Intramuscular injections--what's best practice? Why is there such a gap between what is taught in nursing schools about the best sites end technique for intramuscular injections and whet actually happens in practice? Two nurses decided to find out.
As a first step, we conducted a literature search which revealed little published information on the use of IM injections. Intramuscular injections have been part of everyday nursing practice for many years now (1,2) and are usually used for medication "requiting a relatively quick uptake by the body but with reasonably prolonged action". (1)
Two writers discussed the use of IN injections and IM injection sites, described each site in detail and recommended the correct needle length to use for each site. (1) Issues of pain were also discussed, as well as the volume of fluid to be injected and injuries associated with IM injections. (1)
The guidelines for evidence-based practice in relation to IN injections have been reviewed. (3) Site selection, medication type and volume, needle length, the injection procedure and post injection care were discussed. There was no mention of whether it is of value for nurses to wear gloves.
Although the use of IN injections is very commonplace, there have been many injuries associated with them. (4) The most serious of these is injury to the sciatic nerve. Furthermore, IM injections are not always effective, due to unintentional injection into subcutaneous or adipose tissue, where they cannot be fully absorbed. "Poor and slow drug uptake can be associated with medication deposited in the subcutaneous fat, as it takes longer to be absorbed". (5)
None of the writers commented on the administrator wearing gloves.
One writer stated the most used site for IM injections is the dorsogluteal site "despite the fact this choice of site is ineffective, inappropriate and potentially dangerous". (2)
The literature search revealed that very few people use the ventrogluteal and vastus lateralis sites. (3,4,5)
The vastus lateralis site can be located between the greater trochanter of the femur and the lateral femoral condyle of the knee. The area is divided into thirds, with the middle third being identified as the injection site. An advantage of this site is its easy access and tack of major blood vessels or significant nerve structures. (1) Also, the bulk of muscle tissue reduces the possibility of injury.
The vastus lateralis site has been associated with injury, either to the femoral artery or femoral nerve. (3,6,7,8) Injury can be avoided by correct injection location and appropriate length of needle. (9) The ventrogluteal site is the preferred site for IM injections because it is deemed to have the least potential problems. (1) The client is placed on their side (either right or left) with the nurse positioned behind the client. The ventrogluteal site is located "by the nurse placing his/her opposing hand (ie right hand for left hip) on the client's greeter trochanter. The index finger of the hand is placed on the client's anterior superior iliac spine and the middle finger stretched dorsally towards but below the iliac crest. The triangle formed by the index finger, the third finger and the crest of the ilium is the injection site". (1)
The ventrogluteal site is relatively free of major nerves and brood vessels (2) and suggested best practice is the use of the ventrogluteal site for IN injections. (5)
The ventrogluteal site appears to be the safest IM injection site with its absence of major brood vessels, nerves and overlapping deep muscle structures. There is also less fat than in the dorsogluteal site. (9) However, it has been argued that the infrequent use of the ventrogluteal site may account for the tack of reported problems associated with this site. (1)
Reluctance to change
Nurses are reluctant to change to the ventrogluteal site for IM injections for a variety of factors. (2) These include the difficulty of land marking this site, and because nursing texts throughout the 1960s perpetuated the use of the dorsogluteal site. (10) Nurses are reluctant to adopt a different method than the one they have been used to using, and evidence atone is not enough to change practice, particularly if the ventrogluteal site is not observed in practice. (5) It has been suggested that, despite known iatrogenic complications from IM injections, the technique has become ritualistic, based on tradition and passed from one generation of nurses to the next. (3)
Site selection is important because the effect of the medication can be enhanced or diminished depending on the site used. Medications which are more viscous and larger in volume should be administered in the large muscles, particularly the ventrogluteal site. Final site selection should be based on the size of the muscle and the client's body mass.
