Giving an Intra-Muscular Injection
Definition: Intra-muscular injection is the injection of medicine into muscle tissue. To produce
quick action an patient as the medicine given by injection is rapidly absorbed. Intramuscular
injections are often given in the deltoid, vastus laterials, ventrogluteal and dorsogluteal
muscles.
Purpose:
1.To relieve symptoms of illness
2. To promote and prevent from disease
3. To treat the disease accordingly
Contraindication: IM injections may be contraindicated in clients with; · Impaired coagulation
mechanisms · Occlusive peripheral vascular disease · Edema · Shock · After thrombolytic
therapy · during myocardial infarction (Rationale: These conditions impair peripheral
absorption)
Equipment required:
1. Client’s chart and kardex
2. Prescribed medication
3. Sterile syringe (3-5 mL) (1)
4. Sterile needle in appropriate size: commonly used 21 to 23 G with 1.5”(3.8cm) needle (1)
5. Spirit swabs
6. Kidney tray (1)
7. Disposable container (1)
8. Ampoule cutter if available (1)
9. Steel Tray (1)
10. Disposable gloves if available (1)
11. Pen
❖Nursing Alert❖
The needle may be packaged separately or already attached to the sterile syringe.
Prepackaged loaded syringes usually have a needle that is 1” long. BUT! check the package
with care before open it.
The needles used for IM injections are longer than subcutaneous needles (Rationale: Needles
must reach deep into the muscle.)
Needle length also depends on the injection site, client’s size, and amount of subcutaneous fat
covering the muscle.
The needle gauge for IM injections should be larger to accommodate viscous solutions and
suspensions.
❖Nursing Alert❖ Selection of appropriate site for IM injection
Procedure:
Care Action Rationale
1. Assemble equipments and check the Dr.’s This ensures that the client receives the right
order medication at the right time by the proper route
2. Explain the procedure to the client Explanation fosters his/her cooperation and allays
anxiety
3. Perform hand hygiene and put on gloves if To prevent the spread of infection
available
Gloves act as a barrier and protect the nurse’s
hands from accidental exposure to blood during
the injection procedure
4. Withdraw medications from an ampoule or a To prepare correct medication safely before using
vial as described in the procedure “Removing
medication from an ampoule” or ” Removing Some references recommend adding air to the
medication from a vial” syringe with mediation. But the addition of air
❖Nursing Alert❖ Do not add any air to the bubble to the syringe is unnecessary and
syringe potentially dangerous because it could result in
an overdose of medication
5. Identify the client carefully using the following You should not rely on the name on the door, on
way: the board or over the bed. It is sometimes
a. Check the name in the identification bracelet inaccurate.
b. Ask the client his/her name This is the most reliable method if available · This
c. Verify the client’s identification with a staff requires an answer from the client. In the elderly
member who knows the client and/or illness the method may causes confusion.
· This is double-checked identify
6. Close the door and put a screen. To provide for privacy
7.
1) Assist the client to a comfortable position. Collect site identification decreases the risk of
2) Select the appropriate injection site using injury
anatomic landmarks
3) Locate the site of choice Good visualization is necessary to establish the
correct location of the site and avoid damage to
tissues
❖Nursing Alert❖ Ensure that the area is not
tender and is free of lumps or nodules Nodules or lumps may indicate a previous
injection site where absorption was inadequate
8. Cleanse the skin with a spirit swab: 1) Start Cleansing the injection site prepares it for the
from the injection site and move outward in a injection
circular motion to a circumference of about 2” (5
cm) from the injection site This method remove pathogen away from the
2) Allow the area to dry injection site
Alcohol or spirit gives full play to disinfect after
dried
3) Place a small, dry gauze or spirit swab on a To prepare a dry gauze or spirit swab to give light
clean, nearby surface or hold it between the pressure immediately after I.M.
fingers of your non-dominant hand.
