NURSING PR ACTICE & SKILL

Administration of Medication: Intramuscular

What Is Intramuscular Administration of Medication?

44 Intramuscular (I.M.) administration of medication (commonly referred to as I.M. injection) refers to the deposition of a pharmaceutical agent or other medicinal compound into muscle tissue using a needle and syringe. Large striated muscles, such as the thigh, upper arm, or buttocks, are usually appropriate for I.M. administration of medication What: During I.M. injection, a drug is deposited into striated muscle for bloodstream absorption How: The prescribed medication is drawn up into an age-/size-appropriate needle and syringe. The skin is cleaned with an antimicrobial solution (e.g., alcohol) and allowed to air dry. The needle is inserted through the subcutaneous (SC) tissue into the muscle below. The drug is then injected from the syringe by depressing the plunger Where: An I.M. injection can be administered to a patient in a medical office/clinic, in an inpatient setting, or at home Who: An I.M. injection should be given by a nurse or other healthcare professional and may not be delegated to assistive personnel. Sometimes, after receiving appropriate instruction, the I.M. injection can be administered by the patient or a caregiver. It is appropriate for family members to remain present during administration of I.M. medications with the patients consent

Why Is I.M. Administration of Medication Ordered?

44 I.M. injection is ordered when I.V. administration of the drug would irritate the veins; because a suitable vein cannot be located; or when the drug is not tolerated or would be destroyed by the digestive system if given orally

Why Is I.M. Administration of Medication Important?

44 I.M. injections offer an alternative to I.V. or oral administration of medication when these routes are not available 44 Muscle is less sensitive to irritating or viscous medications because muscle has fewer pain receptors than subcutaneous tissue 44 Drug absorption is faster with I.M. injection than subcutaneous injection because of the rich blood supply in deep muscle tissue 44 Skeletal muscle can accommodate a larger volume of medication than subcutaneous tissue 44 I.M. injections avoid the risk for inactivation of the drug by the digestive system
Authors
Nathalie Smith, RN, MSN, CNP Carita Caple, RN, BSN, MSHS

Facts and Figures

44 The preferred route of administration of some drugs is I.M. because the drugs are particularly irritating to veins. The U.S. Food and Drug Administration (FDA) recommends that promethazine (e.g., Phenergan) be given via the I.M. route for this reason. However, there continue to be risks associated with promethazine when given I.M.; these include local tissue injury, swelling, and blistering at the injection site. To reduce these risks, experts recommend using suitable alternatives (e.g., ondansetron [e.g., Zofran]) and encouraging patients to readily report signs or symptoms of irritation following the injection (Harrington, 2010) 44 Emergency department clinicians may be tempted to reduce the observation time following I.M. injection in order to discharge patients more quickly. However, experts recommend observing patients for at least 30 minutes following I.M. injection because it may take up to 20 minutes or longer for medications delivered intramuscularly to produce mild to severe allergic reactions (e.g., anaphylaxis). Drugs that require extra vigilant monitoring include antibiotic drugs (especially penicillin) and nonsteroidal anti-inflammatory drugs (NSAIDs); (Miles, 2010)

Reviewers
Darlene A. Strayer, RN, MBA Cinahl Information Systems Glendale, California Eliza Schub, BSN, RN Cinahl Information Systems Glendale, California Nursing Practice Council Glendale Adventist Medical Center Glendale, California

Editor
Diane Pravikoff, RN, PhD, FAAN Cinahl Information Systems

What You Need to Know Before I.M. Administration of Medication

44 The clinician must be aware of the five rights of medication administration. The five rights refer to the following: Right patient