Some nursing schools are teaching the ventrogluteal injection technique but students rarely observe the technique in practice. An informal survey by NZNO identified that nursing schools or procedure manuals had information on the ventrogluteal site and its use. (11) The injection sites chosen in the clinical setting are generally the dorsogluteal (despite the risks associated with it), vastus lateralis and deltoid. (2)
A 2003 working party, which reviewed the literature and Accident Compensation Corporation (ACC) data relating to injections resulting in harm, concluded there was a lack of substantial information to support one gluteal site over another. But it did recommend that health practitioners be educated in both the dorsogluteal and ventrogluteal sites for IM injections. In determining the most suitable site, consideration should be given to the patient's age, physical condition, including musculature and skin condition, and the medication manufacturer's instructions. (11) The working party concluded there was an urgent need for research on the two different sites, including safety and patient preference. (11)
The Z tracking technique
The Z tracking technique of IM injection prevents irritation, leakage and staining of medication into the subcutaneous tissue. This techniques involves the non-dominant hand pulling skin and subcutaneous tissue two to three centimetres sideways, prior to inserting the needle (see illustration above). The skin is released following withdrawal of the needle, creating a disjointed pathway which locks in the medication. This technique can also be used in elderly patients who have decreased muscle mass. Although the benefits of Z tracking have been demonstrated for a long time, (1) many nurses are unaware of this technique. Advantages are the prevention of backflow or leaking of the medication into the needle track. The medication is locked in and potential skin staining is minimised. Complications include discomfort and tissue irritation, as unabsorbed medication can build up, forming an abscess from drug leakage into the subcutaneous tissue. (1)
It appears very little is written on the use of gloves when administering IM injections, although one writer states "gloves should be worn as a protective barrier to prevent contamination of the hands or transmission of micro-organisms from hands during a procedure". (12)
Best practice guidelines recommend that nurses wear gloves before giving injections to clients. (13) "Wash your hands and don gloves" were the instructions in one explanation of how to administer an IM injection. (14)
After the literature search, we conducted a survey of registered nurses (RNs)on IM injections sites and technique. An anonymous questionnaire, accompanied by an explanatory letter, was sent to 173 RNs working in general practice, prisons, and to community and inpatient mental health nurses. Registered nurses working in hospitals were excluded, as very few IM injections are given in this setting. By returning the questionnaire in the enclosed prepaid envelope, the RNs indicated their consent to participate in the research. Seventy-three questionnaires were returned, a response rate of 71 percent.
The results of the questionnaires were collated and trends were identified. Themes, which will be discussed below, began to emerge. A thematic analysis was done to clarify distinctions and similarities. In this process, meaningful patterns or concerns are considered, rather than just words or phrases. (15) As the themes began to emerge, they were highlighted using a selective/highlighting approach. (16)
The vast majority of the respondents were working in general practice, with a small number being employed at a prison, accident and emergency facility or inpatient mental health institution. The majority (61 percent) of respondents had been RNs for more than 15 years.
The responses regarding injection sites used by RNs were predictable. Ninety-nine percent of respondents indicated they had used the dorsogluteal site; 97 percent indicated they had used the deltoid site; and 87 percent indicated they had used the vastus lateralis site. Only nine percent indicated they had used the ventrogluteal site.
Common responses included "I have never felt comfortable about this site as it seems very foreign to me" and "Old habits die hard, no problems with other sites but have yet to learn the advantages of ventrogluteal".
Comments on the questionnaires indicated some of the RNs were unsure of the location of the ventrogluteal site, while others were clearly reluctant to change and tacked the confidence to try a less familiar site. The participants indicated a number of reasons for this reluctance, including: Never had adequate training for ventrogluteal"; and "have attempted ventrogluteal site a couple of times but am not confident I have the correct site".
The majority of respondents (88 percent) stated that the medication being administered was a factor in determining which IM injection site would be best. The ACC's Medical Misadventure Unit Report identified that 155 claims had been accepted relating to injection complications between July 1, 1992 and January 6, 2003. Of these, 33 were accepted on the basis of medical error, with Kenakort (triamcinlone) and Voltaren (diclofenac) injections predominating, with the incorrect site being a factor. (11)
The injection technique of Z tracking is not widely discussed in the literature. Although, 87 percent of respondents had heard of Z tracking, only 14 percent used this technique consistently, with 46 percent using it sometimes. Annotations included "yes taught it as a student" and "never used it except as a student in mental health placement".
Of the group who used Z-tracking consistently or sometimes, 68 percent were influenced by the type of medication they were administering. Explanations stated it was used for "staining medications and steroids, iron injections and depo". In there literature, there were five other reasons commonly stated as considerations when choosing an injection site and whether the use of Z-tracking was indicated. These were pain, age of the patient, patient wishes, convenience and muscle mass. The choice of IM injection site is determined by the age and general, both physical and mental, condition of the patient. (9) The injection site is critically important because the medication effect can be enhanced or diminished, depending on the site of the injection. (3)
Our research revealed that very few RNs consistently wore gloves when administering IM injections. Only four percent of respondents always wore gloves; 42 percent said they sometimes wore gloves; and 54 percent said they didn't wear gloves. A typical response was "only when known hap B or HIV". Others said they wore gloves only for methotrexate injections, with one respondent double gloving for this medication.
Other typical responses were "only when giving injections to known infective patients", "I always wash my hands first but can manage the injection with better control with no gloves", and "only if obvious blood or bleeding around".