9. Remove the needle cap by pulling it straight This technique lessens the risk of accidental
off needle-stick and also prevents inadvertently
unscrewing the needle from the barrel of the
syringe
10. Spread the skin at the injection site using This makes the tissue taut and facilitates needle
your non-dominant hand entry. You may minimize his/her discomfort
11. Hold the syringe in your dominant hand like a This position keeps your fingers off the plunger,
pencil or dart. preventing accidental medication loss while
inserting the needle
12. Insert the needle quickly into the tissue at a A quick insertion is less painful
90 degree angle This angle ensures you will enter muscle tissue
13. Release the skin and move your non- To prevent movement of the syringe
dominant hand to steady the syringe’s lower end
14. Aspiration blood: 1) Aspirate gently for blood A blood return indicates IV needle placement
return by pulling back on the plunger with your Possibly a serious reaction may occur if a drug
dominant hand intended for intramuscular use is injected into a
2) If blood enters the syringe on aspiration, vein
withdraw the needle and prepare a new injection Blood contaminates the medication, which must
with a new sterile set-up. be redrawn
15. If no blood appears, inject the medication at a Rapid injection may be painful for the client.
slow and steady rate(; 10 seconds/ mL of Injecting slowly reduces discomfort be allowing
medication) time for the solution to disperse in the tissues
16. Remove the needle quickly at the same Slow needle withdrawal may be uncomfortable for
angle you inserted it the client
17. Massage the site gently with a small, dry Massaging the site promotes medication
gauze or spirit swab, unless contraindicated for absorption and increases the client’s comfort.
specific Medication. If there are contraindications Do not massage a heparin site because of the
to massage, apply gentle pressure at the site medication’s anticoagulant action
with a small, dry gauze or a spirit swab. Light pressure causes less trauma and irritation
the tissues. Massage can force medication into
the subcutaneous tissues in some medications
18. Discard the needle: Most accidental needle-sticks occur while
1) Do not recap the needle recapping needles
2) Discard uncapped needle and syringe in
appropriate container if available Proper disposal prevents injury
19. Assist the client to a position of comfort To facilitate comfort and make him/her relax
20. Remove your gloves and perform hand To prevent the spread of infection
hygiene
21.Recording: Record the medication Documentation provides coordination of care
administered, dose, date, time, route of
administration, and IM site on the appropriate Site rotation prevents injury to muscle tissue
form.
22. Evaluation the client’s response: Drugs administered parenterally have a rapid
1) Check the client's response to the onset
medication within an appropriate time
2) Assess the site within 2 to 4 hours after Assessment of the site deters any untoward
administration effects
❖Nursing Alert❖
No more than 5 mL should be injected into a single site for an adult with well-developed
muscles
If you must inject more than 5 mL of solution, divide the solution and inject it at two separate
sites.
The less developed muscles of children and elderly people limit the intramuscular injection to 1
to 2 mL
Special considerations for pediatric:
The gluteal muscles can be used as the injection site only after a toddler has been walking for
about 1 year
Special considerations for elder:
IM injection medications can be absorbed more quickly than expected because elder clients
have decreased muscle mass.
Intradermal and Subcutaneous Injections
Intradermal injections (ID) are injections administered into the dermis, just below the epidermis.
The ID injection route has the longest absorption time of all parenteral routes. These types of
injections are used for sensitivity tests, such as TB, allergy, and local anesthesia tests. The
advantage of these tests is that the body reaction is easy to visualize, and the degree of reaction
can be assessed. The most common sites used are the inner surface of the forearm and the upper
back, under the scapula. Choose an injection site that is free from lesions, rashes, moles, or scars,
which may alter the visual inspection of the test results (Lynn, 2011).
