Intramuscular Injections

Injections into muscle tissue, or intramuscular (IM) injections

are absorbed more quickly than subcutaneous injections because of the

greater blood supply to the body muscles.

An adult with well-developed muscles can usually safely tolerate up to

3 mL of medication in the gluteus medius and gluteus maximus muscles

A volume of 1 to 2 mL is usually recommended for adults with less developed

muscles.

In the deltoid muscle, volumes of 0.5 to 1 mL are recommended. Usually

a 3- to 5-mL syringe is needed.

The standard prepackaged intramuscular needle is 1 1/2 inches and #21 or

#22 gauge.

Several factors indicate the size and length of the needle to be used:

■ The muscle

■ The type of solution

■ The amount of adipose tissue covering the muscle

■ The age of the client.

Several body sites can be used for IM injections

Ventrogluteal Site

in the gluteus medius muscle, which lies over the gluteus minimus (see
Figure 35–34).

The ventrogluteal site is the preferred site for intramuscular

injections because the area:

■ Contains no large nerves or blood vessels.

 ■ Provides the greatest thickness of gluteal muscle consisting of both
the gluteus medius and gluteus minimus.

■ Is sealed off by bone.

■ Contains consistently less fat than the buttock area, thus eliminating
the need to determine the depth of subcutaneous fat.

safest site of choice for an IM injection of more than 1 mL in clients

older than 7 months

The client position for the injection can be a back, prone, or side-lying
position. The side-lying position, however, helps locate the
ventrogluteal site more easily. Position the client on his or her side
with the knee bent and raised slightly toward the chest. The trochanter
will protrude, which facilitates locating the ventrogluteal site. To
establish the exact site, the nurse places the heel of the hand on the
client’s greater trochanter, with the fingers pointing toward the
client’s head. The right hand is used for the left hip, and the left hand
for the right hip. With the index finger on the client’s anterior superior
iliac spine, the nurse stretches the middle finger dorsally (toward the
buttocks), palpating the crest of the ilium and then pressing below it.
The triangle formed by the index finger, the third finger, and the crest
of the ilium is the injection site .

Vastus Lateralis Site

The vastus lateralis muscle is usually thick and well developed in both
adults and children. It is recommended as the site of choice for
intramuscular injections for infants 1 year and younger.It is situated
on the anterior lateral aspect of the infant’s thigh.The middle third
of the muscle is suggested as the site. In the adult,the landmark is
established by dividing the area between the greater trochanter of the
femur and the lateral femoral condyle into thirds and selecting the middle
third. The client can assume a back-lying or a sitting position for an
injection into this site.

Dorsogluteal Site
This site is close to the sciatic nerve and the superior gluteal nerve
and artery. As a result, complications (e.g., numbness, pain, paralysis)
occurred if the nurse injected a medication near or into the sciatic nerve.

The medication may be injected into the subcutaneous tissue instead of

the muscle, which can then affect the intended therapeutic effect.
Developmentally, infants and children have larger ventrogluteal than
dorsogluteal muscle mass (Malkin, 2008).

Because of the above safety issues and, as stated previously, the

ventrogluteal site is the preferred site for intramuscular injection.

Several reasons for this preference include ease of site identification,

more experience with using the dorsogluteal site, less confidence using
the ventrogluteal site, and lack of emphasis to use the ventrogluteal site
over the dorsogluteal site when learning about intramuscular injections.

Rectus Femoris Site

is used only occasionally for intramuscular injections. It is situated

on the anterior aspect of the thigh.

Its chief advantage is that clients who administer their own injections
can reach this site easily.

Its main disadvantage is that an injection here may cause considerable

discomfort for some people.

Deltoid Site

The deltoid muscle is found on the lateral aspect of the upper arm. It
is not used often for intramuscular injections because it is a relatively
small muscle and is very close to the radial nerve and radial artery. The
upper landmark for the deltoid site is located by the nurse placing four
fingers across the deltoid muscle with the first finger on the acromion
process. The top of the axilla is the line that marks the lower border
landmark (Figure 35–41 ■). A triangle within these boundaries indicates
the deltoid muscle about 5 cm (2 in.) below the acromion process (Figures
35–42 ■ and 35–43 ■). Firmly pressing the injection site for 10 seconds
before inserting the needle is thought to reduce the sensory input from
an injection, regardless of the site (Zimmerman, 2010)
. Intramuscular Injection Technique

The Z-track method has been found to be less painful than the traditional
injection technique and decreases leakage of irritating medications into
the subcutaneous tissue Although the Z-track technique is not always used
in practice, research evidence supports its effectiveness and recommends
its routine use.

