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Clinical Practice Keywords Intramuscular injection/

Medicine administration/Absorption
Practical procedures
Injection technique This article has been
double-blind peer reviewed

Injection technique 1: administering

drugs via the intramuscular route

Author Eileen Shepherd is clinical editor
at Nursing Times.
Abstract The intramuscular route allows
for rapid absorption of drugs into the
circulation. Using the correct injection
technique and selecting the correct site
will minimise the risk of complications.
Citation Shepherd E (2018) Injection
technique 1: administering drugs via
the intramuscular route. Nursing Times
[online]; 114: 8, 23-25.
D
rugs administered by the intra-
muscular (IM) route are depos-
ited into vascular muscle
tissue, which allows for rapid
absorption into the circulation (Dough-
erty and Lister, 2015; Ogston-Tuck, 2014).
Complications of poorly performed IM
injection include:
l P ain – strategies to reduce this are
outlined in Box 1;
l B leeding;
l A bscess formation;
l C ellulitis;
l M uscle fibrosis;
l I njuries to nerves and blood vessels
(Small, 2004);
l I nadvertent intravenous (IV) access.
These complications can be avoided if
the site for injection is accurately identi-
fied and a skilled evidence-based tech-
nique is used (Greenway, 2014).
Evidence base
The procedure for IM injection has been dis-
cussed 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outdated and ritualistic practice relating to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 selection
Four muscle sites are recommended for IM
administration:
l V astus lateris;
l R ectus femoris
l D eltoid;
l V entrogluteal (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

Fig 1. Sites for intramuscular injection

Deltoid Vastus lateralis and rectus femoris

Greater
trochanter
Deltoid muscle of femur

Scapula Rectus
femoris
Deep brachial
Box 1. How to reduce pain artery Vastus
caused by injection technique lateralis
Radial nerve
l Use the correct technique Vastus
Humerus medialis
l Rotate injection site to prevent
indurations or abscesses
l Explain the benefits of the injection Dorsogluteal (NOT RECOMMENDED) Ventrogluteal
to the patient Posterior
l Position the patient so the muscles superior iliac Iliac crest
spine
are relaxed Anterior superior
l Use distraction Gluteus medius iliac spine
l Insert and remove the needle Gluteus
maximus Gluteus medius
smoothly and quickly
l Hold the syringe steady during the Greater Greater
procedure trochanter of trochanter of
femur femur
l Inject medication slowly but smoothly
PETER LAMB

Sciatic nerve
Source: Dougherty and Lister (2015)

Nursing Times [online] August 2018 / Vol 114 Issue 8 23 www.nursingtimes.net


Clinical Practice
Practical procedures
longer recommended for IM injections – in
spite of this, many nurses continue to use
it (Ogston-Tuck,2014; Walsh and Brophy,
2011; Malkin, 2008).
Needles
Safety needles should be used for IM injec-
tions 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 com-
monly 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:
l M uscle mass;
l P atient’s weight;
l A mount of subcutaneous fat.
Women have more subcutaneous fat
than men (Zaybak et al, 2007) and consid-
eration 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 preparation
There is some debate about using alcohol-
impregnated swabs to clean injection sites.
PHE (2013) suggests that, if a patient is phys-
ically 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.
Aspiration
It 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
Professional responsibilities
This procedure should be undertaken
only after approved training, supervised
practice and competency assessment,
and carried out in accordance with local
policies and protocols.
Nursing Times [online] August 2018 / Vol 114 Issue 8
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articles, go to
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from the ampoule. Some medicines are
Table 1. Injectable volumes available in pre-filled syringes and manu-
per site in adults facturer’s instructions should be followed.
Site Maximum volume
7. Disperse air bubbles from the syringe.
Ventrogluteal 2.5ml
(recommended)
8. Change the needle. Doing so will ensure
Vastus lateralis 5ml that the needle used for the injection is
(recommended) sharp, thereby reducing pain (Agac and
Deltoid 1ml Günes, 2011). A safety-engineered needle
should be used as this reduces the risk of
Rectus femoris 5ml
sharps injury.
Dorsogluteal 4ml
(not recommended) 9. Dispose of the used needle in a sharps
container according to local policy.
Source: Adapted from Dougherty and Lister
(2015)
10. Place the filled syringe in a tray and take
it to the patient, along with a sharps bin so
important to aspirate if the DG muscle site the used sharps can be disposed of immedi-
is used – because of proximity to the gluteal ately after the procedure.
artery – it is not required for other IM injec-
tion sites (PHE, 2013; Malkin, 2008). 11. Check the patient’s identity, according
to local medicines management policy.
Gloves
The World Health Organization (2010, 2009) 12. Position the patient comfortably with
states that gloves need not be worn for this the injection site exposed (Fig 1). The site is
procedure if the health worker’s and influenced by the assessment of the patient,
patient’s skin are intact. It also notes that the drug and the volume to be injected
gloves do not protect against needle-stick (Table 1) (Dougherty and Lister, 2015).
injury. Nurses need to risk assess individual
patients (Royal College of Nursing, 2018) 13. Check the site for signs of oedema,
and be aware of local policies for glove use. infection or skin lesions. If any of these are
present, select a different site.
Procedure
Equipment: 14. Wash and dry hands.
l N
 eedles – one of which should be a
safety-engineered device; 15. If gloves are considered necessary,
l S
 yringe; following the risk assessment, these
l D
 rug for administration; should be applied.
l M
 edicines administration chart/
prescription; 16. Ensure the skin is clean and follow local
l R
 eceiver or tray to carry the drug; policy on skin cleansing.
l S
 harps container.
17. If skin cleansing is considered neces-
1. Explain the procedure and gain consent. sary, swab for 30 seconds with isopropyl
alcohol and allow to dry for 30 seconds
2. Screen the patient to ensure privacy (Dougherty and Lister, 2015).
during the procedure.
18. Inform the patient you are going to
3. Before drug administration, check carry out the procedure. Use distraction
whether the patient has any allergies. and relaxation techniques to reduce pain if
needed (Box 1).
4. Check the prescription is correct, fol-
lowing the ‘five rights’ of drug administra- Box 2. Five rights of
tion (Box 2) and local medicines adminis- medicines administration
tration policy to reduce the risk of error.
l Right patient
5. Wash and dry hands to reduce the risk of l Right drug
infection. l Right time
l Right dose
6. Assemble the syringe and needle, and l Right route
withdraw the required amount of drug
24 www.nursingtimes.net

