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Intramuscular (IM) injections administer medication deep into the muscle tissue, enabling faster absorption and larger systemic doses than subcutaneous injections. This guide discusses how to perform an IM injection in an artificial OSCE setting and should not be used as a guide to administering injections to actual patients without first consulting your local medical school or hospital guidelines. Check out the Intramuscular (IM) injection OSCE mark scheme here.

Introduction

Introduce yourself

Wash hands

Confirm the patient’s details

Explain the procedure

Check the patient’s understanding of the medication being given, and explain the indication for the medication.

Check for allergies

Check if the patient has a bleeding disorder or takes anticoagulant medication (possible contraindications).

Check if the patient has a preferred injection site and if the patient is receiving regular IM injections, ensure that the injection sites are rotated.

Gain consent to proceed

Gather equipment

  • Equipment tray
  • The medication to be administered
  • Patient’s prescription
  • Syringe – the smallest syringe that will accommodate the medication volume
  • Injecting needle – (21–23 gauge) – 25mm in length is standard 
  • Drawing up needle / Blunt filter needle (These filter out sub-visible particles of glass, rubber and other residues when drawing up from vials and glass ampoules)
  • Antiseptic swab –  70% isopropyl alcohol wipe
  • Gauze or cotton swab
  • Sharps container (for disposal of the needle)
  • Apron
  • Non-sterile gloves
  • Gather equipment

7 Rights

Return to the patient. Before proceeding, check the 7 rights of medication administration

1. Right person – check the patient’s arm band against the name on the prescription. Where possible aim to use 2 identifiers (e.g. from the patient and the arm band)

2. Right drug – check the labelled drug against the prescription – ensure expiry date is appropriate

3. Right dose – check the dose against the prescription

4. Right time – confirm when the last dose was given

5. Right route

6. Right to refuse – has the patient consented?

7. Right documentation of prescription and allergies – does the patient have any allergies?

Once these have been confirmed prepare the medication. Always use a separate drawing up needle and injection needle.

Injection steps

1. Wash hands

2. Don gloves and apron

3. Draw up the appropriate medication into the syringe using a drawing up needle.

4. Remove the drawing up needle and immediately dispose of it in the sharps bin, then attach the needle to be used for injection.

5. Choose an appropriate site, common sites include:

  • Deltoid (upper arm)
  • Ventrogluteal (upper outer buttock) – ideal for larger volumes
  • Vastus lateralis (anterior lateral thigh)
  • Do NOT use a site that is inflamed, irritated, bruised or contains scar tissue.

See the end of the guide for further information regarding the most commonly used sites.

If multiple injections are given, use different sites for each subsequent injection. If frequent injections are given, rotate sites.

6. Position the patient to provide optimal access to your chosen site.

7. Cleaning the site:

  • When administering a vaccination the site does not need to be routinely cleaned prior to injection unless the skin is visibly soiled (in which case you would need to clean the site with soap and water). 4
  • There is some debate as to whether the skin should be cleaned with an alcohol wipe prior to administration of intramuscular medication, with WHO stating that cleaning is likely unnecessary. Many hospitals however still recommend routinely cleaning with an alcohol wipe to reduce the risk of hospital acquired infections, so you should adhere to your local medical school and hospital guidelines.

8. Gently place traction on the skin with your non-dominant hand away from the injection site, continuing the traction until the needle has been removed from the skin. This is known as the Z-track technique (see below).   If the patient is elderly with a reduced muscle mass or the patient is emaciated, do not apply traction, instead ensure that the muscle is ‘bunched up’ to ensure adequate bulk before injecting.

9. Warn the patient of a sharp scratch.

10. Holding the syringe like a dart in your dominant hand, pierce the skin at a 75 – 90 degree angle. Insert the needle quickly and firmly, with the bevel facing upwards, leaving approximately 1/3 of the shaft exposed (however this varies between sites and patients).

11. Aspirate to check the location of the needle:

  • If blood appears, remove the syringe and prepare a new injection (explaining what occurred to the patient)
  • It is recommended that you aspirate when giving IM medications as these are often given via deep IM injection (e.g. ventrogluteal) with a higher risk of accidental administration into a vessel
  • If administering a vaccination via a shallow IM injection UK guidance suggests there is no need to aspirate prior to injection of the vaccine 5

12. If no blood appears on aspiration, inject the contents of the syringe while holding the barrel firmly. Inject the medication slowly at a rate of approximately 1ml every 10 seconds.

13. Remove the needle and immediately dispose of it appropriately (into a sharps container).

14. Release the traction on the skin.

15. Apply gentle pressure over the injection site with a cotton swab or gauze.  Do NOT rub the site.

16. Replace gauze with a plaster.

Z – track technique – releasing the traction on the skin changes the alignment of the subcutaneous and muscle tissue layers, ‘locking’ the medication into the muscle layer.

  • Wash hands

To complete the procedure

Thank the patient

Discuss post injection care:

  • Warn them that the injection site may be sore for one or two days, but this is normal.
  • Other potential complications include: haematoma, persistent nodules, local irritation (and rarely anaphylaxis).
  • Advise the patient to watch for a developing rash, breathing difficulty or other relevant concerning symptoms. They should discuss this with a doctor if concerned.

Wash hands

Document that the medication has been given on the medication chart and in the patient’s notes.

Injection sites

Below are some more details surrounding the common sites used for IM injections, however these are brief notes and therefore should NOT be relied upon in isolation for carrying out IM injections, instead you should consult your local medical school or hospital guidelines.

Deltoid site

Position of patient

  • Have the patient sitting down, with their entire shoulder and arm exposed.
  • Position their elbow flexed and ask them to relax.

Site of injection

  • Palpate the lower edge of the acromial process and inject approximately 2.5cm below this.

Ventrogluteal site

In the past the dorsogluteal site was very popular, however due to potential complications such as sciatic nerve injury or superior gluteal artery injury it is now not recommended. Instead the ventrogluteal site is used as a safer alternative as it avoids all major nerves and blood vessels.

Position of patient

  • The patient can be prone, semi-prone or supine for this procedure, so choose whichever is most comfortable for the patient.

Site of injection

  • Place palm of your right hand over the greater trochanter of the patients left hip (or vice versa).
  • Extend your index finger to touch anterior superior iliac crest.
  • Then stretch your middle finger to form a V (thumb pointing towards the front of leg)
  • Insert the needle into the V at 90  ̊
CONTENT REVIEWED BY

Graham Bone Senior Clinical Lecturer in Medical Education

References

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  1. Department of Health. (2014). Intramuscular Injections. Government of Western Australia. Retrieved from: http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectiona/1/a1.10.pdf
  2. Department of Health. (2016) The Australian Immunisation Handbook – Administration of vaccines. Ed. 10 The Australian Government. Retrieved from: http://www.health.gov.au/internet/immunise/publishing.nsf/content/Handbook10-home~handbook10part2~handbook10-2-2#2-2-5
  3. World Health Organisation – WHO Best Practices for Injections and Related Procedures Toolkit. Retrieved from: http://apps.who.int/iris/bitstream/10665/44298/1/9789241599252_eng.pdf
  4. Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. Yvan Hutin et al. 2003. Retrieved from: http://www.who.int/bulletin/volumes/81/7/en/Hutin0703.pdf
  5. Immunisation procedures: the green book, chapter 4. Public Health England. Published 20th March 2013. Accessed 20th March 2017. Retrieved from: https://www.gov.uk/government/publications/immunisation-procedures-the-green-book-chapter-4

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