Intramuscular injection techniques

Hunter, Janet . Nursing Standard 22.24 (Feb 20-Feb 26, 2008): 35-40.
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Abstract (summary)
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The administration of intramuscular (IM) injections is an important part of
medication management and a common nursing intervention in clinical practice. A
skilled injection technique can make the patient's experience less painful and
avoid unnecessary complications.
Headnote
Summary
The administration of intramuscular (IM) injections is an important part of
medication management and a common nursing intervention in clinical practice. A
skilled injection technique can make the patient's experience less painful and
avoid unnecessary complications.
Headnote
Keywords
Clinical procedures; Drug administration; Injection technique
These keywords are based on the subject headings from the British Nursing Index.
This article has been subject to double-blind review. For author and research
article guidelines visit the Nursing Standard home page at www.nursingstandard.co.uk. For related articles visit our online archive and search using the
keywords.
THE NURSING and Midwifery Council's (NMC's) (2007) Standards for
Medicines Management state that administration of medicines 'is not solely a
mechanistic task to be performed in strict compliance with the written prescription
of a medical practitioner (now independent/supplementary prescriber). It requires
thought and the exercise of professional judgement.' Therefore, the administration
of intramuscular (IM) injections requires the healthcare practitioner to possess the
knowledge and rationale of the guiding principles that underpin these clinical
skills. It is essential that all aspects of these techniques - anatomy, physiology,

patient assessment, preparation and nursing interventions -are evidence based so

that the nurse can perform safe and accountable practice (Shepherd 2002, NMC
2007). The aim of this article is to update the nurse's knowledge and skills on
injection techniques. This article describes the practical, step-by-step approach for
administering IM injections, which will assist nurses to perform this skill safely
and competently.
Intramuscular injections
An IM injection is chosen when a reasonably rapid systemic uptake of the drug
(usually within 15-20 minutes) is needed by the body and when a relatively
prolonged action is required. The amounts of solution that can be given will
depend on the muscle bed and range from 1-5ml for adults. Much smaller
volumes are acceptable in children (Rodger and King 2000, Corben 2005).
The medication is injected into the denser part of the muscle fascia below the
subcutaneous tissues. This is ideal because skeletal muscles have fewer painsensing nerves than subcutaneous tissue and can absorb larger volumes of solution
because of the rapid uptake of the drug into the bloodstream via the muscle fibres.
This means that IM injections are less painful when administered correctly and
can be used to inject concentrated and irritant drugs that could damage
subcutaneous tissue (Rodger and King 2000, Greenway 2004). Examples of drugs
administered via this route are analgesics, anti-emetics, sedatives, immunisations
and hormonal treatments.
It is important to recognise and understand potential complications associated
with IM injections and that rapid absorption of the drugs may increase these risks
(Foster and Hilton 2004). The administration of any medication can present a risk
and, therefore, the nurse must 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 site and poor
technique can increase the risk of patient injury and lead to pain, nerve injury,
bleeding, accidental intravenous administration and sterile abscesses caused
through repeated injections at one site with poor blood flow (Rodger and King
2000).
Intramuscular injection sites
There are five sites that can be considered for IM injections (Figure 1 ). The two
recommended sites for IM injections are the vastus lateralis and the ventrogluteal
sites (Donaldson and Green 2005, Nisbet 2006). However, when the patient is
obese, the vastus lateralis is a better option (Nisbet 2006).
When choosing an appropriate site for administration, the nurse needs to ensure
that the medication will be absorbed. The nurse needs to consider whether the
patient is receiving regular IM injections because the site will need to be rotated to

