Ratified by Healthcare Governance Committee 25 April 2006

UNDER REVIEW
Guidelines for Administration of Medicines Through Intramuscular Injections

1.

Introduction Intra muscular (IM) injections, as the name implies, administers drugs directly into the muscle beneath the subcutaneous tissue. This route allows quicker absorption than the subcutaneous method. The Z-track method is widely used, advocated by Beyea and Nicholl (1996) also see 8 below. This method controls leakage into the surrounding tissues and is generally more comfortable for the patient. It is recognised that some people may have mobility problems. The nurse should assist the person to adopt the most suitable position possible before administering the injection. It is proposed that: The Z track technique will be used for intra-muscular injections within the Trust. The Trust proposes the dorsogluteal and ventrogluteal as injection sites of choice. Reasons for departure from proposed injection sites will need to be documented in nursing/medical notes. Ongoing use of a non-approved site must be discussed with the prescriber.

These guidelines should be read in conjunction with Infection Control policies and procedures (needle stick injuries, safe disposal of needles, aseptic techniques, etc). 2. Aim To promote and facilitate the safe administration of medications, via intramuscular injections, required by clients/patients receiving treatment in the community, day care and inpatient areas.

3.

Administration Administration of intramuscular injections may be carried out by medical staff and Nurses who have completed their nurse training and are now are registered with the Nurses and Midwives Council under the following parts:

Kingfisher House, Kingfisher way, Hinchingbrooke Business Park, Cambs, PE29 6FH Phone: 01480 398500

Sub-part 1, i.e. Level 1 nurses, for example, Registered Nurse Adults (RN1), Registered Nurse Mental Health (RN3) and Registered Nurse Learning Disabilities (RN5) Sub-part 2, i.e. Level 2 nurses, for example, Adult Nurse (RN2), Mental Health Nurse (RN4) and Learning Disabilities Nurse (RN6).

4.

Prescription charts 4.1. Intramuscular injections may only be administered according to instructions on the service users prescription chart. The medicines policy states that the authorisation of a suitably qualified prescriber must be obtained before medicines can be administered to service users, this should be in the form of an instruction written on a trust medicines chart, prescription or depot administration card. The administration should be recorded on the medicine chart or the depot administration card (whichever is in use)

Prescription charts must be written legibly, dated, signed and include the following: 4.2.1. Name of medication ordered 4.2.2. Amount prescribed 4.2.3. Dosage 4.2.4. Frequency of administration 4.2.5. Route

5.

Method Intramuscular injections should be given into the dorsogluteal site (upper outer quadrant of the buttock) or into the ventrogluteal site of the thigh. 5.1 5.2 Correctly identify the site (see Figs. b and d). Place client on their side with their top leg flexed to relax the muscle. The client may also wish to stand, respecting the clients wishes as to the preferred position.

Injections into gluteal muscles Recent research has raising concerns regarding injections sites due to increasing obesity in the general population (Nesbit, 2006). The Royal Marsden Hospital Manual of Clinical Nursing Procedures, quotes Lenz (1983) who suggested use of the service users weight to calculate the needle length required. Weight 31.5 to 40 Kg 40.5 to 90 Kg 90 Kg 6. Skin Preparation Needle size 2.5 cm 5 to 7.5 cm 10 to 15 cm

The Royal Marsden Hospital Manual of Clinical Nursing Procedures (Sixth Edition) advises that the skin should be cleaned prior to giving injections in order to reduce the risk of contamination from the service users skin flora. It further suggests the use of 'alcohol swab' for 30 seconds but to allow the skin to dry before proceeding.

7.

Injection sites Current research evidence suggests that there are five sites that can be utilised for the administration of intramuscular injections (Workman 1999; Rodger & King 2000) However, as indicated in (1) above, The Trust proposes the dorsogluteal and ventrogluteal as intramuscular injection sites of choice. These sites are:

7.1. The mid-deltoid site (Fig. a). This site has the advantage of being easily accessible whether the patient is standing, sitting or lying down. Owing to the small area of this site, the number and volume of injections which can be given into it are limited.

7.2. The dorsogluteal site (Fig. b) is used for deep intramuscular and Z-track injections. The gluteal muscle has the lowest drug absorption rate. The muscle mass is also likely to have atrophied in older people, nonambulant and emaciated patients. This site carries with it the danger of the needle hitting the sciatic nerve and the superior gluteal arteries (Workman, 1999).

