Intramuscular Injections (IMI)

[Andre01]

Pardon my ignorance, but I have been reading some of these posts in regards to your injection sites. I have added below the new “best practice” that I was given as part of my Nurses training. I hope that it helps. Sorry that the pics have not loaded but you can goggle them if you need them. I just wanted to update you all on what is safer than what used to be considered safe.

BACHELOR OF NURSING

INTRAMUSCULAR INJECTION GUIDELINE

• Reads medical order and reviews drug information if unfamiliar with the medication prescribed. Check any known patient allergies.

• Gains consent and explains to the client the actions, expected effects and method of administration.

• Washes/ decontaminates hands.

• Selects equipment: prescription, drug (diluent if necessary) appropriate needle (21 – 24g for adult patients/ 25mm – 38mm bearing in mind that women generally have a larger subcutaneous layer) for client(size) & type of drug, syringe size (volume of drug), (alcohol swab if appropriate), gloves, gauze and receptacle.

• Reads the label on the medication and compares with medical prescription, checking with a Registered Nurse.

• Calculates drug volume and checks with a RN. Use filter needle/ needleless cannula to draw up drug using an aseptic non-touch technique. Change needle to appropriate size for patient.

• Identifies client by checking identification band in the presence of a Registered Nurse.

• Ensures client warmth and privacy and clearly exposes injection site.

• Decontaminate hands/ don gloves.

• Selects injection site appropriately by palpating landmarks i.e. recommended sites: ventrogluteal/ vastus lateralis. (Deltoid should only be used for near-neutral pH drugs with a volume less than 1ml).Consider patient’s age, physical condition, presence of inflammation, swelling, infection & drug to be given. Also consider drug manufacturer’s recommended site.

• Position pt accordingly (and to ensure maximum comfort).If supine, bend knee, if side-lying place upper leg in front of lower leg. Side-lying position recommended for ventrogluteal injection.

• Cleanses site with alcohol swab if necessary (recommended for injections into thigh, in the elderly or immunocompromised pts or injections close to infected or colonised lesions/ skin is visibly dirty). If using alcohol swab should be used for 30 secs & allowed to dry.

• Stretch the skin or use z-track procedure (recommended for all types IMIs):

z-track procedure:

Displace skin, using ulnar side of hand, by 2.5 – 3.5cm laterally before skin punctured then release after contents have been injected.

• Hold syringe like a pen and insert in a dart-like motion up to the hub. Insert needle quickly at 90o angle.

• Steady the lower end of the syringe (aspiration need ONLY be performed if using dorso-gluteal site).

• Inject medication at steady pace (1ml/ 10seconds), wait a few seconds then remove the needle and place uncapped syringe in receptacle/ Sharps bin.

• Apply gentle pressure over site. DO NOT massage.

• Assists client into comfortable position and provides call-bell.

• Washes hands

• Signs for medication on medication chart

• Checks the client in ~20 minutes to evaluate response to medication

Sites for injection

Mid deltoid:

• Use denser part of deltoid

• Give IMI ~2.5cm down from acromial process.

Vastus Lateralis:

• Located outer side of femur

• Measure a hands breadth from greater trochanter & the knee – identifies the middle third of the quadriceps muscle.

Ventrogluteal:

• Client placed on side with nurse behind client (P&P: pt may lie on side or back. Flexing knee & hip helps pt relax this muscle).

• Place palm of hand on pt’s opposite greater trochanter i.e. nurse’s right palm on pt’s left hip.

• Extend index finger to anterior superior iliac spine & middle finger spread posteriorly away from the index finger as far as possible, to make a ‘V’.

• Give IMI in centre of V

Inconsistencies in literature (as of May 2010):

• Aspiration of blood

• Inserting needle to hub/ leaving 1cm of needle showing.

• Use of gloves

Most literature recommends NOT using dorsogluteal site

Latest JBI (March 2010)

• Choose site carefully depending on pt’s general physical status & purpose of injection

• Z-track recommended for all IMIs

• Ventrogluteal site safest (over 7 months of age)

Carstens, J. (2010). Injection (intramuscular): Clinician

information. Evidence Summaries – Joanna Briggs Institute. Retrieved 10 May, 2010 from ProQuest.

Cocoman, A. & Murray, J. (2008). Intramuscular injections: a review

of best practice for mental health nurses. Journal of Psychiatric and Mental Health Nursing, 15, 424 – 434. Retrieved 22 March, 2010, from Ebsco Cinahl Full Text.

Crisp, J. & Taylor, C. (2009). Potter & Perry’s fundamentals of

nursing 3e (7th ed). Sydney: Elsevier Mosby.

