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WOMEN AND NEWBORN HEALTH SERVICE

King Edward Memorial Hospital CLINICAL GUIDELINES SECTION A: GUIDELINES RELEVANT TO OBSTETRICS AND
GYNAECOLOGY

1 STANDARD PROTOCOLS 1.10 INTRAMUSCULAR INJECTIONS


Date Issued: June 2010 Date Revised: Review Date: June 2013 Authorised by: OGCCU Review Team: OGCCU 1.10 Intramuscular Injections Section A Clinical Guidelines King Edward Memorial Hospital Perth Western Australia

1.10 INTRAMUSCULAR INJECTIONS


AIM The correct site selection and administration of medication by the intramuscular route. KEY POINTS 1. All medication administration shall comply with the following clinical guidelines P 2.1 Administration of Medications P 2.3 Administration of Prescription Only medication schedule 4 P 2.4 Administration of Schedule 8 Controlled Medications 2. Intramuscular injections (IMI) are a method of administering medications deep into the muscle tissues. This route of administration provides rapid system action and absorption of relatively large doses (up to5mL) with some sites1. IMI usually have a longer effect compared with an intravenous injection and slower onset 2 3. The following patients may not be suitable for IM injection Patients with clotting abnormalities e.g. thrombocytopenia Patients who are neutropeanic Liaise with the RMO before giving IM injections to patients receiving anticoagulant / thrombolytic therapy. 4. IMI may also be contraindicated in patients with occlusive vascular disease, oedema, shock, after 1 thrombolytic therapy as these conditions impair peripheral absorption. 5. Potential complications can include 1, 2 Fibrosis and contracture of the muscles Nerve injuries Abscess and/or haematoma formation and local discomfort Local irritation Infection Neuropathy Tissue necrosis Gangrene Muscle contraction 6. Do not administer the IMI if the site Is inflamed Is oedematous

2010

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

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Is irritated. Contains moles, birthmarks, scar tissue or other lesions.3

7. The injection site is critically important because the medication effect can be enhanced or diminished depending on the site of injection.

FACTORS TO CONSIDER WHEN SELECTING THE PREFERRED INJECTION SITE Purpose of the injection Body size Age Muscle condition (sore or inflamed) Medical diagnosis 4

IM injections may be given in the following sites:

VENTROGLUTEAL: THIS SITE SHOULD BE USED WHENEVER POSSIBLE. This site has the greatest thickness of the gluteal muscle and is free of penetrating nerves. It is most commonly used for antibiotics, antiemetics, deep IM and z- track injections. Up to 2.5mL can be injected safely.1,5 It is capable of absorbing larger volumes and has the most consistent depth of adipose tissue reducing inadvertent subcutaneous administration.1 Locate the ventrogluteal site by placing the palm of the hand against the greater trochanter of the femur and the index finger on the anterior superior iliac spine of the pelvis. Extend the middle finger posteriorly along the iliac crest. The V between the two fingers is the site for injection.4,5

Date Issued: June 2010 Date Revised: Review Date: June 2013 Written by:/Authorised by: OGCCU Review Team: OGCCU 2010

1.10 Intramuscular Injections Section A Clinical Guidelines King Edward Memorial Hospital Perth Western Australia Page 2 of 6

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

DELTOID The maximum volume to be administered is 1mL1,5 This is the most accessible site however due to the size of this area the number and volume of injections that can be administered are limited.5 Locate the deltoid muscle- ask the patient to relax their arm at the side and flex the elbow. Palpate the lower edge of the acromion process which forms the base of the triangle in line with the midpoint of the lateral aspect of the upper arm. The injection site is in the centre of the triangle, approximately 2.5-5cm below the acromion process. Deltoid Site
5

DORSOGLUTEAL This site has the lowest drug absorption rate.1 Be aware the muscle mass may have atrophied in older people, non ambulant patients and emaciated patients.1 Locate the Dorsogluteal muscle in the upper quadrant of the buttock approximately 5-8cm below the iliac crest. Palpate the posterosuperior iliac spine and the greater trochanter of the femur. An imaginary line is drawn between the two anatomical landmarks. The injection site is above and lateral to the line.

Date Issued: June 2010 Date Revised: Review Date: June 2013 Written by:/Authorised by: OGCCU Review Team: OGCCU 2010

1.10 Intramuscular Injections Section A Clinical Guidelines King Edward Memorial Hospital Perth Western Australia Page 3 of 6

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Dorsogluteal Site 5

RECTUS FEMORIS. The rectus femoris muscle is used primarily for antiemetics, opioids, sedatives, injections in oil, deep intramuscular and z- track injections. This site is rarely used by midwives / nurses but is easily accessible for self administration of injections .1,5

VASTUS LATERALIS Up to 5mL can be injected safely.5 The vastus lateralis is located on the anterior lateral aspect of the thigh and extends from a handbreadth above the knee to a handbreadth below the greater trochanter of the femur. The middle third muscle is the best site for injection ( see diagram above)

PROCEDURE 1. Select the site of injection. 2. Position the patient comfortably exposing the chosen site. Encourage the patient to relax the muscle.

Date Issued: June 2010 Date Revised: Review Date: June 2013 Written by:/Authorised by: OGCCU Review Team: OGCCU 2010

1.10 Intramuscular Injections Section A Clinical Guidelines King Edward Memorial Hospital Perth Western Australia Page 4 of 6

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

3. Perform hand hygiene and don gloves. 4. Clean the chosen site with isopropyl 70% swab and allow to air dry. 5. Ensure the site is completely dry before performing the injection. 6. Remove the needle cap and hold the syringe in the dominant hand. 7. Stretch the skin tautly prior to injection. 8. Insert the needle at a 72-90 angle. 9. Withdraw the plunger to observe for blood. 10. If blood is visible Withdraw the needle completely. Explain what has happened to the patient. Dispose of the needle and syringe in the sharps container. Draw up new solution and repeat the procedure in a different site. 11. If no blood is visible in the syringe, slowly depress the plunger until the full dose of medication is administered. 12. Withdraw the needle and release the skin. 13. Apply gentle pressure with a dry swab. 14. Do not re cap the used needle. 15. Dispose of the needle and syringe in a sharps container. 16. Assist the patient to reposition as required. 17. Perform hand hygiene. 18. Sign the medication chart MR 810. 19. Provide education as required. REFERENCES 1. JasekaraR. Evidence Summary: Injection (Intramuscular): Clinical Information.2009.Joanna Briggs Institute. 2. McGarvey MA.Intramuscular injections: a review of nursing practice for adults. All Ireland Journal of Nursing & Midwifery.2001; 1(5):185-188. 3. Heckenberg G. Evidence Summary: Injection (intramuscular).2008.Joanna Briggs Institute. 4. Evans-Smith P. Lippincotts Atlas of Medication Administration.2nd edPhiladelphia: Lippincott Williams & Wilkins.2005. 5. Doherty L, Lister S. The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 7th ed. United Kingdom; Wiley-Blackwell Publishing; 2008.

Date Issued: June 2010 Date Revised: Review Date: June 2013 Written by:/Authorised by: OGCCU Review Team: OGCCU 2010

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All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

ACKNOWLEDGEMENT Royal Perth Hospital. Nursing Practice Standard -Medications. 2009.

Date Issued: June 2010 Date Revised: Review Date: June 2013 Written by:/Authorised by: OGCCU Review Team: OGCCU 2010

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All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual