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Are we on the same page?: a comparison of intramuscular injection explanations in nursing fundamental texts.

While evidence-based practice (EBP) is the clinical goal for nurses, many practices performed in the clinical setting have been based on ritual. Over a decade ago, Bostrom and Suer (1993) reported that only 21% of nurses in their study (n=1,200) used evidence in their practice. Nurses have looked to sources such as textbooks for the most current information, believing that textbooks are based on up-to-date research and are indicative of EBP regarding techniques, interventions, and concepts applied within clinical settings. In this article, researchers compare instructions for intramuscular injection (IM) techniques from five fundamental nursing textbooks. Several aspects of the IM injection process varied among texts. Issues related to needle size selection and common procedures associated with IM injections (z-track, bubble technique, filter needle, site selection) are explored and reported. Recommendations for future research are identified and offered.

The World Health Organization (2006) estimates that 16 billion injections are given per year. Though it is commonplace for many nurses, this skill is not a simple one. Many risks are involved with administering IM injections, including injury to surrounding vessels, tissue, and nerves. Unsafe injection practices may have noteworthy impacts on health care in terms of negative patient care outcomes and excessive costs (Nicoll & Hesby, 2002). Evidence shows that many errors associated with IM injection are preventable.

It is well accepted that incorporation of evidence-based practices in clinical practice improves patient outcomes (Heater, Becker, & Olson, 1988). Many clinical practices are learned during basic nursing education, but variations exist among fundamental textbooks in regard to the instruction of basic nursing skills. Kuhn (1996) described textbooks as "pedagogic vehicles of perpetuating normal science" (p. 137). From that point of reference, the argument could be made for consistency of technical procedure protocols within a specific discipline. However, findings for this article indicated discrepancies among several nursing fundamental texts in regard to IM technique.

Nicoll and Hesby (2002) noted that instruction materials and clinician practice do not always reflect a research base, a point that can he perplexing to students and novice nurses. Why these discrepancies? Lee, Lee, and Eldridge (1995) described the methods used by nurses in administering IM injections as ritualistic practices that were shared between nurses. This has not changed, based on the report by Nicoll and Hesby (2002), many nurses do not utilized research conducted in nursing and related disciplines, such as pharmacy and physical therapy, as a foundation for injection practices. They further suggested that many techniques are contradictory to the research. This disregard for evidence-based injection practices supports the conclusion offered by Pravikoff, Tanner, and Pierce (2005) that nurses are not ready for evidence-based practice; these authors also determined that although nurses recognized the need for information in their practice, their most frequent source of that knowledge was a peer or colleague.

Safe Practice

The following discussion identifies several variations within the literature related to the skill of IM injection (see Table 1).

All sources and researchers state that the clinician should know how to identify each IM site properly by using bony landmarks and should be familiar with potential complications specific to each site (deltoid, dorsogluteal, ventrogluteal, vastus lateralis, and rectus femoris).

Deltoid muscle. The deltoid is the preferred site for vaccinations in adults (Nicoll & Hesby, 2002; Potter & Perry, 2005; Workman, 1999). A potential for injury to the radial, median, ulnar, and axillary nerves exists with deltoid injections (Nicoll & Hesby 2002). In addition, this muscle is not well developed in many patients. The deltoid should be used when other sites are inaccessible and the volume to be administered is small (0.5-2 mL) (Nicoll & Hesby, 2002; Potter & Perry, 2005). Literature reviewed on use of the deltoid was largely in agreement. Discrepancies were related to the method for determining the exact injection site within the area for this muscle. Some authors recommended using an imaginary triangle to isolate the injection site (Rodger & King, 2000), while others suggested a site two finger breadths below the acromion process (Potter & Perry, 2005).

Dorsogluteal (DG) muscle. A query of 36 nurses at local clinical institutions yielded 27 responses to the Evidence-Based Practice Information Sheet, a tool designed in an undergraduate baccalaureate nursing research course to collect data from practicing nurses on IM injection techniques. Seventy-five percent stated that they utilized the DG muscle as the site of choice for administering large-volume IM injections; 4% of the respondents did not identify a specific site (Avery et al., 2006). However, Beyea and Nicoll (1995), Nicoll and Hesby (2002), Potter and Perry (2005), and Rodger and King (2000) did not advocate the utilization of this site for IM injections.

