Running head: INJECTION SIGHTS

Evidence-Based Intramuscular Injection Sights vs. Dorsogluteal Injection Sight Kelli J. Koop Ferris State University

INJECTION SIGHTS Introduction

In current healthcare settings, intramuscular (IM) injections are considered a basic skill performed in everyday practice by registered nurses. For most nurses, IM injections are simple tasks executed without much concentration or thought. Contrary to belief, history has proven IM injections to be complicated and potentially harmful to the patient. Prior to performing an IM injection, there are many nursing considerations and assessments to complete. In the past, there were four evidence-based intramuscular injection sights: dorsogluteal, ventrogluteal, vastus lateralis and deltoid. For many years, the most popular injection sight was the dorsogluteal. Today, there are many studies on the pros and cons for each intramuscular injection sight. Though not adopted by all nurses, there has been evidence-based research that has suggested and proven the dorsogluteal sight to be dangerous and no longer considered an appropriate injection sight. Evidence-Based Practice Healthcare practices and skills are evolving every day. New evidence-based research discoveries are slowly being implemented into healthcare policies and standards. Though evidence-based practices (EBP) are crucial to patient safety and success, most clinical decisions are made by traditional practices and personal preferences (Cocoman, pp.1171, 2010). Research shows there can be anywhere from an eight to thirty year deficit between evidence-based discoveries and implementation into the healthcare settings (Hauck, pp. 665, 2013). There are many factors that contribute to the discrepancy: lack of access to EBP research and skills to evaluate and integrate the research into practice, lack of technical skills, and negative attitudes (Hauck, pp. 665,

INJECTION SIGHTS 2013). Though it is the nurses responsibility to learn the skills, it falls on administration leaders to introduce EBP research.

Registered nurses have a busy career, especially with the current nursing shortage, which makes it difficult for them to find time to read about new practices and skills. Time-consuming and difficult research for evidence-based articles increase the chance nurses will ask other co-workers for information or advice before researching new EBPs. It is essential that administrative leaders provide easy access to these resources to encourage initiative in their nurses to research and find EBPs on their own. Learning and perfecting new skills take time and effort nurses have little to none of by the end of the workday. Skill labs should be required for all nurses during work hours if they are expected to perform new skills in the practice setting. For example, if the ventrogluteal sight is the best but most unfamiliar injection sight, workshops need to be available so nurses can become skilled at administering them. This will not only increase technical skills, but also create positive attitudes about EBPs by increasing the nurses comfort and confidence in the new skills. Nurses need to be evolving with the new EBPs if they expect to provide the best healthcare possible. Evidence-Based Injection Sights According to Taylor, the deltoid is one of four intramuscular sights and the most popular for vaccine injections. It is located in the upper arm. This sight does come with risks, a misplaced injection could cause damage to the radial nerve or artery. In order to find the correct placement, palpate for the acromion process and axilla. Next, form a triangle on the lateral aspect of the upper arm in-between the acromion process and axilla and inject into the middle of the triangle. No more than one milliliter should be injected

INJECTION SIGHTS into this sight (Taylor, pp. 753, 2011).

As stated by Taylor, the vastus lateralis injection sight is located at the mid thigh. This sight is one of the preferred sights because it has no large nerves or blood vessels to damage. This sight is also the largest, allowing for multiple injections at the same sight. To locate the injection location, divide the thigh into thirds horizontally and vertically, placing the needle in the outer middle section. This injection sight is used most often on infants and children because the muscles at the other injection sights are poorly developed (Taylor, pp.753, 2011). According to Taylor, the ventrogluteal injection sight is suggested to be the ideal injection sight, although no evidence-based research has proven this to be true. This sight provides a large muscle mass with little subcutaneous tissue (fat tissue) and very little blood vessels and nerves, perfect for intramuscular injections. In order to find its location, place the palm of the hand on the greater trochanter, placing the index finger on the anterosuperior iliac crest and extending the middle finger dorsally along the iliac crest. This forms a triangle in-between the fingers, and the needle is injected centrally. Use the right hand on the patients left hip and the left hand on the patients right hip. Though this sight is one of the preferred locations, it is the least used due to unfamiliarity (Taylor, pp. 752-753, 2011). Dorsogluteal Injection Sight The dorsogluteal, according to Taylor, is traditionally the most favored intramuscular injection sight for most nurses. The location of this injection sight is described as the upper-outer quadrant of the buttocks. Nurses could be more precise by visually cutting the first quadrant into four sections again and using that upper-outer

INJECTION SIGHTS quadrant section (Taylor, pp. 753-754, 2011).

