Should you pinch the skin when giving an IM injection?
Part 1 of this two-part series on injection techniques describes the evidence base and procedure for administering an intramuscular injection Show This article has been updatedThe evidence in this article is no longer current. Click here to see an updated and expanded article AbstractThe intramuscular route allows the rapid absorption of drugs into the circulation. Using the correct injection technique and selecting the correct site will minimise the risk of complications. This is part 1 of a two-part series on injection techniques. Part 2 covers the subcutaneous route. Citation: Shepherd E (2018) Injection technique 1: administering drugs via the intramuscular route. Nursing Times [online]; 114: 8, 23-25. Author: Eileen Shepherd is clinical editor at Nursing Times.
IntroductionDrugs administered by the intramuscular (IM) route are deposited into vascular muscle tissue, which allows for rapid absorption into the circulation (Dougherty and Lister, 2015; Ogston-Tuck, 2014). Complications of poorly performed IM injection include:
These complications can be avoided if the site for injection is accurately identified and a skilled evidence-based technique is used (Greenway, 2014). Box 1. How to reduce pain caused by injection technique
Source: Dougherty and Lister (2015) Evidence baseThe procedure for IM injection has been discussed widely in the literature but there are concerns that nurses are still performing outdated and ritualistic practice relating to site selection, aspirating back on the syringe (Greenway, 2014) and skin cleansing. Site selectionFour muscle sites are recommended for IM administration (Fig 1, Table 1):
Traditionally the dorsogluteal (DG) muscle was used for IM injections but this muscle is in close proximity to a major blood vessel and nerves, with sciatic nerve injury a recognised complication (Small, 2004). In addition, drug absorption from the DG muscle may be slower than other sites and this can lead to a build-up of drugs in the tissues and risk of overdose (Malkin, 2008). Many patients find the use of the DG site intrusive and are reluctant to undress to give access to the relevant area. For these reasons, the DG muscle is no longer recommended for IM injections – in spite of this, many nurses continue to use it (Ogston-Tuck,2014; Walsh and Brophy, 2011; Malkin, 2008). NeedlesSafety needles should be used for IM injections to reduce the risk of needle-stick injury (Health and Safety Executive, 2013). Needle size is measured in gauges (diameter of the needle). A 21G is commonly used but selection depends on the viscosity of the liquid being injected (Dougherty and Lister, 2015). Public Health England (2013) recommends 23G or 25G needle for IM vaccines. Needles need to be long enough to ensure the drug is injected into the muscle; length depends on:
Women have more subcutaneous fat than men (Zaybak et al, 2007) and consideration needs to be given to using longer needles for patients who are obese. PHE (2013) recommends that a 25mm or 38mm needle is used in adults. Traditionally nurses have been taught to leave a few millimetres between the skin and the hub of the needle in case the needle breaks off during the injection. This practice is not evidence based, may cause medication to be delivered into the subcutaneous fat layer and, with modern single-use needles, is no longer necessary (Greenway, 2014). Skin preparationThere is some debate about using alcohol-impregnated swabs to clean injection sites. PHE (2013) suggests that, if a patient is physically clean and generally in good health, swabbing the skin is not required. In older or immunocompromised patients, skin preparation using an alcohol-impregnated swab may be recommended (70% isopropyl alcohol) (Dougherty and Lister, 2015). Follow local policy. AspirationIt is common practice to draw back on a syringe after the needle is inserted to check whether it is in a blood vessel. While it is important to aspirate if the DG muscle site is used – because of proximity to the gluteal artery – it is not required for other IM injection sites (PHE, 2013; Malkin, 2008). GlovesThe World Health Organization (2010, 2009) states that gloves need not be worn for this procedure if the health worker’s and patient’s skin are intact. It also notes that gloves do not protect against needle-stick injury. Nurses need to risk assess individual patients (Royal College of Nursing, 2018) and be aware of local policies for glove use. Equipment
Procedure
Box 2. ‘Five rights’ of medicines administration
Ağaç E, Güneş UY (2011) Effect on pain of changing the needle prior to administering medicines intramuscularly: a randomized controlled trial. Journal of Advanced Nursing; 67: 3, 563-568. Dougherty L, Lister S (2015) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell. Greenway K (2014) Rituals in nursing: intramuscular injection. Journal of Clinical Nursing; 23: 23-24, 3583-3588. Health and Safety Executive (2013) Health and Safety (Sharp Instruments in Healthcare) Regulations 2013: Guidance for Employers and Employees. Malkin B (2008) Are techniques used for intramuscular injection based on research evidence? Nursing Times; 104: 50/51, 48-51. Ogston-Tuck S (2014) Intramuscular injection technique: an evidence-based approach. Nursing Standard; 29: 4, 52-59. Public Health England (2013) Immunisation Procedures: The Green Book, Chapter 4. Royal College of Nursing (2018) Tools of the Trade: Guidance for Health Care Staff on Glove Use and the Prevention of Contact Dermatitis. Small SP (2004) Preventing sciatic nerve injury from intramuscular injections: literature review. Journal of Advanced Nursing; 47: 3, 287-296. Walsh L, Brophy K (2011) Staff nurses’ sites of choice for administering intramuscular injection to adult patients in the acute care setting. Journal of Advanced Nursing; 67: 5, 1034-1040. World Health Organization (2010) WHO Best Practices for Injections and Related Procedures Toolkit. World Health Organization (2009) WHO Guidelines on Hand Hygiene in Health Care. Zaybak A et al (2007) Does obesity prevent the needle from reaching muscle in intramuscular injections? Journal of Advanced Nursing; 58: 6, 552-556. Do you pull skin taut for IM injection?Pull the skin tight around the injection site. Hold the prepared syringe with the hand you will use to give the injection. Insert the IM needle to a depth of at least one inch into the muscle at a 90 degree angle with one quick and firm motion (FIGURE 7).
Which type of injection requires a pinch of the skin?A subcutaneous injection is a method of administering medication. Subcutaneous means under the skin. In this type of injection, a short needle is used to inject a drug into the tissue layer between the skin and the muscle.
What is the proper way to give an IM injection?Your thumb should point to the person's groin and your fingers point to the person's head. Pull your first (index) finger away from the other fingers, forming a V. You may feel the edge of a bone at the tips of your first finger. Put the injection in the middle of the V between your first and middle finger.
Why do we stretch skin for IM injection?By stretching the skin downwards or sideways at the site before injection the track is closed when the skin is released, preventing leakage.
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