Good injection technique can mean the difference between less pain and injury. Angela Cocoman and John Murray explain

The administration of intramuscular injections is a common nursing intervention in clinical practice.¹ This article aims to, raise awareness in relation to the injection sites used for intramuscular injection and, to highlight best practice in relation to IM injection administration.

The importance of good injection technique cannot be understated. It should not be forgotten that among potential complications of IM injection are abscess, cellulites, tissue necrosis, granuloma, muscle fibrosis, contractures, haematoma and injury to blood vessels, bones and peripheral nerves.² Although IM injection is a commonplace nursing practice, there is a dearth of guidelines for nursing staff in this area.^3,4 It has been outlined that there are no working policies or procedures on administering injections to which nursing staff can refer.³ Furthermore, the technique and preparation by certain staff may not be substantiated by evidence.⁴

Sites of the thigh (Rectus femoris and Vastus lateralis)
The uptake of drugs from the thigh region is slower than from the arm but faster than from the buttock, thus facilitating better drug serum concentrations than is possible with the gluteal muscles.⁵

The thigh may be utilised when other sites are contraindicated or by clients who administer their own medication, as it is readily available in the sitting or lying back position. However, the main disadvantage is that injections in the Rectus femoris site may cause considerable discomfort.⁶

This site can be used for infants, children and adults. Needle length used is usually 2.5cm or less.

The dorsogluteal site
This site is commonly referred to as the outer upper quadrant and is contraindicated in children.

IM injection into the Gluteus medius site (buttock)

Find the trochanter. It is the knobbly top portion of the long bone in the upper leg (femur). It is the size of a golf ball Find the posterior iliac crest. Many people have ‘dimples’ over this bone Draw an imaginary line between the two bones After locating the centre of the imaginary line, find a point one inch toward the head. This is where (X) to insert the needle Stretch the skin tight Hold the syringe like a pencil or dart. Insert the needle at a right angle to the skin Up to 3ml of fluid can be given in this site

The presence of major nerves and blood vessels, the relatively slow uptake of medication from this site compared with others and the thick layer of adipose tissue commonly associated with it, makes this site problematic.⁷ The sciatic nerve and superior gluteal artery lie only a few centimetres distal to the injection site, thus great care needs to be taken to identify landmarks accurately. Palpating the ileum and the trochanter is important; using visual calculations alone can result in injection being placed too low and injuries to other structures.⁸

Risks associated with an IM injection to the dorsogluteal site

• Contact with sciatic nerve
• Contact with the superior gluteal artery
• Too much fatty tissue – poor absorption rates.

The deltoid site
The ease of access, especially in an outpatient setting, possibly adds to the frequency with which the deltoid site is used for IM injections. This site is used for immunisations/non-irritating medications, hence vaccines which are usually small in volume tend to be administered into the deltoid site.⁹ This is a relatively small area and muscle mass, especially in atrophied patients compounded by the close proximity of the radial nerve, brachial artery and bony processes to this site means that more substantial injuries can occur.

Giving an IM injection into the deltoid site

Find the knobbly top of the arm (acromion process) The top border of an inverted triangle is two finger widths down from the acromion process Stretch the skin and then bunch up the muscle Insert the needle at a right angle to the skin in the centre of the inverted triangle Caution: This is a small site – give only 1-2ml or less of fluid in this site

It is important to limit volume of medication based upon size of muscle, ie. 0.5-2ml.

The ventrogluteal site
The Ventrogluteal site provides the greatest thickness of gluteal muscle (consisting of both the gluteus medius and gluteus minimus), is free of penetrating nerves and blood vessels, and has a narrower layer of fat of consistent thinness than is present in the dorsogluteal.¹⁰

The ventrogluteal site has come to attract significant attention in the nursing literature and there is wide agreement that this site is the preferable site for intramuscular injection.² There is a dearth of research in this area in Ireland as to the extent to which the ventrogluteal site is used.

Administrating an IM injection
There is a large research base for nursing practice to be guided by in relation to the administration of intramuscular injections and it is the responsibility of nurse educators to ensure that appropriately informed guidelines are devised.⁴

Tracking technique: An intramuscular injection is designed to deposit medications deep into muscle tissue

It has been suggested⁴ that the following points should be incorporated into clinical guidelines:

• IM injections should be administered in the Ventrogluteal region whenever possible
• The medication should be administered with a needle long enough to reach the muscle without penetrating underlying structures
• The patient should be positioned so as to relax the muscle
• The ‘Z track’ technique should be used at all times (see diagram).

These measures should ensure optimal nursing care for patients.

Angela Cocoman is mental health lecturer at DCU and John Murray is a community mental health nurse for Water ford Mental Health Services (HSE South Eastern Area)

References

1. Greenway K. Using the ventral gluteal site for intramuscular injection. Nursing Standard 2004; 18 (29): 39-42
2. Small SP. Preventing sciatic nerve injury from intramuscular injection: literature review: J Advanced Nursing 2004; 47(3): 287-296
3. MacGabhan L. A comparison of two depot injection techniques. Nursing Standard 1996; 11(52): 33-37
4. McGarvey MA. Intramuscular injections: a review of nursing practice for adults. All Ireland J Nursing & Midwifery 2001; 1(5): 185-193
5. Newton M, Newtown DW, Fudin J. Reviewing the big three injection routes. Nursing 1992; 22: 34-42
6. Berger KJ, Williams MS. Fundamentals of Nursing: Collaborating for Optimal Health. Appletone Large: Connecticut, 1992
7. Bolander VR. Sorenson & Luckmann’s Basic Nursing, A Psychophysiological Approach (3rd ed.) Saunders: Philadelphia, 1994
8. Kozier et al. Techniques in Clinical Nursing (4th ed). Sage: California, 1993
9. Mallett J, Bailey C. The Royal Marsden NHS Trust Manual of Clinical Procedures (5th ed.) Blackwell Science: London, 1996
10. Zelman S. Notes on the techniques of intramuscular injection. Am J Med Sc 1961; 241: 47-58
11. Rodger MA, King L. Drawing up and administering intramuscular injections: a review of literature. J Advanced Nursing 2000; 31(3): 574-582