Verify the order on the patient's medication record by checking it against the physician's order. Also note whether the patient has any allergies, especially before the first dose.
Check the prescribed medication for color and clarity. Also note the expiration date. Never use medication that's cloudy or discolored or contains a precipitate unless the manufacturer's instructions allow it. Remember that for some drugs (such as suspensions), the presence of drug particles is normal. Observe for abnormal changes. If in doubt, check with the pharmacist.
Choose equipment appropriate to the prescribed medication and injection site, and make sure it works properly. The needle should be straight, smooth, and free of burrs.
For single-dose ampules
Wrap an alcohol pad around the ampule's neck and snap off the top, directing the force away from your body. Attach a filter needle to the needle and withdraw the medication, keeping the needle's bevel tip below the level of the solution. Tap the syringe to clear air from it. Cover the needle with the needle sheath.
Before discarding the ampule, check the medication label against the patient's medication record. Discard the filter needle and the ampule. Attach the appropriate needle to the syringe.
For single-dose or multidose vials
Reconstitute powdered drugs according to instructions. Make sure all crystals have dissolved in the solution. Warm the vial by rolling it between your palms to help the drug dissolve faster.
Wipe the stopper of the medication vial with an alcohol pad, and then draw up the prescribed amount of medication. Read the medication label as you select the medication, as you draw it up, and after you've drawn it up to verify the correct dosage.
Don't use an air bubble in the syringe. A holdover from the days of reusable syringes, air bubbles can affect the medication dosage by 5% to 100%. Modern disposable syringes are calibrated to administer the correct dose without an air bubble.
Gather all necessary equipment and proceed to the patient's room.
Implementation
Confirm the patient's identity by asking his name and checking his wristband for name, room number, and bed number.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Provide privacy, explain the procedure to the patient, and wash your hands.
Select an appropriate injection site. The gluteal muscles (gluteus medius and minimus and the upper outer corner of the gluteus maximus) are used most commonly for healthy adults, although the deltoid muscle may be used for a small-volume injection (2 ml or less). Remember to rotate injection sites for patients who require repeated injections.
PEDIATRIC ALERT For infants and children, the vastus lateralis muscle of the thigh is used most often because it's usually the best developed and contains no large nerves or blood vessels, minimizing the risk of serious injury. The rectus femoris muscle may also be used in infants but is usually contraindicated in adults.
Position and drape the patient appropriately, making sure the site is well exposed and that lighting is adequate.
Loosen the protective needle sheath, but don't remove it.
After selecting the injection site, gently tap it to stimulate the nerve endings and minimize pain when the needle is inserted. (See Locating I.M. injection sites, page 244.) Clean the skin at the site with an alcohol pad. Move the pad outward in a circular motion to a circumference of about 2″ (5 cm) from the injection site, and allow the skin to dry. Keep the alcohol pad for later use.
Put on gloves. With the thumb and index finger of your nondominant hand, gently stretch the skin of the injection site taut.
While you hold the syringe in your dominant hand, remove the needle sheath by slipping it between the free fingers of your nondominant hand and then drawing back the syringe.
Position the syringe at a 90-degree angle to the skin surface, with the needle a couple of inches from the skin. Tell the patient that he'll feel a prick as you insert the needle. Then quickly and firmly thrust the needle through the skin and subcutaneous tissue, deep into the muscle.
Support the syringe with your nondominant hand, if desired. Pull back slightly on the plunger with your dominant hand to aspirate for blood. If no blood appears, slowly inject the medication into the muscle. A slow, steady injection rate allows the muscle to distend gradually and accept the medication under minimal pressure. You should feel little or no resistance against the force of the injection.
NURSING ALERT If blood appears in the syringe on aspiration, the needle is in a blood vessel. If this occurs, stop the injection, withdraw the needle, prepare another injection with new equipment, and inject another site. Don't inject the bloody solution.
After the injection, gently but quickly remove the needle at a 90-degree angle.
Using a gloved hand, cover the injection site immediately with the used alcohol pad or 2″ × 2″ gauze pad, apply gentle pressure, and unless contraindicated, massage the relaxed muscle to help distribute the drug.
Remove the alcohol pad, and inspect the injection site for signs of active bleeding or bruising. If bleeding continues, apply pressure to the site; if bruising occurs, you may apply ice.
Watch for adverse reactions at the site for 10 to 30 minutes after the injection.
ELDER ALERT An older patient will probably bleed or ooze from the site after the injection because of decreased tissue elasticity. Applying a small pressure bandage may be helpful.
Discard all equipment according to standard precautions and your facility's policy. Don't recap needles; dispose of them in an appropriate sharps container to avoid needle-stick injuries.
