Related Reading

This related reading is based an article in the National Library of Medicine website. It is written
by Javier Polania Gutierrez and Sunil Munakomi, last updated on October 23, 2022. The article
mainly fucoses on intramuscular injection.
Intramuscular injection is administering medication into the depth of a specific selected muscles.
Usual sites for IM injections are deltoid muscles of the arm, vastus lateralis of the thigh,
ventrogluteal muscles of the hip, and dorsogluteal muscles of the buttocks.
Based on the article, there is still a lack of adherence to recommended guidelines and an
algorithm for giving IM among health professional worldwide.
Drugs may be given intramuscularly for prophylactic, around 5% for immunization and 95% for
curative purposes of IM injections. These are the most common IM route for medications:
Antibiotics – penicillin G benzathine penicillin, streptomycin
Biologicals – immunoglobulins, vaccines, and toxoids
Hormonal agents – testosterone, medroxyprogesterone
Streptomycin - first discovered aminoglycoside antibiotic, originally isolated from the bacteria
Streptomyces griseus. It is now primarily used as part of the multi-drug treatment of pulmonary
tuberculosis. It has additional activity against several aerobic gram-negative bacteria. This
activity will discuss the indications, mechanism of action, and contraindications of using
streptomycin in both children and adults. It will also describe the administration, dosing, and
monitoring of streptomycin. Additionally, it will touch on the adverse event profile and other key
factors to keep in mind as a healthcare team when using streptomycin as an antibiotic agent to
treat pulmonary tuberculosis or other aerobic gram-negative infections.
Medroxyprogesterone acetate (MPA) - a progestin, is similar in structure to naturally-
occurring progesterone. The mechanism of action of progestin involves binding the progesterone
receptor in the hypothalamus, female reproductive tract, and the pituitary and inhibiting the
secretion of gonadotropin-releasing hormone (GnRH). By decreasing the frequency of release of
GnRH, MPA blunts the midcycle LH surge and prevents follicular maturation and ovulation.
MPA changes a proliferative endometrium to a secretory one in the endometrium, making it
difficult for implantation. Finally, MPA also impairs sperm migration into the uterus by
increasing the viscosity of the cervical mucus.

Indications
 IM for therapeutic purposes is indicated for the following patients:
 Noncompliant
 Uncooperative
 Reluctant 
 Unable to receive drugs through other common routes
 Do not tolerate oral medications
Contraindications
 Active infection, cellulitis, or dermatitis at the site of administration.
 Known allergy or hypersensitivity to the drug.
 Acute myocardial infarction- the release of muscle enzymes complicates the management
strategy.
 Thrombocytopenia.
 Coagulation defects.
 Hypovolemic shock - the drug's absorption may be hampered due to compromised
vascularity of the muscle.
 Myopathies.
  Associated muscular atrophy - leads to delayed drug absorption and increases the risk of
neurovascular complications.
Complications
 Common complications:
 Persistent pain at the site of injection
 Muscle fibrosis and contracture
 Abscess at the injection site
 Gangrene
 Nerve injury -the sciatic nerve in gluteal injection, the femoral nerve in vastus lateralis
injection, the superior gluteal nerve in dorsogluteal injection, the femoral nerve in vastus
lateralis injection, radial nerve in deltoid injection
 Skin slough
 Periostitis, osteomyelitis
 Transmission of HIV, hepatitis virus
 Inadvertent injection of glass particles while using glass vials and ampoules.
 Vascular injury
Nursing, Allied Health, and Interprofessional Team Monitoring
Issues of True IM Injections
True intramuscular injections are observed only in 32 to 52%, with the incidence even falling to
8% among females. Female sex, obesity, subcutaneous fat thickness, and injection site play
significant roles in governing the same. Ultrasound guidance and proper needle length are key
factors in ensuring true IM injections among patients with increased body mass index
[BMI]. However, there is still ongoing debate over this point.
The Practice of Aspiration Prior to Drug Administration
Though nurses continue practicing aspirations, most do it for a short duration than the
recommended time of 5 to 10 seconds. Blood aspiration is observed mainly in the dorsal gluteal
(15%) and deltoid (12%) injections. The World Health Organization and Centers for Disease
Control and Prevention do not recommend it. Aspiration is unnecessary and is now reserved only
for dorsogluteal site injections.
Use of Filter Needles
The syringe filters significantly minimize the risk of glass particle contamination. However,
economic constraints, time consumption, and workforce shortages are significant hindrances to
its routine practice. The risk increases with larger bore, unfiltered needles (safe with 23G). Vial
breakage by neck wrapping with a cotton ball from an outward direction results in low glass
particles than the entire ampoule neck wrapping with a gauze pad from an inward direction
method.
Some of the current nursing practices pertaining to IM injections seem to evolve more like a
tradition passing from one generation to the next and based upon Schön’s and Benner's learning
concepts. Evidence-based nursing practice is pivotal in ensuring patient safety, and regular
updates, monitoring, and intervention mapping strategies may help improve practitioners'
adherence to clinical recommendations.

