain from washing it. Complete by as sessing and documenting.

Intravenous Line Insertion

• Indications:
  • Patients need fluids, electrolytes, or nutritional supplements.
  • Infuse blood or blood products.
  • Administration of intravenous medications.
• Hazards:
  • Provide entry for infectious organisms.
  • Allow air to be introduced and act as emboli.
  • Bleeding.
  • The equipment and solution can irritate the tissue.

Intravenous Line Insertion Equipment

• An infusion set.
• Appropriate IV catheter (cannula).
• Infusions pump if needed.
• Kidney basin.
• Tourniquets.
• Disposable gloves.
• Antiseptic solution (70 % alcohol, povidone-iodine).
• IV fluids.
• Strips of plaster.
• Assessment:
  • Assess patient's medical record for the type, concentration, and amount of IV fluid, frequency of administration, rate of flow, and additives (name and dose of medication).
  • Assess patient's condition, including vital signs, CVP (if present), intake and output, signs and symptoms of fluid and electrolyte imbalance, level of consciousness, and sensitivity to adhesive tape.
  • Assess condition of the vein, including the presence of scars, bruises, or swelling, the size of the vein, and any pathology or surgery on extremities.
• Expected outcomes include minimal complications from IV therapy, minimal discomfort to the patient, restoration of normal fluid and electrolyte balance, and the patient's ability to verbalize complications requiring immediate nursing intervention.