Injections should enter the gluteus maximus muscle. Care should be taken to avoid damage to the sciatic nerve and vessels surrounding this area. Due to variations in the route of the sciatic nerve among individuals, use of the DG site may be discouraged by many researchers (Potter & Perry, 2005). However, Harkreader and Hogan (2004) recommended this site for adults and children over age 3 because these muscles are developed by walking; they did not endorse its use for infants and children under age 3 because the gluteal muscles are small and underdeveloped. Nicoll and Hesby (2002) identified confusion in the clinical literature regarding the gluteal sites and the procedures used to identify those sites. Taylor, Lillis, and LeMone (2005) suggested the nurse refer to his or her institutional policy when considering the dorsogluteal site.

Ventrogluteal (VG) muscle. Beyea and Nicoll (1995) acknowledged that research on the topic of the VG site spans several decades but they indicated that its utilization in clinical practice still is infrequent. The ventrogluteal site is favored for administering large volumes of medications, or viscous or potentially irritating medications (Nicoll & Hesby, 2002). This site also is chosen by some clinicians because of its lack of major blood vessels and nerves (Small, 2004; Workman, 1999). Others indicated it is easy to identify by many prominent bony landmarks (Greenway, 2004). Potter and Perry (2005) reported that "research has shown that injuries such as fibrosis, nerve damage, abscess, tissue necrosis, muscle contraction, gangrene, and pain have been associated with all the common IM sites reported except the ventrogluteal site" (p. 888). Small (2004) reported one complication (paralysis of the tensor fasciae lateral muscle) from utilization of the VG site, but still suggested that the VG site might be the site of choice for older adult patients with little muscle mass.

Nicoll and Hesby (2002) identified the VG as a large muscle well developed in young children and adults. They recommended using it for most injections given to adults and children over 7 months. Beecroft and Konglebeck (1994) recommended the VG as the site of choice for IM injections, regardless of patient age.

The only published case study of a complication at the VG site was a local reaction to the medication (Nicoll & Hesby, 2002). Injection into the rectus femoris or the vastus lateralis is a common practice among pediatric and family care nurses (Nicoll & Hesby, 2002).

A great deal of evidence exists to support the ventrogluteal site as the site of choice for most IM injections unless it is otherwise contraindicated. However, it has been noted that this site is often difficult for the novice nurse with little experience to identify and utilize. It is extremely important for nurses to identify and utilize the recommended landmarks corresponding with the site of injection.

Vastus lateralis (VL) muscle. Consensus does not exist regarding the most appropriate injection site in children. Hockenberry, Wilson, Winkelstein, and Kline (2003) supported the vastus lateralis as the preferred site for IM injection in infants (less than 12 months); however, charts in the same text (p. 154) offered the VG as an option even for infants less than 4 months. Although many publications claim that fewer complications are linked with the VG site, some authors recommend using the VL or rectus femoris for pediatric patients (Hemsworth, 2000). However, Beyea and Nicoll (1995) cited the American Academy of Pediatrics recommendation that the VL site should be used for infants up to 7 months. In adults, the VL is usually thick and well developed, and often used by persons who self-medicate with IM injections because of its ease of access. The VL is considered a good option for administering IM injections when the client is obese (Hunter, 2008).

Related Procedures

Z-track. The Z-track method, once only used for administering irritating medications being administered via IM route, is now recommended for all IM injections (Potter & Perry, 2005). Taylor and colleagues (2005) stated that utilization of the Z-track method reduces pain and prevents seepage of medication into surrounding tissues; it was suggested for older adult patients with diminished muscle mass. Harkreader and Hogan (2004) suggested using the Z-track only in the ventrogluteal or dorsogluteal areas.