Floyd, S. & Meyer, A. (2007). Intra-muscular injections – what’s

best practice? Kai Tiaki Nursing New Zealand, 13 (6), 20 – 22. Retrieved 8 March, 2010, from Ebsco Cinahl Full Text.

Hunter, J. (2008). Intramuscular injection techniques. Nursing

Standard, 22 (24), 35 – 40. Retrieved 8 March, 2010, from Ebsco Cinahl Full Text.

Jayasekara, R. (2009). Injection (subcutaneous): clinician

information. Evidence Summaries – Joanna Briggs Institute. Retrieved 9 March, 2010 from ProQuest.

Shaw, A. (2002/2003). Choosing the right injection site. Kai Tiaki

Nursing New Zealand.

Xue, Y. (2009). Skin disinfection prior to injection. Evidence

Summaries – Joanna Briggs Institute. Retrieved 9 March, 2010, from Proquest.

Zimmerman, P.G. (2010). Revisiting IM injections. American Journal

of Nursing, 110 (2), 60-61.

http://www.nursingtimes.net/nursing-pra ... le?query=0

http://www.dh.gov.uk/prod_consum_dh/gro ... 063616.pdf

[clash]

Nice read and good advise for general applications

[musclenz]

Interesting to note no aspiration advised except in dorso glut site. I believe you should swab the site after the injection as well. Often you will need to remove blood spots & a swab is still ideal IMO unless you have got a gusher

[Chemo]

Apply gentle pressure over site. DO NOT massage.

err woops, any reason for this?

[genetic freek]

I have friends doing nursing. They are taught that when you swap you need to leave it for at least 30 sec before pining. If not you may as well not swab.

[Andre01]

Interesting to note no aspiration advised except in dorso glut site. I believe you should swab the site after the injection as well. Often you will need to remove blood spots & a swab is still ideal IMO unless you have got a gusher

The reason behind this is that you should have it in the right place. The only reason that I aspirate in the glut is to make sure that I have not hit one of the nerves/veins/arteries that are in the area.

[Andre01]

If you are clean with not dirty areas on the area that you wish to inject then there is no point to swap. The only reason that you would need to swab is to clean the area, and yes you will need to wait approx 30 seconds before you inject.

The reason that you no longer massage is that you have just injected yourself with something and the tissue is very sensitized. The gentle pressure will assist with the clotting.

[clash]

If you are clean with not dirty areas on the area that you wish to inject then there is no point to swap. The only reason that you would need to swab is to clean the area, and yes you will need to wait approx 30 seconds before you inject.

The reason that you no longer massage is that you have just injected yourself with something and the tissue is very sensitized. The gentle pressure will assist with the clotting.

"Clean" is not sterile. Bacteria are always present on the skin (and in the air) even if you are "clean" the fingers where you palpitate the area prior to injection are always prone to have bacteria even if you have just washed them. Always swab, leave 30 seconds and inject. swab again after. If you inject immediately after swabbing you may also end up with trace amounts of alcohol from the swab entering the wound. This can sting! Applying gentle pressure or gently massaging the area with the swab will help to spread the oil which will alleviate the pressure on the nerves caused from the oil sitting in one mass at the site.

[thatwaslight]

If you are clean with not dirty areas on the area that you wish to inject then there is no point to swap. The only reason that you would need to swab is to clean the area, and yes you will need to wait approx 30 seconds before you inject.

The reason that you no longer massage is that you have just injected yourself with something and the tissue is very sensitized. The gentle pressure will assist with the clotting.

"Clean" is not sterile. Bacteria are always present on the skin (and in the air) even if you are "clean" the fingers where you palpitate the area prior to injection are always prone to have bacteria even if you have just washed them. Always swab, leave 30 seconds and inject. swab again after. If you inject immediately after swabbing you may also end up with trace amounts of alcohol from the swab entering the wound. This can sting! Applying gentle pressure or gently massaging the area with the swab will help to spread the oil which will alleviate the pressure on the nerves caused from the oil sitting in one mass at the site.

Great post clash.

The problem with this site is dumb asses like this guy giving potentially dangerous advice to noobs, thankfully logic usually prevails in this case but be careful out there kids! i have heard shocking stories of meathead practice when injecting

[Dontrunwithknives]

i have heard shocking stories of meathead practice when injecting

Not injecting but defiantly meathead practice with a syringe :puke:

[clash]

It is great for people to be able to gather information to help them make informed decisions. But the information needs to have health and safety in mind and not encourage bad practices that could cause injury or infection. Sure you may get away with it for years, but its the same principles that compel us to listen when people tell us "Don't Run With Knives" one day, one mistake may kill . Prevention is better that the cure.

[severe]

Peace of mind ensures I always aspirate. I have only had two blood draws so far, (looked like a mini lava lamp), but without finding out I wouldve been injecting into a vein.