Clinical Practice
Practical procedures
Fig 2. Z-track technique
(a) The skin to be pulled down by
2a. Pull the2.5cm
about skin by
andabout 2.5-3.75cm
held during the
(Malkin,
injection2008) to displace the
underlying tissue
19. Hold the syringe and needle in your
dominant hand and gently stretch the skin
around the injection site using the non-
dominant hand. This displaces the subcu-
taneous tissue and aids needle entry
(Dougherty and Lister, 2015).
20. A Z-track technique can be used to pre-
vent backtracking and leakage from the
injection site (Fig 2).
21. Insert the needle at a 90-degree angle
using a dart-like action. This prevents
accidental depression of the plunger
during insertion of the needle (Malkin,
2008) (Fig 3).
22. Aspiration to check whether the
needle is in a blood vessel is not usually
necessary (PHE, 2013). Aspiration is only
required when the DG site is used, which
is not recommended (Greenway, 2014;
Malkin, 2008).
Fig 3. The needle should be inserted at 90 degrees and
penetrate the muscle layer
Skin
PETER LAMB
Nursing Times [online] August 2018 / Vol 114 Issue 8
(b) The drug is administered
2b. While holding the skin, adminster
the injection
23. Depress the plunger slowly at a rate of
1ml/10 seconds; this aids absorption of the
drug and reduces pain (Dougherty and
Lister, 2015).
24. Wait for 10 seconds to allow the drug to
diffuse into the tissue and then quickly
withdraw the needle (Dougherty and
Lister, 2015).
25. Dispose of the sharps directly into the
sharps bin and the syringe according to
local policy.
26. Ensure the patient is comfortable and
wash your hands.
27. Record administration on the prescrip-
tion chart, as well as the administration
site as repeated injections into the same
site can lead to induration and abscesses.
28. Monitor the patient for any effects of
Muscle
25
Copyright EMAP Publishing 2018
This article is not for distribution
except for journal club use
(c) The skin is allowed to return to its
2c.normal
A
 llowposition
the skintrapping
to return
theto its in
drug
normal
the muscleposition, trapping the drug
in the muscle
the prescribed medicine and any problems
with the injection site. NT
References
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;
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Health and Safety Executive (2013) Health and
Safety (Sharp Instruments in Healthcare)
Regulations 2013: Guidance for Employers and
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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
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Public Health England (2013) Immunisation
Procedures: The Green Book, Chapter 4. Bit.ly/
GreenBookCh4
Royal College of Nursing (2018) Tools of the Trade:
Guidance for Health Care Staff on Glove Use and the
Prevention of Contact Dermatitis. Bit.ly/RCNGloves
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. Bit.ly/WHOinjection2010
World Health Organization (2009) WHO
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Bit.ly/WHOHands2009
Zaybak A et al (2007) Does obesity prevent the
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CLINICAL
SERIES Injection technique series
Part 1: Intramuscular route Aug
Part 2: Subcutaneous route Sep
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