May 6, 2011

Published by Cinahl Information Systems. Copyright2011, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Right medication Right time Right dose Right route of administration 44 The clinician should be familiar with the principles of administration of I.M. medications and knowledge of the anatomy of the muscular and circulatory systems Absorption of an I.M. injected drug depends on blood flow and the condition of the muscle used for injection Absorption occurs more rapidly if the patient exercises shortly after the injection as a result of dilated blood vessels and rapid blood flow through the muscle tissue. Absorption will be negligible if the patient is in shock and circulation has almost stopped Emaciated muscles absorb injections poorly and should not be used; injected drugs may be absorbed faster in older adults because they have less muscle mass Older adult patients may have diminished muscle mass which may reduce absorption of medications administered intramuscularly Injection into muscles that are tense is more painful, and the site is more likely to bleed With I.M. injection, there is a theoretical risk that the needle will pierce a blood vessel and send the drug directly into the bloodstream. To avoid this, some I.M. injection protocols require aspiration after the needle is inserted to ensure a blood vessel has not been penetrated. Follow your facilitys protocol for I.M. injection aspiration 44 Knowledge of appropriate sites for I.M. injection is essential. These include The ventrogluteal site (i.e., the upper, lateral portion of the buttocks between the iliac crest and the anterior and posterior gluteal lines) is the safest site for adults and children over 7 months of age because it is deep and removed from major blood vessels and nerves The vastus lateralis (i.e., the lateral portion of the upper thigh) is used for adults and children and is the preferred site for immunization administration in children The deltoid, a small muscle in the upper extremity that can accommodate 0.5 mL injection volume, is the site often used for administration of influenza vaccination. The deltoid is rarely used for injection of other medications because the volume exceeds what the muscle can hold 44 The following preliminary steps should be taken prior to administering an I.M. medication: Review facility protocol for I.M. medication administration, if available Review the treating clinicians order for prescribed medication Identify the patient using facility protocol and obtain verbal consent for the procedure Assess for knowledge deficit, and reinforce patient/family education related to the purpose of I.M. medication administration and related procedures, as needed Explain that the injection will be administered into the muscle and may result in tingling, pain, or mild burning at the injection site Review the patients history for evidence of any allergies (e.g., latex, medications, or other substances); use alternative materials as appropriate Gather supplies, which typically include the following: Medication administration record (MAR) Prescribed medication Nonsterile gloves Alcohol swabs Gauze pads and/or adhesive bandage Appropriate size syringe: 23 mL for adults 0.51 mL for infants and small children Appropriate size and bore needle: Select a 19- to 25-gauge needle, depending upon the size and age of the patient (a 22- to 25-gauge needle should be used for newborns) The length of the needle may vary from 5/8 inch to 2 inches depending upon the size/age of the patient and muscle selected

How to Administer Medication Intramuscularly

44 Perform hand hygiene and apply nonsterile gloves 44 Identify the patient per facility protocol and review the MAR to verify the five rights of medication administration 44 Draw up the correct amount of medication from the container into the syringe and expel any air bubbles. Check the medication for color and clarity; if the formulation is a suspension, it will contain small particles 44 Remove the needle used for medication withdrawal and dispose of it in a sharps container; attach a new sterile needle that is appropriate for I.M. injection to the syringe 44 Locate an injection site that is free of pain, infection, bruising, and abrasions 44 Position the patient for comfort and to ensure that the muscle you have chosen for the injection site is relaxed For ventrogluteal I.M. injections, position the patient on his/her side or back with the knees and hips flexed For vastus lateralis I.M. injections, position the patient supine with the knee slightly flexed or sitting upright For deltoid I.M. injections, instruct the patient to relax his/her arm at the side or support the patients arm and flex the elbow 44 Use alcohol swab to clean the injection site using a circular motion. Allow the site to air dry (e.g., approximately 3060 seconds)