avoid irritation, pain and sterile abscesses. Choice will also be influenced by the
patient's physical condition and age. Active patients are more likely to have a
greater muscle 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 presence of inflammation, swelling or infection should be
avoided (Workman 1999).
Patient preparation
It is important to explain the procedure so that the patient fully understands and is
able to give his or her informed 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 any concerns or anxieties
relating to the procedure and the patient's knowledge can be evaluated. It is
important to check whether the patient has any known allergies to identify
potential reactions to the medication.
Preparation of the equipment All the necessary equipment should be prepared
before commencing the procedure to avoid any delays or interruptions during the
procedure. The equipment required for administering IM injections is listed in
Box 1 and preparation of the equipment is described in Box 2. The techniques
used for administering IM injections are outlined in Box 3.
Skin cleansing
There are inconsistencies regarding skin preparation for IM injections. It is known
that cleansing the injection site with an impregnated alcohol swab before an IM
injection reduces the number of bacteria on the skin (Workman 1999, Lister and
Sarpal 2004). However, if the injection is given before the skin is dry this
procedure is ineffective and the patient may experience pain and a stinging
sensation from the antiseptic. This may allow entry of bacteria into the injection
site and cause local irritation (Workman 1999, Lister and Sarpal 2004). Therefore,
when using an alcohol swab to prepare the skin it should be used for 30 seconds
and then allowed to dry (Lister and Sarpal 2004). Some local policies no longer
recommend skin cleansing if the patient's skin is physically clean (Little 2000,
Wynaden et al 2005) and the nurse maintains the required standard of hand
washing and asepsis during the procedure (Workman 1999).
Needles
Re-sheathing a needle before the medication is administered to a patient is safe.
This method is achieved by using the aseptic non-touch technique (Figure 3) and
prevents droplets of the medication from being sprayed onto the skin or inhaled
when air is being expelled from the syringe (Nicol et al 2004).

When giving an IM injection a 'green' or size 21 gauge needle is used for all adult
patients to ensure that the 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 pressure to
inject the solution, which will increase the patient's discomfort (King 2003).
Single and multi-dose powder vials
Some medications come in single or multi-dose vials and need to be reconstituted
before being drawn up and injected. This method involves some key principles to
ensure safe practice.
* Before reconstituting any medication, the nurse should first read the
manufacturer's information sheet.
* It is important that the powder is at the bottom of the vial so that all the
medication is dissolved.
* The cap must be cleaned with an alcoholimpregnated swab and allowed to dry
to prevent bacterial contamination.
* It is vital that the correct volume of diluent is used according to the
manufacturer's 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 of the needle and syringe from the vial (Nicol et al 2004). 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 venting needle to prevent contamination
of the drug and the atmosphere. Agitate or roll the ampoule until the powder has
dissolved (Jamieson et al 2002, 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.
* To draw up the drug, hold the ampoule upside down to avoid drawing in air,
insert the needle so that it is below the level of the 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.

The Z-track technique

The literature suggests two methods for administering IM injections. The first has
already been outlined and the second method involves the Z-track technique. It is
recommended that this technique should be used for many IM injections because
it causes less discomfort and prevents leakage from the needle site (Rodger and
King 2000).
Using the non-dominant hand, pull the skin 2-3cm sideways or downwards from
the injection site. This action causes the skin and subcutaneous tissues to slide
over the underlying muscle by 12cm. With the dominant hand, hold the needle at a
90 degree angle above the injection site and quickly pierce the skin in a dart-like
motion until lem of the needle is left. Aspirate for blood, if no blood is withdrawn
then slowly inject the medication (1ml per 10 seconds) and hold in place for 10
seconds. Withdraw the needle quickly and release the tension on the skin. This
causes the tissues to return to their original position to create a disjointed pathway
and seals the injection entry point to prevent the medication from seeping into the
subcutaneous tissues or from leaking out though the injection site (Workman
1999, Rodger and King 2000, Jamieson et al 2002).
General principles for practice
To provide a safe standard of practice, nurses should adhere to local policies,
procedures and guidelines for their organisation. These will provide guidance on
whether one or two nurses are required to check the medication for the procedure.
Only registered nurses may administer medications unsupervised. It is essential
that nursing students are supervised by a registered nurse so that they can develop
safe and competent practice. A registered nurse must countersign any
documentation signed by a nursing student (NMC 2007).
Hands must be washed and dried thoroughly before starting this procedure and
immediately afterwards. Gloves should be worn during all invasive procedures
such as IM drug administration (Pratt et al 2007). Gloves help to prevent crossinfection and drug-induced allergies, which occur through contact with the skin.
Gloves do not protect the nurse from needlestick injury so careful and immediate
disposal of all sharps is essential following administration (Workman 1999).
Conclusion
Although IM injection is considered a routine procedure, it is a valuable and
necessary skill for nurses. To provide safe practice and ensure accurate and
merapeutic drug administration, the nurse should use clinical judgement when
choosing the injection site, understand the relevant anatomy and physiology, as
well as the principles for administering an IM injection.