Lifespan Considerations Intramuscular Injections

INFANTS ■ The vastus lateralis site is recommended as the site of choice

for intramuscular injections for infants. There are no major blood vessels
or nerves in this area, and it is the infant’s largest muscle mass. It
is situated on the anterior lateral aspect of the thigh.

■ Obtain assistance to immobilize an infant or young child. The parent

may hold the child. This prevents accidental injury during the procedure.

CHILDREN ■ Use needles that will place medication in the main muscle
mass; infants and children usually require smaller, shorter needles (#22
to #25 gauge, 5/8 to 1 inch long) for intramuscular injections.

■ The vastus lateralis is recommended as the site of choice for toddlers

and children.

■ For the older child and adolescent, the recommended sites are the same
as for the adult: ventrogluteal or deltoid. Ask which arm they would like
the injection in.

OLDER ADULTS ■ Older clients may have a decreased muscle mass or muscle
atrophy. A shorter needle may be needed. Assessment of an appropriate
injection site is critical. Absorption of medication may occur more
quickly than expected.

PURPOSE
■ To provide a medication the client requires (see specific drug action)
Determine whether the size of the muscle is appropriate to the amount of
medication to be injected. An average adult’s deltoid muscle can usually
absorb 0.5 mL of medication, although some authorities believe 1 mL can
be absorbed by a well-developed deltoid muscle. The gluteus medius muscle
can often absorb 1 to 4 mL, although 4 mL may be very painful and may be
contraindicated by agency protocol.

ASSESSMENT Assess ■ Client allergies to medication(s) ■ Specific drug

action, side effects, and adverse reactions ■ Client’s knowledge of and
learning needs about the medication ■ Tissue integrity of the selected
site ■ Client’s age and weight to determine site and needle size ■
Client’s ability or willingness to participate

Equipment ■ Client’s MAR or computer printout ■ Sterile medication

(usually provided in an ampule or vial or prefilled syringe) ■ Syringe
and needle of a size appropriate for the amount and type of solution to
be administered ■ Antiseptic swabs ■ Clean gloves

IMPLEMENTATION

Preparation 1. Check the MAR. • Check the label on the medication

carefully against the MAR to make sure that the correct medication is being
prepared. • Follow the three checks for administering the medication and
dose. Read the label on the medication (1) when it is taken from the
medications.

cart, (2) before withdrawing the medication, and (3) after withdrawing
the medication. • Confirm that the dose is correct. 2. Organize the
equipment.

2. Prepare the medication from the ampule or vial for drug withdrawal.
• See Skill 35–2 (ampule) or 35–3 (vial). • Whenever feasible, change
the needle on the syringe before the injection. Rationale: Because the
outside of a new needle is free of medication, it does not irritate
subcutaneous tissues as it passes into the muscle. • Invert the syringe
needle uppermost and expel all excess air. 3. Provide for client privacy.
4. Prepare the client. • Prior to performing the procedure, introduce self
and verify the client’s identity using agency protocol. Rationale: This
ensures that the right client receives the medication. • Assist the client
to a supine, lateral, prone, or sitting position, depending on the chosen
site. If the target muscle is the gluteus medius (ventrogluteal site),
have the client in the supine position flex the knee(s); in the lateral
position, flex the upper leg; and in the prone position, toe in. Rationale:
Appropriate positioning promotes relaxation of the target muscle. •
Obtain assistance in holding an uncooperative client. Rationale: This
prevents injury due to sudden movement after needle insertion. 5. Explain
the purpose of the medication and how it will help, using language that
the client can understand. Include relevant information about effects of
the medication. Rationale: Information can facilitate acceptance of and
compliance with the therapy. 6. Select, locate, and clean the site. •
Select a site free of skin lesions, tenderness, swelling, hardness, or
localized inflammation and one that has not been used frequently. • If
injections are to be frequent, alternate sites. Avoid using the same site
twice in a row. Rationale: This is to reduce the discomfort of
intramuscular injections. If necessary, discuss with the prescribing
primary care provider an alternative method of providing the medication.
• Locate the exact site for the injection. See the

Imsert pg 892