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BAUTISTA, JESTHER ROWEN B.

BSN III-1

BLDH, 7-3, WARD

THINK AGAIN: Revisiting IM Injections


Polly Gerber Zimmermann MS, MBA, RN, CEN

AJN, American Journal of Nursing


February 2010
Volume 110 Number 2
Pages 60 61

Abstract

The ventrogluteal site is the safest for intramuscular injections.

Deltoid, dorsogluteal, rectus femoris, vastus lateralis, or ventrogluteal:


which site do you choose for giving an intramuscular (IM) injection? Each has
varying potential for adverse effects. Although nurses have traditionally
chosen the dorsogluteal site (also called the buttock or upper outer
quadrant), which targets the gluteus maximus muscle, it poses unnecessary
and unacceptable risks of injury to the superior gluteal artery and sciatic
nerve. In fact, juries have awarded damages to patients of nurses whose
dorsogluteal IM injections injured the sciatic nerve. In addition, using this site
can cause skin and tissue trauma, muscle fibrosis and contracture,
hematoma, nerve palsy and paralysis, and infectious processes such as
abscess and gangrene.

In contrast, the ventrogluteal site is the only one of these sites to


which no major complications have been attributed. Also called the anterior
gluteal site, it targets the gluteus medius and avoids all major nerves and
blood vessels. The only contraindications to using this site are obvious
deformities and apparent scarring.

The ventrogluteal site is now strongly recommended for IM injections


of more than 1 mL in patients older than seven months. (These muscles,
which develop with crawling and walking, are of insufficient size in infants-
and possibly in patients who are unable to walk. In these cases, the vastus
lateralis site should be used instead.)

LOCATING THE VENTROGLUTEAL SITE

The standard of care is to completely expose the area and then use
anatomical landmarks to locate the correct muscle group. Because the
buttocks include fat tissue that extends well below the gluteal muscles,
relying only on visualization to select the site can lead to inaccurate needle
placement.

Find the ventrogluteal site by palpating the greater trochanter of the


femur, which feels like a golf ball. Place the heel or palm of your hand over it
and position your index finger on or pointing toward the anterior superior
iliac spine. Spread apart your third finger from your index finger and give the
injection in the center of the V formed by the two fingers.

In obese patients, care must be taken to guard against delivering


medication to the subcutaneous tissue, rather than the muscle. This is
especially true in women, who typically have more adipose tissue around the
buttocks. In one study, 72% of adults-90% of women and 44% of men-were
found to have dorsogluteal fat deposits that were deeper than the 1-in.
length of the shorter IM needles. The ventrogluteal site offers a shorter
distance to the muscle.

Other techniques that will help you reach the muscle are using a
90[degrees] insertion angle, stretching rather than pinching the skin (unless
the patient is emaciated), and choosing the appropriate needle based on the
patient's body mass index. Using the Z-track technique-displacing the skin
by 2.5 to 3.75 cm laterally before puncturing it, releasing it, and applying
gentle pressure immediately after withdrawing the needle-is also
recommended. This technique "seals off" the site, preventing tracking or
leaking of the medication into the subcutaneous tissue.

PROMOTING COMFORT

To minimize the discomfort of an IM injection regardless of the site selected:

* Position the patient. Enhance muscle relaxation in a supine patient by


having her bend her leg at the knee, in a prone patient by having him point
his toes inward, and in a side-lying patient by having her place her upper leg
in front of her lower leg.

* Apply manual pressure. Firmly press the site for 10 seconds before
inserting the needle. Stimulating the surrounding nerve endings is thought to
reduce the sensory input from the injection.
* Depress the plunger slowly. Give medications at a rate of 10 seconds per
milliliter to allow the fluid to absorb.

SOURCE: http://www.nursingcenter.com/library/JournalArticle.asp?
Article_ID=966822

SUMMARY:

Nurses have traditionally chosen the dorsogluteal site which targets the
gluteus maximus muscle. However, recent studies show that it poses unnecessary
and unacceptable risks of injury to the superior gluteal artery and sciatic nerve.
Using this site can cause skin and tissue trauma, muscle fibrosis and contracture,
hematoma, nerve palsy and paralysis, and infectious processes such as abscess and
gangrene.

Nevertheless, the ventrogluteal site is the only one of these sites to which no
major complications have been attributed. At present, it is strongly recommended
for IM injections of more than 1 mL in patients older than seven months.

The journal gives a simple set of instructions on how to administer medicines


via the gluteal area. It was stated as the following: Find the ventrogluteal site by
palpating the greater trochanter of the femur, which feels like a golf ball. Place the
heel or palm of your hand over it and position your index finger on or pointing
toward the anterior superior iliac spine. Spread apart your third finger from your
index finger and give the injection in the center of the V formed by the two fingers.

Meanwhile, care must be taken to obese and female clients to guard against
delivering medication to the subcutaneous tissue, rather than the muscle. In
addition, women typically have more adipose tissue around the buttocks.

To minimize the discomfort of an IM injection regardless of the site selected,


the journal recommends positioning the patient, applying manual pressure and
depressing the plunger slowly.
REACTION:

The route of administration critically influences the pharmacokinetic


properties of a drug. Parenteral route of administration encompasses intravenous
(IV), intramuscular (IM), and subcutaneous (SQ) routes.

The muscle that is injected into at the ventrogluteal injection site is the
gluteus medius. The advantages to a ventrogluteal injection are that it is reasonably
free of major nerves and vascular branches. The bony landmarks such as the
greater trochanter and the iliac spine make this injection site easy to locate. The
muscle mass at the ventrogluteal injection site is adequate enough for deep IM or Z-
track injections. The last advantage of this Intramuscular (IM) injection site is it can
be administered from numerous patient positions such as the supine, lateral (left or
right), and on the abdomen.

To a patient, this location could be considered a private area as the pants


need to come down a bit to be able to locate the IM injection properly. The
procedure should be explained so that the patient understands what is going to
happen so they are not startled or if an alternate location needs to be considered.

Parenteral administration of medicine can be influenced by Jean Watsons


Human Caring Theory. Nurses must remember that administering medications
(which is primarily focused on treatment) should be done in a caring way. Allowing
the patient to verbalize anxiety to parenteral medications is an exemplification of
the Promotion and acceptance of the expression of positive and negative feelings.
As stated in Watsons Assumption of Caring, Caring occasions involve action and
choice by nurse and client. Informing the client of the advantages of ventrogluteal
route of drug administration is an example of this. It is a way of letting the client
choose what is best for him.

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