The actions of the nurse can enhance the physical and emotional experience of the
patient which, in turn, influences the nurse's confidence. Nurses should regularly
update their knowledge and skills and be cognisant with, and adhere to, the
organisation's local policies, procedures and guidelines. The revised and renamed
Standards for Medicines Management (NMC 2007) provide standards by which
the administration of medications should be performed and act as a benchmark to
measure performance in clinical practice.
This article has emphasised the principles of best practice when administering IM
injections, accompanied with a rationale to encourage nurses to practise safely and
competently
Sidebar
Hunter J (2008) Intramuscular injection techniques. Nursing Standard. 22, 24, 3540. Date of acceptance: October 29 2007.
Sidebar
BOX 1
Equipment for intramuscular Injections
1. Prescription chart.
2. Prescribed drug to be administered.
3. If required, diluent for reconstitution.
4. Clean tray or receiver for equipment,
5. Syringe of appropriate size (2-5ml).
6. Sterile 21G (green) needle for adult patients.
7 Alcohol-impregnated swab with isopropyl alcohol 70%.
8. Gloves.
9. Tissue or clinical wipe.
10. Clinical sharps container.
BOX 2
Preparation for intramuscular (IM) injection administration

The following steps describe the procedure when preparing the equipment for an
IM injection.
* Wash and dry hands thoroughly with bactericidal soap and water or use
bactericidal handrub to prevent any contamination of the equipment or
medication. Put on gloves. Gloves are required for all invasive procedures
including IM injection (Pratt et ol2007). Check the patient's prescription chart and
determine 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 withhold
the medication and inform the medical team.
* Check the drug against the prescription chart As all medications deteriorate over
time, check the expiry date - this shows when a drug will no longer be guaranteed
to be effective.
* To prepare the syringe for medication:
(a) Check all packaging is intact to retain sterility. Check the expiry date. If any
packaging is damaged or has expired, discard.
(b) Open the packaging of the syringe at the plunger end and remove the syringe.
Make sure that the plunger moves freely inside the barrel. Take care not to touch
the nozzle end to prevent contamination.
(c) Open the needle packaging at the hilt (coloured) end. Hold the syringe in one
hand and then attach the needle firmly 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 ampoule for cloudiness or sedimentation. This may
show that the medication is contaminated or unstable. Make sure that all the
contents are in the bottom of the ampoule by tapping the neck gently. To prevent
injury, splashing or contact with the medication use a clinical wipe or tissue to

cover the neck of the ampoule and break it open. Observe the solution for any
glass fragments because these pose a risk to the patient if injected. Discard the
ampoule and contents if any foreign matter is visible. If you are using a plastic
ampoule, break the top off, making sure not to touch the top.
* Pick up the syringe and allow the sheath to fall off the needle 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 will blunt the needle.
* Pull back the top of the plunger with one finger on the flange and draw up the
required dose. It may be necessary to tilt or hold the ampoule upside 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 level and let any air rise to the top
of the syringe. To encourage air bubbles to rise, lightly tap the barrel of the
syringe. Slowly, push the plunger to expel the air until the solution is seen at the
top of the needle.
Sidebar
BOX 3
Intramuscular (IM) Injection technique
The following steps should be undertaken when administering IM injections to
patients:
* Take the tray with the syringe, ampoule, impregnated alcohol swab, tissue,
prescription and sharps container to the patient's bedside. Re-check the
prescription and medication with the patient's name band according to local
policy. Draw the curtains for privacy and assist the patient into a comfortable
position to allow access to the injection site and to 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
patient's 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.
* Withdraw 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. Remove 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 effectiveness of the
medication, especially anti-emetics and analgesics. Observe the injection site
within two to four hours for signs of local irritation (Rodger and King 2000).

References
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AuthorAffiliation
Author
Janet Hunter is lecturer in adult nursing, City Community and Health Sciences,
incorporating St Bartholomew School of Nursing and Midwifery, City University,
London. Email: [email protected]
Word count: 3481
Copyright RCN Publishing Company Feb 20-Feb 26, 2008