Proper Injection Techniques
The World Health Organization estimates that 16 billion injections are given per year. Giving injections was once the province of doctors, but with the advent of penicillin in the 1940’s it became an extended role activity of the nurse (Beyea and Nicholl 1995). It is now such a routine nursing activity that nurses can become complacent about it. While evidence-based medicine is the clinical goal for nurses, several studies over the years have shown that many practices performed in the clinical setting have been based on ritual, shared knowledge by a peer or colleague, or on variations in technique found in nursing fundamental texts. Good injection technique can make the experience for the patient relatively painless; however, mastery of technique without developing the knowledge base from which to work can still put a patient at risk of unwanted complications. Today, with increasing demands upon nurses to practice evidence-based medicine, it is appropriate to reappraise such a fundamental procedure.
There are four main considerations regarding injections: the route, site, techniques and equipment.
The most effective route to administer the medication is dependent on the purpose of its use, the type of medication to be administered, and the condition of the patient receiving the drug. The most common injection routes practiced by nurses include intradermal (ID), subcutaneous (SC), intramuscular (IM), and intravenous infusion (IV).
ROUTE AND SITE
1. The intradermal route injection provides a local, rather than systemic, effect and is used primarily for diagnostic purposes such as allergy or tuberculin testing, or for local anesthetics. The sites suitable for ID injection are similar to those for subcutaneous injections (Fig 2) but also include the inner forearm and shoulder blades (Springhouse Corporation 1993).
2. The subcutaneous route is used for slow, sustained absorption of medication, up to 1-2 ml being injected into the subcutaneous tissue. It is used for insulin injections which require a slow and steady release, it is a relatively pain free and suitable for frequent injections.
3. The intramuscular (IM) route injection delivers medication into well perfused muscle, providing rapid systemic action and absorbing relatively large doses. The choice of the site should take into account the patient’s general physical condition and age; and the amount of medication to be given. The five sites that are used for IM injections are:
The Deltoid muscle of the upper arm which is the preferred site for vaccinations in adults.
The Dorsogluteal (DG) performed by entering through the gluteus maximus muscle. Care should be given to avoid damage to the sciatic nerve and vessels surrounding this area.
The Ventrogluteal site is a safer option which accesses the gluteus medius muscle. Research of IM injections has shown this site to be the primary location for IM use as it avoids all major nerves and blood vessels; and there have been no reported complications (Beyea and Nicholl 1995).
The Vastus Lateralis is a quadriceps muscle situated on the outer side of the femur and is used as a primary site for children. It does have risks associated to it due to overuse but has been suggested safe for children up to seven months old.
The Rectus femoris is the anterior quadriceps muscle which is rarely used by nurses but is easily accessed for self- administration, or for infants.
There is interesting research which shows that several aspects of the IM injection process varied among texts. In an article titled “Are We On the Same Page? : A comparison of intramuscular injection explanations in nursing fundamental texts” by Heather Carter-Templeton, and Tammie McCoy, researchers compare instructions for IM techniques from five fundamental nursing textbooks. 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.
For example, in the use of the Deltoid muscle, the literature reviewed for the use of this muscle was largely in agreement. Discrepancies were related to the method for determining the exact injection site with 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).
Regarding the Dosogluteal muscle, a query of 36 nurses at local clinical institutions yielded 27 responses to the EBP Information Sheet, a tool designed in an undergraduate baccalaureate nursing 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!
4. Intravenous route injection uses a hypodermic injection into a vein for the purpose of instilling a single dose of medication, injecting a contrast medium, or beginning an IV infusion of blood, medication, or a fluid solution, such as saline or dextrose in water.
TECHNIQUES AND EQUIPMENT
Before giving an injection of any kind the health care provider is obliged to undertake the following when administering an injection:
Inform and educate the patient on the need and effect of the medication being delivered
Ensure the correct identification and verification procedures are followed
Provide privacy for the patient during the procedure
Understand the theory behind selecting appropriate injection sites
Ensure that the proper equipment and dosage is selected
Clean the site with an alcohol swab or other cleansing agent
Demonstrate correct technique when undertaking the procedure
Monitor for complications
Document all relevant information and ensure safe disposal of equipment
The technique will vary depending on the route and site used; however, the angle of the needle entry is important to understand as it relates to reducing the pain for the patient. For example, IM injections should be given at a 90 degree angle to ensure the needle reaches the muscle. A study by Katsma and Smith (1997) revealed that nurses did not always ensure needle entry to the skin at 90 degrees and they speculated that this would cause more pain for the patient due to the needle shearing through the tissues. The following is a review of the most common injections and the proper technique to administer them:
1. To give an ID injection, a 25-gauge needle is inserted at a 10-15 degree angle, bevel up, just under the epidermis, and up to 0.5 mL is injected until a wheal appears on the skin surface. If it is being used for an allergen testing, the area should be labeled indicating the antigen so that an allergic response can be monitored after a specific time lapse.
2. Traditionally, SC injections have been given at a 45 degree angle into a raised skin fold. However, with the introduction of shorter insulin needles (5, 6, or 8 mm), the recommendation for insulin injections is now an angle of 90 degrees. The skin should be pinched up to lift the adipose tissue away from the underlying muscle, especially in thin patients. It is no longer necessary to aspirate after needle insertion before injecting subcutaneously as studies have shown that piercing a blood vessel in a SC injection is very rare.