Equipment used for ID injections is a tuberculin syringe calibrated in tenths and hundredths of a
millilitre, and a 1/4 to 1/2 in., 26 or 27 gauge needle. The dosage of an ID injection is usually
under 0.5 ml. The angle of administration for an ID injection is 5 to 15 degrees. Once the ID
injection is completed, a bleb (small blister) should appear under the skin. Checklist 56 outlines
the steps to administer an intradermal injection.
CHECKLIST 56: ADMINISTERING AN INTRADERMAL (ID) INJECTION
Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety Considerations:
Do not aspirate. It is not necessary to aspirate because the dermis is relatively without vessels.
Always take steps to eliminate interruptions and distractions during medication preparation.
If the patient expresses concerns about the medication or procedure, stop and explore the
concerns. Re-verify order with physician if appropriate.
STEPS ADDITIONAL INFORMATION
1. Prepare medication or solution as per agency Properly identifying medication decreases risk
policy. Ensure all medication is properly of inadvertently administering the wrong
identified. Check physician orders, Parenteral medication.
Drug Therapy Manual (PDTM), and MAR to
validate medication order and guidelines for Preparing medications ensures patient safety
administration. with medication administration.
Compare physician orders and MAR Prepare
medication from a vial
2. Perform hand hygiene. Gather all supplies: medication syringe, non-
sterile gloves, alcohol swab and sterile gauze,
Band-Aid (if required).
Required supplies
3. Enter room and introduce yourself, explain Explaining rationale increases the patient’s
procedure and the medication, and allow knowledge and reduces their anxiety.
patient time to ask questions.
4. Close the door or pull the bedside curtains. This provides patient privacy.
5. Compare MAR to patient wristband and This ensures accuracy of the medication or
verify this is the correct patient using two solution and prevents errors.
identifiers.
Two patient identifiers are patient name and
date of birth.
Compare MAR with patient wristband
6. Assess patient for any contraindications to Assessment is a prerequisite for every
the medications. medication given.
7. Select appropriate site for administration. Site should be free from lesions, rashes, and
Assist the patient to the appropriate position as moles. Selecting the correct site allows for
required. accurate reading of the test site at the
appropriate time.
Assess site for ID injection
8. Perform hand hygiene and apply non-sterile Gloves help prevent exposure to contaminants.
gloves. Apply non-sterile gloves
9. Clean the site with an alcohol swab or Pathogens from the skin can be forced into the
antiseptic swab. Use a firm, circular motion. tissues by the needle. Allowing the skin to dry
Allow the site to dry. prevents introducing alcohol into the tissue,
which can be irritating and uncomfortable.
Clean injection site
10. Remove needle from cap by pulling it off This decreases risk of accidental needle-stick
in a straight motion. injury.
Remove needle from cap
11. Using non-dominant hand, spread the skin Taut skin provides easy entrance for the
taut over the injection site. needle.
Hold skin taut prior to injection
12. Hold the syringe in the dominant hand This allows for easy handling of the syringe.
between the thumb and forefinger, with the Hold needle with bevel up
bevel of the needle up.
13. Hold syringe at a 5- to 15-degree angle Keeping the bevel side up allows for smooth
from the site. Place the needle almost flat piercing of the skin and induction of the
against the patient’s skin, bevel side up, and medication into the dermis.
insert needle into the skin. Insert the needle ID injection
only about 1/4 in., with the entire bevel under
the skin.
14. Once syringe is in place, slowly inject the The presence of the weal or bleb indicates that
solution while watching for a small weal or the medication is in the dermis.
bleb to appear. Presence of a bleb (white raised circle)
15. Withdraw the needle at the same angle as Withdrawing at the same angle as insertion
insertion, engage safety shield or needle guard, minimizes discomfort to the patient and
and discard in a sharps container. damage to the tissue.
Do not massage area after injection. Proper needle disposal prevents needle-stick
injuries.
Discard syringe in sharps container
Massaging the area may spread the solution to
the underlying subcutaneous tissue.
Gently pat with sterile gauze if blood is
present.