This sight, however, has been proven by evidence-based research to be potentially harmful for the patient. There are many harmful complications that could occur if the sight is not properly landmarked. The sciatic nerve and gluteal artery are located only a few centimeters from the dorsogluteal sight (Cocoman, pp. 1171, 2010). If a nurse accidentally deviated slightly outside the quadrant, the needle could hit the sciatic nerve or gluteal artery causing a variety of effects, such as minor motor/sensory abnormalities or even complete paralysis of the leg (Small, pp. 288, 2004). Another complicated issue with using the dorsogluteal injection sight is the anatomy of the location. The buttock area commonly has a thick layer of subcutaneous tissue ranging from one to nine centimeters (Cocoman, pp.1171, 2010). This creates the problem of administering the medication into the correct location, the gluteal muscle. In one study of two hundred and thirteen patients, only five to fifteen percent received an accurate intramuscular injection (Cocoman, pp. 1171, 2010). Also, with Americans becoming increasingly obese, patients will have a thicker layer of subcutaneous tissue in the buttocks. This will decrease the chances even more of giving a proper intramuscular injection in the dorsogluteal sight. Suggestions have been made to increase the length of the needle to better bypass the subcutaneous tissue, but this will likely increase the risk for harm and discomfort to the patient (Cocoman, pp. 1171, 2010). Nursing Considerations When administering an intramuscular injection, there are many issues to address. Nurses should only perform intramuscular injections after an individualized assessment for an appropriate sight (Small, pp. 291, 2004). One of the most important issues is

INJECTION SIGHTS deciding on the correct sight and locating appropriate landmarks and boundaries. Traditionally in the practice setting, the injection sight is chosen by using the nurses or patients personal preference. This is not an evidence-based practice. The nurse should assess the patient fully, including weight and muscle mass, before choosing an appropriate injection sight. If the patient has too much subcutaneous tissue at the sight, the medication might not reach the muscle and cause future complications. On the other

hand, if the patients muscle is underdeveloped, the injection could cause serious damage and pain to the patient. After the injection sight has been chosen, it is important to be able to identify anatomic landmarks and site boundaries and use an accurate, careful technique when administering intramuscular injections (Taylor, pp. 751, 2011). Inaccurate positioning of the needle could cause a number of harmful and painful problems to the patient, such as an abscess, cellulitis, tissue necrosis, granuloma, muscle fibrosis and contracture, hematoma, and injury to blood vessels, bones and peripheral nerves (Small, pp. 287, 2004). Experienced nurses might not use landmarks and site boundaries anymore because of the belief that they have enough experience to eye-ball the sight; again, this is not evidence-based practice and could cause harm to the patient as well as to the nurses career. Conclusion Though the dorsogluteal injection sight has evidence-based research proving to be harmful, it is still being used to this day. Evidence-based practice is not being implemented into healthcare settings as efficiently as it should be. The amount of responsibility nurses have for patient care and safety is increasing everyday, making it

INJECTION SIGHTS more and more important for nurses to use evidence-based practices. The dorsogluteal injection sight should be discontinued and the promotion of the ventrogluteal, vastus lateralis, or deltoid sights should be encouraged. To avoid complications for all intramuscular injection sights, nurses must know the anatomy, advantages and disadvantages of each injection site, and be able to accurately identify anatomic landmarks and boundaries (Small, pp. 294, 2004). Incorporating evidencebased practice will create successful nursing practice and patient outcomes (Hauck, pp. 673, 2013).

INJECTION SIGHTS References Hauck, S., Winsett, R. P., & Kuric, J. (2013). Leadership facilitation strategies to establish evidence-based practice in an acute care hospital. Journal Of Advanced Nursing, 69(3), 664-674. doi:10.1111/j.1365-2648.2012.06053.x

Small, S. (2004). Preventing sciatic nerve injury from intramuscular injections: literature review. Journal Of Advanced Nursing, 47(3), 287-296. doi:10.1111/j.13652648.2004.03092.x Cocoman, A., & Murray, J. (2010). Recognizing the evidence and changing practice on injection sites. British Journal Of Nursing, 19(18), 1170-1174. Retrieved from http://illiad.ferris.edu. Taylor, C., LeMone, P., Lillis, C., & Lynn, P. (2011) Fundamentals of Nursing: The Art and Science of Nursing Care. Wyoming: Lippinocott Williams & Wilkins.