[musclenz]

If you are clean with not dirty areas on the area that you wish to inject then there is no point to swap. The only reason that you would need to swab is to clean the area, and yes you will need to wait approx 30 seconds before you inject.

The reason that you no longer massage is that you have just injected yourself with something and the tissue is very sensitized. The gentle pressure will assist with the clotting.

Can I ask how many injections have you done? Every medical professional will ALWAYS swab the site & wait 30 secs then inject. As Clash points out washing or showering is not sterilising the area sufficiently to avoid staph bacteria entering the injection site or contamination from another external source.

[bob26]

If you are clean with not dirty areas on the area that you wish to inject then there is no point to swap. The only reason that you would need to swab is to clean the area, and yes you will need to wait approx 30 seconds before you inject.

The reason that you no longer massage is that you have just injected yourself with something and the tissue is very sensitized. The gentle pressure will assist with the clotting.

Can I ask how many injections have you done? Every medical professional will ALWAYS swab the site & wait 30 secs then inject. As Clash points out washing or showering is not sterilising the area sufficiently to avoid staph bacteria entering the injection site or contamination from another external source.

Just had to take our new baby to get his first & second shots at the doctors & they didn't use a alcohol swab either time.

The first time i never said anything but the second time i just said to the nurse "hey i haven't given him a shower this morning so do you need to swab?" She replied "No we don't use alcohol swabs these days".

[clash]

If you are clean with not dirty areas on the area that you wish to inject then there is no point to swap. The only reason that you would need to swab is to clean the area, and yes you will need to wait approx 30 seconds before you inject.

The reason that you no longer massage is that you have just injected yourself with something and the tissue is very sensitized. The gentle pressure will assist with the clotting.

Can I ask how many injections have you done? Every medical professional will ALWAYS swab the site & wait 30 secs then inject. As Clash points out washing or showering is not sterilising the area sufficiently to avoid staph bacteria entering the injection site or contamination from another external source.

Just had to take our new baby to get his first & second shots at the doctors & they didn't use a alcohol swab either time.

The first time i never said anything but the second time i just said to the nurse "hey i haven't given him a shower this morning so do you need to swab?" She replied "No we don't use alcohol swabs these days".

I find this quite disturbing and I hope never to be proved wrong on this but there is no evidence that the protocols used for injecting have changed in recent years and I would be questioning your nurse to justify the statement - "No we don't use alcohol swabs these days" ! These are the people that should be leading by example not disguising their own laziness behind a ridiculous and potentially dangerous statement.

[Andre01]

Can I ask how many injections have you done? Every medical professional will ALWAYS swab the site & wait 30 secs then inject. As Clash points out washing or showering is not sterilising the area sufficiently to avoid staph bacteria entering the injection site or contamination from another external source.

Just had to take our new baby to get his first & second shots at the doctors & they didn't use a alcohol swab either time.

The first time i never said anything but the second time i just said to the nurse "hey i haven't given him a shower this morning so do you need to swab?" She replied "No we don't use alcohol swabs these days".

I find this quite disturbing and I hope never to be proved wrong on this but there is no evidence that the protocols used for injecting have changed in recent years and I would be questioning your nurse to justify the statement - "No we don't use alcohol swabs these days" !

These are the people that should be leading by example not disguising their own laziness behind a ridiculous and potentially dangerous statement.

As I have already said this is the "BEST PRACTICE". “Best Practice” is what we in the nursing world use, as the information has been researched and looked into and either proven wrong or right. This is the best method to use and is proven to be the safest.

I have provided the Best Practice in regards to IMI, and have also proven references so if you wish to have a look for yourself feel free.

[Andre01]

Peace of mind ensures I always aspirate. I have only had two blood draws so far, (looked like a mini lava lamp), but without finding out I wouldve been injecting into a vein.

If you google the IMI sites that I spoke about earlier it will gove you a better idea of where to do the IMI, I would recommend that you might want to look at doing it into your thigh.

[Andre01]

If you are clean with not dirty areas on the area that you wish to inject then there is no point to swap. The only reason that you would need to swab is to clean the area, and yes you will need to wait approx 30 seconds before you inject.

The reason that you no longer massage is that you have just injected yourself with something and the tissue is very sensitized. The gentle pressure will assist with the clotting.

Can I ask how many injections have you done? Every medical professional will ALWAYS swab the site & wait 30 secs then inject. As Clash points out washing or showering is not sterilising the area sufficiently to avoid staph bacteria entering the injection site or contamination from another external source.

I have lost count, and yes I am still training, but as I have said before Best Practice and I have also already incluided up to date referances to back me up.