16. If injection is a TB skin test, circle the area Draw circle around injection site
around the injection site to allow for easy
identification of site in three days.
17. Discard remaining supplies, remove gloves, This prevents the spread of microorganisms.
and perform hand hygiene
Hand hygiene with
ABHR
18. Document the procedure and findings Proper documentation helps ensure patient
according to agency policy. safety. Document time, date, location, and type
of medication injected.
19. Evaluate the patient response to injection The patient will need to be evaluated for
within appropriate time frame. therapeutic and adverse effects of the
medication or solution.
Starting an Intra-Venous Infusion
Definition: Starting intra-venous infusion is a process that gives insertion of Intra-venous
catheter for IV therapy
Purpose:
1. To give nutrient instead of oral route
2. To provide medication by vein continuously
Equipment required:
1. I.V. solution prescribed
2. I.V. infusion set/ IV. tubing (1)
3. IV. catheter or butterfly needle in appropriate size (1)
4. Spirit swabs
5. Adhesive tape
6. Disposable gloves if available (1)
7. IV. stand (1)
8. Arm board, if needed, especially for infant
9. Steel Tray (1)
10. Kidney tray (1)
Procedure:
Care Action Rationale
1. Assemble all equipment and bring to Having equipment available saves time and
bedside. facilitates accurate skill performance
2. Check I.V. solution and medication Ensures that the client receives the correct
additives with Dr.’s order. I.V. solution and medication as ordered by
Dr.
3. Explain procedure to the client Explanation allays his/her anxiety and
fosters his/her cooperation
4. Perform hand hygiene To prevent the spread of infection
5. Prepare I.V. solution and tubing:
1) Maintain aseptic technique when opening This prevents spread of microorganisms
sterile packages and I.V. solution
2) Clamp tubing, uncap spike, and insert into This punctures the seal in the I.V. bag.
entry site on bag as manufacturer directs
3) Squeeze drip chamber and allow it to fill at Suction effects cause to move into drip
least one-third to half way. chamber. Also prevents air from moving
down the tubing
4) Remove cap at end of tubing, release This removes air from tubing that can, in
clamp, allow fluid to move through tubing. larger amounts, act as an air embolus
Allow fluid to flow until all air bubbles have
disappeared.
5) Close clamp and recap end of tubing, To maintain sterility
maintaining sterility of set up.
6) If an electric device is to be used, follow This ensures correct flow rate and proper
manufacturer’s instructions for inserting use of equipment
tubing and setting infusion rate
7) Apply label if medication was added to This provides for administration of
container correct solution with prescribed medication
or additive.
Pharmacy may have added
medication and applied label
8) Place time-tape (or adhesive tape) on This permits immediate evaluation of I.V.
container as necessary and hang on I.V. according to schedule
stand
6. Preparation the position: Mostly the supine position permits either
1) Have the client in supine position or arm to be used and allows for good body
comfortable position in bed. alignment
2) Place protective pad under the client’s
arm.
7. Selection the site for venipuncture: The selection of an appropriate site
1) Select an appropriate site and palpate decreases discomfort for the client and
accessible veins possible damage to body tissues
2) Apply a tourniquet 5-6 inches above the Interrupting the blood flow to the heart
venipuncture site to obstruct venous blood causes the vein to distend.
flow and distend the vein. Distended veins are easy to see
3) Direct the ends of the tourniquet away The end of the tourniquet could contaminate
from the site of injection. the area of injection if directed toward the
site of injection.
4) Check to be sure that the radial pulse is Too much tight the arm makes the client
still present discomfort.
Interruption of the arterial flow impedes
venous filling.
8.Palpation the vein Contraction of the muscle of the forearm
1) Ask the client to open and close his/her forces blood into the veins, thereby
fist distending them further.