3. To administer an IM injection, prepare the syringe by removing the needle cover, inverting the syringe, and expelling any excess air. Approximately 0.1-0.2 mL of air should be left in the syringe which will assist in forcing the entire amount of medication to be delivered. When ready to inject, spread the skin using the fingers of the non-dominant hand. Holding the syringe with the thumb and forefinger of the dominant hand, quickly pierce the skin at a 90 degree angle and enter the muscle. It is no longer necessary to aspirate after needle insertion when administering an IM injection. If the person administering the injection is at the correct anatomical location and is educated about where the major vessels lie, there should be no reason to aspirate. Continue to slowly inject the medication at a constant rate until all medication has been delivered. Withdraw the needle and syringe quickly to minimize discomfort. Depending on the medication given, the site may be massaged although it is sometimes not recommended by the manufacturer. Check the site at least once more a short time after the injection to ensure that no bleeding, swelling, or other signs of a reaction to the medication are present.
4. Z- Track technique for IM injections was initially introduced for drugs that stained the skin or were particularly irritant. It is now used more universally for IM injections as it is believed to reduce pain as well as the incidence of leakage into the subcutaneous tissue or skin. The gluteal muscle is the recommended site for this technique. Select a long needle (2-3 inches; 5-7.5 cm) depending on the size of the patient with a 21-or 22-gauge in order to place the medication deeply within the muscle. To give a Z- track injection, begin using the non-dominant hand to move and to hold the skin and subcutaneous tissue about 1-1.5 in (2.5-3.75 cm) laterally from the injection site. Alert the patients when the medication is about to be injected. Ask them to breathe through their mouth and to try to relax the muscle to avoid muscle resistance. Continue holding the displaced skin and tissue until after the needle is removed. Dart the syringe rapidly into the displaced skin at a 90 degree angle. Aspirate on the syringe to be sure that a blood vessel has not been penetrated. Inject the medication slowly into the muscle. Never inject more than 5ml of medication at a time when using the Z-track method. If a larger dose is ordered, divide it and inject it into two separate sites. Be sure that the syringe is completely empty, including air, before withdrawing it. Upon withdrawal of the syringe, immediately release the skin and subcutaneous tissue.
5. Air bubble technique arose historically from the use of glass syringes which required an added air bubble to ensure an accurate dose was given, and was also intended to seal the medication after injection. Since plastic syringes are calibrated more accurately than glass ones, it is no longer recommended by manufacturers as a technique to use. There are also issues related to the accuracy of the dose when using this technique as it may significantly increase the dosage. There have been studies to compare the Z-track and the air bubble techniques with regards to which one is more successful at preventing leakage (Quart ermine &Taylor 1995, and MacGabhann 1998) with the former study finding the air bubble more effective, and the later findings were inconclusive.
6. Intravenous injection technique is considerably more complicated and more dangerous than other types of injection. That said, proper technique can at least minimize the possible damage. First, clean the injection site with isopropyl alcohol. Wrap the tourniquet around your arm just above the injection site. When tying the tourniquet, tuck it in upon itself or use a self-tightening loop. You want it to be able to slip off. Insert the needle at a 45 degree angle with the vein. You are injecting WITH the flow of the vein (which flows to the heart). Pull back the plunger slightly to test for blood. If there is no blood, pull it out as you missed the vein. If the blood is bright red, foamy, and has considerable pressure behind it, pull it out and apply direct pressure as you hit an artery. This is unlikely except when you are going for deep veins. If the blood is dark you connected with the vein. Remove the tourniquet since injecting while a tourniquet is tied will cause too much pressure to build and may cause the vein to burst. Slowly push the plunger and administer the medication. Pull out and apply pressure with clean gauze and band aid.
7. Intraosseous injection is a process of injection directly into the marrow of the bone. This technique is used in emergency situations to provide fluids and medication when an IV line cannot be used. The needle is injected through the bone’s hard cortex and into the soft marrow interior which allows immediate access to the vascular system. Often the antero-medial aspect of the tibia is used as it lies just under the skin and can be easily palpated and located. The anterior aspect of the femur, the superior iliac crest and the head of the humerus are other sites that can be used. Although intravascular access is still the preferred method for medication delivery in the prehospital area, advances in IO access (such as the F.A.S.T. 1 and the EZ-IO system) have made IO more common in emergency medical services (EMS) systems around the world.
In conclusion, giving an injection safely is considered to be a fundamental nursing activity, and yet it requires knowledge of anatomy and physiology, pharmacology, psychology, communications skills and practical experience. Nurses are encouraged to review the current research-based practices and incorporate the best ones into their everyday practice.
Barbara Workman, Safe Injection Technique; Nursing Standard June 16 1999/Vol 13/no 39
Heather Carter-Templeton, Tammie McCoy, Are We On the Same Page?: A comparison of intramuscular injection explanations in nursing fundamental texts; www.findarticles.com August 2008
Elkin M.K., Perry A.G., and Potter P.A. Nursing Interventions and Clinical Skills. Missouri: Mosby-Year Book, Inc., 1996
Encyclopedia of Nursing & Allied Health, Z-Track Injection
Wikipedia.org, Intraosseous Infusion: Routes of Administration, June 10, 2011
www.Learnerstv.com Nursing Lab Take Two lecture series/Nursing procedures and skill