[Android]

Peace of mind ensures I always aspirate. I have only had two blood draws so far, (looked like a mini lava lamp), but without finding out I wouldve been injecting into a vein.

If you google the IMI sites that I spoke about earlier it will gove you a better idea of where to do the IMI, I would recommend that you might want to look at doing it into your thigh.

Got to agree with you there on the thigh as best place for jab.

But swabbing seems no-brainer don't want to push salts and cloth lint into body too often...i never swab for insulin and haven't met anyone that does could be it's only into fat or could b ultra thin needle.

Just never swab back and forth of course!!

[Andre01]

Peace of mind ensures I always aspirate. I have only had two blood draws so far, (looked like a mini lava lamp), but without finding out I wouldve been injecting into a vein.

If you google the IMI sites that I spoke about earlier it will gove you a better idea of where to do the IMI, I would recommend that you might want to look at doing it into your thigh.

Got to agree with you there on the thigh as best place for jab.

But swabbing seems no-brainer don't want to push salts and cloth lint into body too often...i never swab for insulin and haven't met anyone that does could be it's only into fat or could b ultra thin needle.

Just never swab back and forth of course!!

Same reason as for not swabbing for insulin.

[clash]

Peace of mind ensures I always aspirate. I have only had two blood draws so far, (looked like a mini lava lamp), but without finding out I wouldve been injecting into a vein.

If you google the IMI sites that I spoke about earlier it will gove you a better idea of where to do the IMI, I would recommend that you might want to look at doing it into your thigh.

Got to agree with you there on the thigh as best place for jab.

But swabbing seems no-brainer don't want to push salts and cloth lint into body too often...i never swab for insulin and haven't met anyone that does could be it's only into fat or could b ultra thin needle.

Just never swab back and forth of course!!

I also swab for insulin but the reason most people don't is because the needle most usually never contacts the blood stream and infection is minimal risk. The phrase "best practice" seems contradictory in this situation. Even with the back up references it is still a no brainer to swab. Does swabbing offer any possible advantage or protection over "non swabbing" - Yes...So wouldn't this become the "best practice" even if the risk of infection was minimal without swabbing. This risk is decreased by swabbing even if it is only a minor advantage.

[musclenz]

Just had to take our new baby to get his first & second shots at the doctors & they didn't use a alcohol swab either time.

The first time i never said anything but the second time i just said to the nurse "hey i haven't given him a shower this morning so do you need to swab?" She replied "No we don't use alcohol swabs these days".

I find this quite disturbing and I hope never to be proved wrong on this but there is no evidence that the protocols used for injecting have changed in recent years and I would be questioning your nurse to justify the statement - "No we don't use alcohol swabs these days" !

These are the people that should be leading by example not disguising their own laziness behind a ridiculous and potentially dangerous statement.

As I have already said this is the "BEST PRACTICE". “Best Practice” is what we in the nursing world use, as the information has been researched and looked into and either proven wrong or right. This is the best method to use and is proven to be the safest.

I have provided the Best Practice in regards to IMI, and have also proven references so if you wish to have a look for yourself feel free.

So why has this protocol changed? Why do they still give you swabs at the needle exchange? Also my Doc injected me only a month ago & he swabbed. It just goes against what has been the rule for the last 20 years I been doing injections. http://www.howtodoinjections.com still advocates -

"Wash your hands before starting to prepare the injection.

Disinfect the skin over the injection site."

I'm sticking to what I have always done & over thousands of injections never had a staph infection. Not saying what you been taught is wrong but just does not feel right for me.

[WANABJAKD]

medical care is a multi-billion doller business. do you know how much money they would save from neglecting this preparation?

[clash]

I also swab for insulin but the reason most people don't is because the needle most usually never contacts the blood stream and the risk of infection is minimal. The phrase "best practice" seems contradictory in this situation. Even with the back up references it is still a no brainer to swab. The references ans evidence even qualify the following - Does swabbing offer any possible advantage or protection over "non swabbing" - Yes...So wouldn't this become the "best practice" even if the risk of infection was minimal without swabbing. This risk is decreased by swabbing.... Even if this decreased risk is slight, it is still evident and therefore worth observing when describing the "best practice"

[musclenz]

I also swab for insulin but the reason most people don't is because the needle most usually never contacts the blood stream and the risk of infection is minimal. The phrase "best practice" seems contradictory in this situation. Even with the back up references it is still a no brainer to swab. The references ans evidence even qualify the following - Does swabbing offer any possible advantage or protection over "non swabbing" - Yes...So wouldn't this become the "best practice" even if the risk of infection was minimal without swabbing. This risk is decreased by swabbing.... Even if this decreased risk is slight, it is still evident and therefore worth observing when describing the "best practice"

Ditto:D