44 The method of injection depends on the medication involved and individualized muscle tissue characteristics Utilize the Z-track method for injection in patients with normal muscle mass: Uncap the syringe Hold the syringe between thumb and forefinger in your dominant hand, as if holding a dart With your non-dominant hand, pull the skin lateral to the injection site downward or to one side, displacing the skin about 1 inch. This tightens the skin, so that the injection site is more stable. It also keeps the medicine from traveling back up through the subcutaneous tissue along the path the needle made during the injection, because the skin and subcutaneous tissue are moved away from their normal position during the injection Position the needle at a 90 angle to the patients skin Pierce the patients skin with the needle using a smooth, rapid motion Aspirate (i.e., pull back on) the syringe to confirm that the needle has not pierced a blood vessel If no blood appears within the syringe, inject the medication slowly (e.g., approximately 10 seconds per each mL of medication solution) If blood appears in the syringe, dispose of the medication and syringe and prepare another dose for administration Gently withdraw the needle and release the skin to its normal position. After the needle is removed, the portion of the needle path going through the subcutaneous tissue moves away from the portion going into the muscle, thus sealing off the injected fluid If the patients muscle mass is small, instead of using the Z-track method, use the standard method Uncap the syringe Hold the syringe between thumb and forefinger in your dominant hand, as if holding a dart With your non-dominant hand, grasp the muscle body between the thumb and fingers to stabilize it for injection Position the needle at a 90 angle to the patients skin Pierce the patients skin with the needle using a smooth, rapid motion Aspirate (i.e., pull back on) the syringe to confirm that the needle has not pierced a blood vessel If no blood appears within the syringe, inject the medication slowly (e.g., approximately 10 seconds per each mL of medication solution) If blood appears in the syringe, dispose of the medication and syringe and prepare another dose for administration Gently withdraw the needle and release the skin to its normal position 44 Cover the injection site with a piece of gauze or a bandage and apply pressure until it stops bleeding. Do not massage the skin or muscle tissue at the site of the injection because this may irritate the muscle tissue and/or force some of the medication into the subcutaneous tissue 44 Dispose of syringe, gloves, and all other used equipment and materials into the appropriate receptacles 44 Perform hand hygiene 44 After administering the medication, document the following information in the patients medical record Date and time the medication was prepared and administered Name of the medication and dosage Site and technique used to administer the medication Patient status prior to and after administration of the medication Any unexpected outcomes and the interventions performed Patient/family education provided

Other Tests, Treatments, or Procedures That May Be Necessary Before or After I.M. Administration of Medication
44 Observe the patient for 30 minutes for adverse effects. If a severe allergic reaction occurs, initiate emergency treatment per facility protocol or according to the clinician orders (see Red Flags, below) 44 If injections must be given repeatedly, the injection site should be rotated and a record kept of the sites used

What to Expect After I.M. Administration of Medication

44 The medication is administered utilizing the correct technique and per clinicians orders. The patient experiences no local or systemic adverse effects

Red Flags
44 The ventrogluteal site is preferred over the dorsogluteal site (located in the upper outer quadrant of the buttocks) because the latter is associated with greater risk for sciatic nerve injury and accidental injection into a blood vessel 44 Errors and adverse effects that can occur with I.M. injection include accidental I.V. or intraarterial injection tissue irritation or an allergic reaction. In case of serious allergic reaction, administer diphenhydramine or epinephrine per facility protocol sterile abscess formation if the medicine has been injected into a site where the drug cannot be absorbed (e.g., a subcutaneous site) peripheral nerve injury, characterized by continued localized pain, tingling, or numbness infection due to break in aseptic technique

What to Tell the Patient/Patients Family

44 Explain to the patient/family/caregiver the purpose of and steps involved in administering medication intramuscularly 44 Reinforce clinician instructions regarding the treatment regimen, and provide information regarding how to contact their treating clinician should complications arise

References
Altman, G. B. (2010). Medication administration. Fundamental & advanced nursing skills (3rd ed., pp. 606-613). Clifton Park, NY: Delmar Cengage Learning. Harrington, L. (2010). Nurses on guard error prevention and management: Medication administration issue: Promethazine (Phenergan). Texas Board of Nursing Bulletin, 41(3), 5. Miles, G., & Martin, N. (2010). Common practice: Medication waits at discharge. Journal of Emergency Nursing, 36(4), 379-380. Ostendorf, W. (2010). Parenteral medications. In A. G. Perry, & P. A. Potter (Eds.), Clinical nursing skills & techniques (7th ed., pp. 598-603). St. Louis, MO: Mosby Elsevier. Robinson, M. W. (2010). Guide to I.M. injections in newborns. Nursing Made Incredibly Easy, 8(5), 14-17.