2) Observe and palpate for a suitable vein To reduce several puncturing
3) If a vein cannot be felt and seen, do the Lowering the arm below the level of the
following: heart, tapping the vein, and applying warmth
a. Release the tourniquet and have the client help distend veins by filling them with blood.
lower his/her arm below the level of the heart
to fill the veins. Reapply tourniquet and
gently over the intended vein to help distend
it
b. Tap the vein gently
c. Remove tourniquet and place warmed-
moist
compress over the intended vein for 10-15
minutes.
9. Put on clean gloves if available. Care must be used when handling any
blood or body fluids to prevent transmission
of HIV and other blood-born infectious
disease
10. Cleanse the entry site with an antiseptic Cleansing that begins at the site of entry
solution( such as spirit) according to hospital and moves outward in a circular motion
policy. carries organisms away from the site of
a. Use a circular motion to move from the entry
center to outward for several inches
b. Use several motions with same direction Organisms on the skin can be introduced
as from the upward to the downward around into the tissues or blood stream with the
injection site approximate 5-6 inches needle.
11. Holding the arm with un-dominant hand Pressure on the vein and surrounding
a. Place an un-dominant hand about 1 or 2 tissues helps prevent movement of the vein
inches below entry site to hold the skin taut as the needle or catheter is being inserted.
against the vein.
b. Place an un-dominant hand to support the The needle entry site and catheter must
forearm from the back side ❖Nursing Alert❖ remain free of contamination from un-sterile
Avoid touching the prepared site. hands.
12.Puncturing the vein and withdrawing This technique allows needle or catheter to
blood: 1) Enter the skin gently with the enter the vein with minimum trauma and
catheter held by the hub in the dominant deters passage of the needle through the
hand, bevel side up, at a 15-30 degree vein
angle.
2) The catheter may be inserted from directly
over the vein or the side of the vein.
3) While following the course of the vein,
advance the needle or catheter into the vein.
4) A sensation can be felt when the needle
enters the vein.
5) When the blood returns through the lumen The tourniquet causes increased venous
of the needle or the flashback chamber of pressure resulting in automatic backflow.
the catheter, advance either device 1/8 to 1/4
inch farther into the vein.
6) A catheter needs to be advanced until hub Having the catheter placed well into the vein
is at the venipuncture site helps to prevent dislodgement
13. Connecting to the tube and stabilizing the
catheter on the skin:
1) Release the tourniquet.
2) Quickly remove protective cap from the The catheter which immediately is
I.V. tubing connected to the tube causes minimum
bleeding and patency of the vein is
maintained
3) Attach the tubing to the catheter or needle
4) Stabilize the catheter or needle with non-
dominant hand
14.Starting flow
1) Release the clamp on the tubing
2) Start flow of solution promptly Blood clots readily if I.V. flow is not
maintained.
3) Examine the drip of solution and the issue If catheter accidentally slips out of vein,
around the entry site for sign of infiltration solution will accumulate and infiltrate into
surrounding tissue
15. Fasten the catheter and applying the
dressing:
1) Secure the catheter with narrow non- Non-allergenic tape is less likely to tear
allergenic tape fragile skin
3) Loop the tubing near the site of entry The weight of tubing is enough to pull it out
of the vein if it is not well anchored.
There are various way to anchor the hub.
You should follow agency /hospital policy.
16. Bring back all equipments and dispose in To prepare for the next procedure.
proper manner.
17. Remove gloves and perform hand To prevent the spread of infection
hygiene
18. If necessary, anchor arm to an arm board An arm board helps to prevent change in
for support the position of the catheter in the vein. Site
protectors also will be used to protect the
I.V. site.
19.Adjust the rate of I.V. solution flow Dr. prescribed the rate of flow or the amount
according to Dr.’s order of solution in day as required to the client’s
condition
Some medications are given very less
amount. You may use infusion pump to
maintain the flow rate
20. Document the procedure including the This ensures continuity of care
time, site , catheter size, and the client’s
response
21. Return to check the flow rate and To find any abnormalities immediately
observe for infiltration