REFERENCES
Polania Gutierrez, J. J., & Munakomi, S. (2022, October 23). Intramuscular Injection - StatPearls
- NCBI Bookshelf. Intramuscular Injection - StatPearls - NCBI Bookshelf. Retrieved December
22, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK556121/
Waters, M., & Tadi, P. (2022, July 11). Streptomycin - StatPearls - NCBI Bookshelf.
Streptomycin - StatPearls - NCBI Bookshelf. Retrieved December 22, 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK555886/

Sathe, A., & Gerriets, V. (2022, May 19). Medroxyprogesterone - StatPearls - NCBI Bookshelf.
Medroxyprogesterone - StatPearls - NCBI Bookshelf. Retrieved December 22, 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK559192/

SUMMARY

Related Reading
The full benefit of many effective medications will be achieved only if patients adhere to
prescribed treatment regimens. Unfortunately, applying terms such as “noncompliant” and
“nonadherent” to patients who do not consume every pill at the desired time can stigmatize them
in their future relationships with health care providers. This article on medication adherence (or
compliance) reviews strategies to assess and enhance this important aspect of patient care.
Drugs don't work in patients who don't take them.
— C. Everett Koop, M.D.
Adherence to (or compliance with) a medication regimen is generally defined as the extent to
which patients take medications as prescribed by their health care providers. The word
“adherence” is preferred by many health care providers, because “compliance” suggests that the
patient is passively following the doctor's orders and that the treatment plan is not based on a
therapeutic alliance or contract established between the patient and the physician. Both terms are
imperfect and uninformative descriptions of medication-taking behavior. Unfortunately, applying
these terms to patients who do not consume every pill at the desired time can stigmatize these
patients in their future relationships with health care providers. The language used to describe
how patients take their medications needs to be reassessed, but these terms are still commonly
used.1 Regardless of which word is preferred, it is clear that the full benefit of the many effective
medications that are available will be achieved only if patients follow prescribed treatment
regimens reasonably closely.

Epidemiology of Medication-Taking Behavior

Electronic medication-monitoring devices have provided very detailed information about the
patterns of medication-taking behavior. Most deviations in medication taking occur as omissions
of doses (rather than additions) or delays in the timing of doses.  Patients commonly improve
their medication-taking behavior in the 5 days before and after an appointment with the health
care provider, as compared with 30 days after, in a phenomenon known as “white-coat
adherence.” Studies using these monitors have shown six general patterns of taking medication
among patients treated for chronic illnesses who continue to take their medications.
Approximately one sixth come close to perfect adherence to a regimen; one sixth take nearly all
doses, but with some timing irregularity; one sixth miss an occasional single day's dose and have
some timing inconsistency; one sixth take drug holidays three to four times a year, with
occasional omissions of doses; one sixth have a drug holiday monthly or more often, with
frequent omissions of doses; and one sixth take few or no doses while giving the impression of
good adherence.
Simple dosing (one pill, once daily) helps to maximize adherence, particularly when combined
with frequent reinforcing visits, despite the fact that 10 to 40 percent of patients taking these
simple regimens continue to have imperfect dosing. In a large systematic review of 76 trials in
which electronic monitors were used, Claxton and colleagues found that adherence was inversely
proportional to frequency of dose, and patients taking medication on a schedule of four times
daily achieved average adherence rates of about 50 percent (range, 31 to 71 percent).

Interventions
Methods that can be used to improve adherence can be grouped into four general categories:
patient education; improved dosing schedules; increased hours when the clinic is open (including
evening hours), and therefore shorter wait times; and improved communication between
physicians and patients. Educational interventions involving patients, their family members, or
both can be effective in improving adherence. Strategies to improve dosing schedules include the
use of pillboxes to organize daily doses, simplifying the regimen to daily dosing, and cues to
remind patients to take medications. Patients who miss appointments are often those who need
the most help to improve their ability to adhere to a medication regimen; such patients will often
benefit from assistance in clinic scheduling and what is called “cue-dose training” to optimize
their adherence. Clinic-scheduling strategies to improve adherence include making follow-up
visits convenient and efficient for the patient. Delays in seeing patients and problems with
transportation and parking can undermine a patient's willingness to comply with a medication
regimen and to keep follow-up appointments. Interventions that enlist ancillary health care
providers such as pharmacists, behavioral specialists, and nursing staff can improve
adherence. Finally, enhancing communication between the physician and the patient is a key and
effective strategy in boosting the patient's ability to follow a medication regimen

Examples of Challenges to Adherence

HYPERTENSION
Consistent control of blood pressure requires that patients with hypertension follow medication
and dietary regimens. However, antihypertensive therapy may have untoward side effects and
result in little symptomatic relief, since hypertension often causes no symptoms. No matter how
effectively the clinician communicates the benefits of antihypertensive therapy, patients are still
ultimately responsible for taking their medications. Since adherence is enhanced when patients
are involved in medical decisions about their care and in monitoring their care, the traditional
model of the authoritarian provider should be replaced by the more useful dynamic of shared
decision making by the health care provider and the patient. The patient must actively participate
in the selection and adjustment of drug treatment and in changes in lifestyle in order to maximize
the usefulness of the therapeutic regimen. When feasible, self-monitoring of blood pressure can
also enhance adherence. Simplifying instructions to the patient and medication schedules is
essential, and minimizing the total number of daily doses has been found to be more important in
promoting adherence than minimizing the total number of medications.

Conclusions
Poor adherence to medication regimens is common, contributing to substantial worsening of
disease, death, and increased health care costs. Practitioners should always look for poor
adherence and can enhance adherence by emphasizing the value of a patient's regimen, making
the regimen simple, and customizing the regimen to the patient's lifestyle. Asking patients
nonjudgmentally about medication-taking behavior is a practical strategy for identifying poor
adherence. A collaborative approach to care augments adherence. Patients who have difficulty
maintaining adequate adherence need more intensive strategies than do patients who have less
difficulty with adherence, a more forgiving medication regimen, or both. Innovative methods of
managing chronic diseases have had some success in improving adherence when a regimen has
been difficult to follow. New technologies such as reminders through cell phones and personal
digital assistants and pillboxes with paging systems may be needed to help patients who have the
most difficulty meeting the goals of a regimen.
REFERENCE:
Osterberg, & Blaschke. (2005, August 4). Adherence to Medication. Retrieved December 22,
2022, from https://www.nejm.org/doi/full/10.1056/nejmra050100
SUMMARY