LOCATING I.M. INJECTION SITES
Deltoid
Find the lower edge of the acromial process and the point on the lateral arm in line with the axilla. Insert the needle 1″ to 2″ (2.5 to 5 cm) below the acromial process, usually two or three fingerbreadths, at a 90-degree angle or angled slightly toward the process. Typical injection: 0.5 ml (range: 0.5 to 2.0 ml).
Ventrogluteal
Locate the greater trochanter of the femur with the heel of your hand. Then, spread your index and middle fingers from the anterior superior iliac spine to as far along the iliac crest as you can reach. Insert the needle between the two fingers at a 90-degree angle to the muscle. (Remove your fingers before inserting the needle.) Typical injection: 1 to 4 ml (range: 1 to 5 ml).
Dorsogluteal
Inject above and outside a line drawn from the posterior superior iliac spine to the greater trochanter of the femur. Or, divide the buttock into quadrants and inject in the upper outer quadrant, about 2″ to 3″ (5 to 7.6 cm) below the iliac crest. Insert the needle at a 90-degree angle. Typical injection: 1 to 4 ml (range: 1 to 5 ml).
Vastus lateralis
Use the lateral muscle of the quadriceps group, from a handbreadth below the greater trochanter to a handbreadth above the knee. Insert the needle into the middle third of the muscle parallel to the surface on which the patient is lying. You may have to bunch the muscle before insertion. Typical injection: 1 to 4 ml (range: 1 to 5 ml; 1 to 3 ml for infants).
Special considerations
To slow their absorption, some drugs for I.M. administration are dissolved in oil or other special solutions. Mix these preparations well before drawing them into the syringe.
PEDIATRIC ALERT The gluteal muscles can be used as the injection site only after a toddler has been walking for about 1 year.
Never inject into sensitive muscles, especially those that twitch or tremble when you assess site landmarks and tissue depth. Injections into these trigger areas may cause sharp or referred pain, such as the pain caused by nerve trauma.
Keep a rotation record that lists all available injection sites, divided into various body areas, for patients who require repeated injections. Rotate from a site in the first area to a site in each of the other areas. Then return to a site in the first area that is at least 1″ (2.5 cm) away from the previous injection site in that area.
If the patient has experienced pain or emotional trauma from repeated injections, consider numbing the area before cleaning it by holding ice on it for several seconds or consider the use of an eulectic mixture of local anesthetics (EMLA) cream applied 60 to 90 minutes prior to the procedure. If you must inject more than 5 ml of solution, divide the solution and inject it at two separate sites.
Always encourage the patient to relax the muscle you'll be injecting because injections into tense muscles are more painful than usual and may bleed more readily.
I.M. injections can damage local muscle cells, causing elevations in serum enzyme levels (creatine kinase [CK]) that can be confused with elevations resulting from cardiac muscle damage, as in myocardial infarction. To distinguish between skeletal and cardiac muscle damage, diagnostic tests for suspected myocardial infarction must identify the isoenzyme of CK specific to cardiac muscle (CK-MB) and include tests to determine lactate dehydrogenase and aspartate aminotransferase levels. If it's important to measure these enzyme levels, suggest that the physician switch to I.V. administration and adjust dosages accordingly.
Dosage adjustments are usually necessary when changing from the I.M. route to the oral route.
Complications
Accidental injection of concentrated or irritating medications into subcutaneous tissue or other areas where they can't be fully absorbed can cause sterile abscesses to develop. Such abscesses result from the body's natural immune response in which phagocytes attempt to remove the foreign matter.
Failure to rotate sites in patients who require repeated injections can lead to deposits of unabsorbed medications. Such deposits can reduce the desired pharmacologic effect and may lead to abscess formation or tissue fibrosis.
ELDER ALERT Because older patients have decreased muscle mass, I.M. medications can be absorbed more quickly than expected.
Documentation
Chart the drug administered, dose, date, time, route of administration, and injection site. Also, note the patient's tolerance of the injection and the injection's effects, including any adverse effects.
Z-TRACK INJECTION
The Z-track method of I.M. injection prevents leakage, or tracking, into the subcutaneous tissue. It's typically used to administer drugs that irritate and discolor subcutaneous tissue, primarily iron preparations such as iron dextran. It may also be used in elderly patients who have decreased muscle mass. Lateral displacement of the skin during the injection helps to seal the drug in the muscle.
This procedure requires careful attention to technique because leakage into subcutaneous tissue can cause patient discomfort and may permanently stain some tissues.
Equipment
Patient's medication record and chart • two 20G 1¼″ to 2″ needles • prescribed medication • gloves • 3- or 5-ml syringe • two alcohol pads.
Preparation of equipment