7.3. The rectus femoris site (Fig. c) is used for anti-emetics, narcotics, sedatives and injections in oil. The rectus femoris is the anterior quadriceps muscle, which is rarely used by nurses, but is easily accessed for self-administration on injections or for infants (Workman, 1999).

7.4. The ventrogluteal site (Fig. d) is used for antibiotics, antiemetics, deep intramuscular and Z-track injections in oil, narcotics and sedatives. This is the site of choice for intramuscular injections (Rodger & King, 2000) as up to 2.5 ml can be safely injected.

8.

Z Track Technique 8.1. Place the ulnar side of your non-dominant hand on the chosen injection site. 8.2. Pull the skin downwards or to one side of the injection site. 8.3. Hold the needle at 90 degrees (right angle) to the skin. 8.4. Plunge the needle in quickly, penetrating the muscle and leaving about a third of the needle exposed. 8.5. Pull back the plunger to observe for blood aspiration. If blood is aspirated, the procedure should be discontinued. The opposite site to be used if this occurs. If no blood is aspirated, slowly and continuously inject the drug. After a couple of seconds, withdraw the needle at the same angle at which it went in. 8.6. Release the skin. This has the effect of breaking the needle track or sealing off the puncture tract as the skin and subcutaneous layers move back over the muscle. The drug is therefore locked within the muscle.

9.

Monitoring Medication Regime Medication administration and documentation of the users condition must be kept on the users file. 9.1. Compliance, outcome, adverse effects and other matters of concern shall be documented and recorded in the users file by the nurse. 9.2. The Nurse will promptly inform the relevant medical officer or qualified prescriber of any adverse effects.

10.

Medication Teaching The Nurse will explore the clients knowledge and understanding of their current medication.

10.1. Service user should receive written and/or verbal information about their medications including potential benefits and adverse effects. They could also be issued with the Trust leaflet Your Medication Any Questions? These leaflets can be obtained via http://nww.enline.cambsmh.nhs.uk 11. Medication Record Any activity related to review or administration of medication given via intramuscular route, shall be recorded on the users care notes and depot medication chart where appropriate.

Nephat Chege, Professional Nurse Lead

April 2006

References: 1. Dougherty, L., Lister, S (2004). The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Sixth Edition. Blackwell Publishing. Workman, B. (1999). Safe Injection Techniques. Nursing standard 13 (39), pg 47 53. Rodger, M. A., & King, L. (2000). Drawing Up and Administering Intramuscular injections: A Review of the Literature. Journal of Advanced Nursing, 31 (3), pg. 574 582. Beyea, S. C., & Nicholl, L. sH. (1995). Administration of medications via the Intramuscular Route: an integrative review of the literature and research based protocol for the procedure. Appl Nurs Res, 5(1), pg. 23 33. Mac Gabhann, L (1996). A Comparison ot two depot injection techniques. Nursing Standard. 12 (37), pg. 39 41. Greenaway, K. (2004). Using the ventrogluteal site for intramuscular injection. Nursing Standard. 18 (25), 39 42. Nesbit, Andrew Charles. Intramuscular gluteal injections in the increasingly obese population: retrospective study. BMJ 2006; 332: 637-638

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Specific Notes on Antipsychotic Depot Injections Antipsychotic depot injections should be administered into the upper outer quadrant of the buttock. At the discretion of the nurse, the lateral thigh may be used for injections of Depixol and Clopixol. The arm is not an acceptable site. The reasons for the choice of site should be explained to the patient. In the exceptional circumstance of a patient absolutely refusing a depot neuroleptic injection into an approved site (see below) and an alternative site being used, the full justification for this must be recorded in the nursing and/or medical records. Continued use of an alternative site must be discussed with the prescriber.

DRUG Pipotiazine Palmitate (Piportil Depot) Fluphenazine Decanoate (e.g. Modecate)

SITE BUTTOCK

SITE THIGH

+ +

Haloperidol Decanoate (Haldol Decanoate)

Risperidone Consta)

(Risperdal

+ +

Flupentixol Decanoate (Depixol)

Zuclopenthixol Decanoate (Clopixol) + indicates suitable site

Maximum volume on any one site will normally be 2ml. The volume should never exceed 3ml at any one site.