While nurses are taught to wear gloves when administering all injections, in practice this rarely occurs. (4,12) The majority of our respondents (61 percent) have been nursing for more than 15 years and were educated in an era when wearing gloves for IN injection administration was unlikely to be advocated. White nurses are currently being taught to glove up for IN injections, the examples set by more senior and experienced nurses may deter junior/new nurses from following their education.
Aim of research project
The aim of this research project was to explore issues around preferred injection site, IM injection technique, particularly Z-tracking, and the wearing of gloves white administering IM injections. This research has shown that, despite the known iatrogenic complications which could occur when administering IM injections, some RNs' practice does not appear to take this in to consideration. Furthermore, the majority of RNs did not use gloves and Z-tracking was not widely used among the sample group.
Literature suggests the safest sites for IM injections are the ventrogluteal and vastus lateralis muscles. Ongoing education for RNs is needed if they are to feel confident to safely use the ventrogluteal site and to understand the rationale for Z-tracking. RNs should also adhere to best practice regarding the use of gloves, ie wear them.
Intramuscular injections are routine in practice. It is a fundamental skirt, yet there appears to be limited research and evidence to support best practice. It is imperative RNs carrying out this procedure are safe and effective in their practice, to ensure patient safety. Education and support to change practice to reflect current research is paramount, if RNs are to remain competent.
This article was reviewed by Kai Tiaki Nursing New Zealand's practice article review committee in October 2006.
(1) Rodger, M. & King, L. (2000) Drawing up and administering intramuscular injections: a review of the literature. Journal of Advanced Nursing; 31: 3, 574-582.
(2) Greenway, K. (2004) Using the ventrogluteal site for intramuscular injection. Nursing Standard; 18: 25, 39-42.
(3) Nicoll, L. & Hesby, A. (2002) Intramuscular injection: an integrative research review and guideline for evidence based practice. Applied Nursing Research; 16: 2, 149-162.
(4) Small, S. (2004) Preventing sciatic nerve injury from intramuscular injections literature review. Journal of Advanced Nursing; 47: 3, 287-296.
(5) Scott, W. & Marfell-Jones, M. (2004) Evidence alone is not enough to bring about practice change. Koi Tiaki Nursing New Zealand; 10: 1, 14-18.
(6) Haber, M., Koran, E., Andary, M. & Honet, J. (2000) Post injection vastus lateralis atrophy: 2 case reports. Archives of Physical Medicine and Rehabilitation; 81: 9, 1229-1233.
(7) Ozel, A., Yavuz, H, & Erkul, I. (1995) Gangrene after penicillin: A case report. The Turkish Journal of Paediatrics; 37, 67-71.
(8) Talbert, J.L., Haslam, R. H.A. & Haller, J. A. (1967) Gangrene of the foot following intramuscular injection in the lateral thigh: A case report for recommendations for prevention. Journal of Paediatrics; 70: 2, 110-117.
(9) Shaw A. (2002-2003) Choosing the right injection site. Kai Tiaki Nursing New Zealand; 8: 11, 18-19.
(10) Beyer, S. & Nichol, L. (1996) Back to basics. Administering IM injections the right way. American Journal of Nursing; 96: 1, 34-35.
(11) Trim, S., Campbell, N., Scott, W., Payne, C., & Vause. J. (2004) Report from working potty established October 2003 to examine intramuscular injection sites into the gluteal muscle. http//:www. or.nz.I:\Activities\PROFESS\clinical practice\IM Injection into gluteal muscle doc. Retrieved October 2004.
(12) Jeanes, A. (2005) Putting on gloves. Nursing Times; 10: 29, 28-29.
(13) Huang, J., Jiang, D., Wang, X., & Liu, Y. (2002) Changing knowledge, behaviour, and practice related to universal precautions among nurses in China. The Journal of Continuing Education in Nursing; 33: 5, 217-225.
(14) Smith, S., Duell, D. & Martini B. (2000) Clinical nursing skills: basic to advanced skills (5th ed.). New Jersey: Prentice Hall Health.
(15) Banner, P. (1994) Interpretive phenomenology: Embodiment, caring and ethics, health and illness. United States of America: Sage Publications.
(16) Van Manen, M. (1990) Researching lived experiences: Human science for on action sensitive pedagogy. Canada: The Althouse Press.
Sue Floyd RN, BN, MN, is the practicum manager at Eastern Institute of Technology (EIT).
Alannah Meyer RN, BA, MN, is a senior nursing lecturer at EIT.
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|Publication:||Kai Tiaki: Nursing New Zealand|
|Date:||Jul 1, 2007|
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