Air bubble. Beyea and Nicoll (1995) noted that the use of an air bubble is a topic that has caused a heated debate among nurses. Despite their conclusion that drawing up an air bubble in the syringe is outdated and should be eliminated from the IM procedure, the practice is still seen. According to Craven and Hirnle (2007), an air bubble "clears excess medication from the needle after injection" (p. 590). The air bubble seals the medication in the muscle after injection (Craven & Hirnle, 2007; Harkreader & Hogan, 2004). After careful review of the literature, Beyea and Nicoll (1995) stated that the air bubble technique is neither scientifically supported nor appropriate for the procedure, noting that this component of the procedure clearly is outdated, unneeded, and possibly dangerous for the patient. Rodger and King (2000) reported that, because modern syringes are calibrated to deliver the correct dose of medication, an air bubble is not required.

Volume. Volume of medication must be considered when choosing a site for IM injection. Harkreader and Hogan (2004) noted that an adult can receive a maximum of 4 ml in a large muscle such as the gluteus. Taylor and colleagues (2005) stated that no more than 5 ml should be injected into a single site for an adult with well-developed muscles. In regard to pediatric patients, Hockenberry and colleagues (2003) recommended giving no more than 1 ml to small children and older infants. Potter and Perry (2005) noted that up to 3 ml of medication can be administered into a large, well-developed muscle without discomfort; however, children, older adults, and thin patients should be given no more than 2 ml.

Conclusion

Nurses and nursing students should be aware of current literature on nursing skills. Numerous court cases have involved injury associated with IM injections. Sciatic and peripheral nerve injuries and peroneal nerve palsy have resulted. In many cases, courts have decided in favor of the plaintiff (Small, 2004). All nurses, despite where they are along the education continuum, should consult their facility policy and protocol on this skill as well as any protocols they have related to identifying landmarks and sites.

A great deal of information within the literature supports the use of the VG versus the DG site for administration, yet clinical practice has been slow to change. With other means of medication delivery, such as patient-controlled analgesics and epidurals, fewer opportunities exist to administer intramuscular medications; this may result in a decrease of a nurse's confidence in trying a different technique. Reluctance to use the VG site may be attributed to the fact that many are not taught this technique, contributing to a lack of confidence to perform the procedure (Small, 2004). Early education for nursing students may eliminate confusion within the clinical setting at a later date.

The education of a clinical nurse "is steeped in tradition and ritual" (Kessenich, Guyatt, & DiCenso, 1997, p. 25). The use of original research to support skill performance should be commonplace among all nurses, but the reality is that many use ritualistic practices. This is a challenge to conquer. The future of the discipline lies in educating nursing students about the value of evidence-based practice. Some authors indicated the main reason for research practice gaps in nursing is poor information-searching skills (Kessenich et al., 1997; Pravikoff et al., 2005). In addition, many nurses feel more comfortable asking colleagues for information than seeking evidence-based resources themselves (Pravikoff et al., 2005). Nurses should give consideration to all the conclusions within the literature and apply these findings to their own professional practice.

While a review of some of the available literature explaining IM injections techniques is offered here, other skills also may not be explained consistently among textbooks and other literature. The authors invite others to review skill explanation discrepancies to enhance and solidify evidenced-based practice within the nursing discipline. Great variation exists in explanation of IM injection techniques. Using evidence-based guidelines to direct IM medication administration should ensure that patient outcomes are maximized and patient safety risks are decreased.

References

Avery, B., Griffin, J., Harris, A., McGraw, K., Pierce, E., Pounders, J., et al. (2006). Evidence-based practice: Are the current research recommendations regarding intramuscular injections being utilized in the clinical practice of registered nurses ? Unpublished manuscript, Mississippi University for Women.

Beecroft, RC., & Kongelbeck, S.R. (1994). How safe are intramuscular injections? AACN Clinical Issues In Critical Care Nursing, 5(2), 207-215.

Beyea, S.C., & Nicoll, LH. (1995). Administration of medications via the intramuscular route: An integrative review of the literature and research-based protocol for the procedure. Applied Nursing Research, 8(1), 23-33.

Bostrom, J., & Suer, W.N. (1993). Research utilization: Making the link to practice. Journal of Nursing Staff Development, 9, 28-34.

Craven, R.E, & Hirnle, C.J. (2007). Fundamentals of nursing: Human health and function. Philadelphia: Lippincott Williams & Wilkins.

