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By Root 2032 0

which moves the cutaneous and subcutaneous tissues by approximately 1–2 cm (Workman 1999). The injection is given and the needle withdrawn, while releasing the retracted skin at the same time. This manoeuvre seals off the puncture track. An angle of 90° is supported by the DH (2006). The syringe should be held like a pen to insert with a dart-like motion. Aspiration is still an accepted part of an IM injection to ensure that the medication does not enter the capillaries or is inadvertently given intravenously (Hunter 2008), but there is no evidence to support this. Some centres have had to adapt as safety devices do not allow the withdrawal of the plunger as the safety system can then be activated.

Preprocedural considerations

Equipment

The most common size of needle is 21 G (23 G may also be used in a thin patient) but it does depend on the viscosity of the medication. The important aspect of the needle is the length. The correct use of needle length will result in fewer adverse events and reduce complications of absecess, pain and bruising (Malkin 2008). Needles should be long enough to penetrate the muscle and still allow a quarter of the needle to remain external to the skin (Workman 1999). Lenz (1983) states that when choosing the correct needle length for intramuscular injections, it is important to assess the muscle mass of the injection site, the amount of subcutaneous fat and the weight of the patient. It may be necessary to calibrate the BMI to calculate body fat (DH 2006). Without such an assessment, most injections intended for gluteal muscle are deposited in the gluteal fat. The following are suggested as ways of determining the most suitable size of needle to use.

Deltoid and vastus lateralis muscles

The muscle to be used should be grasped between the thumb and forefinger to determine the depth of the muscle mass or the amount of subcutaneous fat at the injection site.

Gluteal muscles

The layer of fat and skin above the muscle should be gently lifted with the thumb and forefinger for the same reasons as before. Use the patient’s weight to calculate the needle length required.

The following are recommended but remembering that women have more subcutaneous tissue than men.

Children

31.5–40.0 kg

40.5–90.0 kg

90 kg

16 mm needle

25 mm needle

25 mm needle

38 mm needle

(Pope 2002)

Specific patient preparations

Skin preparation

There are many inconsistencies regarding skin cleaning prior to subcutaneous or intramuscular injections. Previous studies have suggested that cleaning with an alcohol swab is not always necessary, as not cleaning the site does not result in infections and may predispose the skin to hardening (Dann 1969, Koivistov and Felig 1978, Workman 1999).

Dann (1969), in a study over a period of 6 years involving more than 5000 injections, found no single case of local and/or systemic infection. Koivistov and Felig (1978) concluded that whilst skin preparations did reduce skin bacterial count, they are not necessary to prevent infections at the injection site. Some hospitals accept that if the patient is physically clean and the nurse maintains a high standard of hand hygiene and asepsis during the procedure, skin disinfection is not necessary (Workman 1999).

In the immunosuppressed patient, the skin should be cleaned as such patients may become infected by inoculation of a relatively small number of pathogens (Downie et al. 2003). The practice at the Royal Marsden Hospital is to clean the skin prior to injection in order to reduce the risk of contamination from the patient’s skin flora. The skin should be cleaned using an ‘alcohol swab’ (containing 70% isopropyl alcohol) for 30 seconds and then allowed to dry. If the skin is not dry before proceeding, skin cleaning is ineffective and the antiseptic may cause irritation by being injected into the tissues (Downie et al. 2003).

Procedure guideline 13.19 Medication: intramuscular injection

Essential equipment

Alcohol swab

Needle

Syringe containing prepared IM medication

Preprocedure

Action Rationale

1 Explain and discuss the