DeLaune, S.C., & Ladner, RK. (2006). Fundamentals of nursing: Standards & practice. Clifton Park, NY: Thomson Delmar Learning.

Greenway, K. (2004). Using the ventrogluteal site for intramuscular injection. Nursing Standard, 18(25), 39-42.

Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment. St. Louis: Saunders.

Heater, B., Becker, A., & Olson, R. (1988). Nursing interventions and patient outcomes: A meta-analysis of studies. Nursing Research, 37, 303-307.

Hemsworth, S. (2000). Intramuscular (IM) injections technique. Paediatric Nursing, 12(9), 17-20.

Hockenberry, M., Wilson, D., Winkelstein, M., & Kline, N. (2003). Wong's nursing care of infants and children. St. Louis: Mosby.

Hunter, J. (2008). Intramuscular injection techniques. Nursing Standard, 22(24), 35-40.

Kessenich, C.R., Guyatt, G.H., & DiCenso, A. (1997). Teaching nursing students evidence-based nursing. Nurse Educator, 22(6), 25-29.

Kuhn, T. (1996). The structure of scientific revolutions. Chicago: University of Chicago Press.

Lee, D., Lee, S., & Eldridge, K. (1995). A study of established nursing practice: An intramuscular injection technique. Journal of Royal College of Nursing, 2(3), 32-36.

Nicoll, L.H., & Hesby, A. (2002). Intramuscular injection: An integrative research review and guideline for evidence-based practice. Applied Nursing Research, 16(2), 149-162.

Potter, R, & Perry, A. (2005). Fundamentals of nursing. St. Louis: Mosby.

Pravikoff, D., Tanner, A., & Pierce, S. (2005). Readiness of U.S. nurses for evidencebased practices. American Journal of Nursing, 105(9), 40-51.

Rodger, M.A., & King, L. (2000). Drawing up and administering intramuscular injections: A review of the literature. Journal of Advanced Nursing, 31(3), 574-582.

Small, S. (2004). Preventing sciatic nerve injury from intramuscular injections: Literature review. Journal of Advanced Nursing, 47(3), 287-296.

Taylor, C., Lillis, C., & LeMone, R (2005). Fundamentals of nursing: The art and science of nursing care. Philadelphia: Lippincott Williams & Wilkins.

World Health Organization. (2006). Immunization safety. Retrieved May 31,2008, from http://www.who.int/immunization_safety/safe_injections/en/

Workman, B. (1999). Safe injection techniques. Nursing Standard, 13(39), 47-53.

Heather Carter-Templeton, MSN, RN, is the LISTEN Project Coordinator, University of Tennessee Health Science Center, Memphis, TN.

Tammie McCoy, PhD, RN, is an Associate Professor and the Baccalaureate Nursing Department Chair, Mississippi University for Women, Columbus, MS.
Table 1.
Examples of IM Injection Recommendations

                                     Instruction on:

                                                  Rectus
                              Dorso-              Ventro-     Vastus
Textbook            Deltoid   gluteal   Femoris   gluteal   Lateralis

Craven & Hirnle        X         X                   X          X
(2007)

DeLaune & Ladner       X         X                   X          X
(2006)

Harkreader &           X         X                   X          X
Hogan (2004)

Potter & Perry         X                   X         X          X
(2005)

Taylor, Lillis, &      X         X         X         X          X
LeMone (2005)

                                        Illustrations and
                                         Instructions for
                    Advocated Use of        Locating        References
Textbook            Dorsogluteal Site      DG Provided        Cited

Craven & Hirnle     Not recommended            Yes             Yes
(2007)

DeLaune & Ladner    Not specific               Yes             Yes
(2006)

Harkreader &        Yes, but with              Yes             No
Hogan (2004)        provisions

Potter & Perry      No                         No              Yes
(2005)

Taylor, Lillis, &   Not recommended            Yes             No
LeMone (2005)
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Title Annotation:Research for Practice
Author:Carter-Templeton, Heather; McCoy, Tammie
Publication:MedSurg Nursing
Article Type:Report
Geographic Code:1USA
Date:Aug 1, 2008
Words:2724
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