The document outlines best practices for administering intramuscular injections, including selecting appropriate injection sites based on the patient's age, assessing body mass index to determine needle size, and techniques such as Z-tracking to reduce pain and prevent leakage of medication from the injection site. Evidence-based guidelines are presented for patient positioning, skin cleansing, aspirating for blood, injection angle and speed, and monitoring the patient after injection.

1. Monina Hernandez Gesmundo, RN
October 12, 2011
Auckland, New Zealand

2. Draw 4 lines to connect all the nine dots
without lifting your pen from the paper.

3. Draw 4 lines to connect all the nine dots
without lifting your pen from the paper.

5. After the brief presentation, the participants
will be able to:
A. Define evidence-based practice
B. Identify different sites used for
intramuscular injections
C. Select the best practice site for IM
injections
D. Describe essential steps for safely
administering IM injections
E. Implement evidence-based practice in IM
injection

6. EBP is “the conscientious, explicit and judicious use
of current evidence in making decisions about the
care of individual or groups of patients … This
practice requires the integration of individual clinical
expertise with the best available external clinical
evidence from systematic research, available
resources, and our patient’s unique values and
circumstances.” –Sacketts as cited in Salmond, 2007
Practice based on evidence
Evidence based on:
Research
Input from patients
Case studies and case reports
Expert opinion

8. - used in adults and children with well-developed gluteal muscles
(Berman et al 2008)
- avoided in children <3 unless child has been walking for > 1 year
Client’s Position: prone, with toes pointing inward OR side-
lying, with upper knee flexed
Procedure:
• palpate posterior superior iliac spine
• draw an imaginary line to the greater trochanter of femur
• site is lateral and superior to this line to avoid the sciatic nerve

9. - gluteus medius site
- suitable for children > 1 year and adults
- less fats, no large nerves/blood vessels;
sealed off by bone (Berman et al 2008)
Client’s Position: Side lying, flexed knee
Procedure:
• place heel of hand (right hand for left
hip, left hand for right hip)on client’s
greater trochanter, fingers towards head
• with index finger on client’s anterior
superior iliac spine, stretch middle finger
dorsally
• inject at the triangle formed by index
finger, third finger and iliac crest

10. - IM site of choice for infants < 1 yr
(Berman et al, 2008)
- no major blood vessels/nerves
Client’s Position: supine or sitting
Procedure:
• divide area between greater
trochanter of femur and lateral
femoral condyle into thirds
• middle third is the injection site

11. - used in adults due to rapid absorption
- < 1 ml only because of small size
- close to radial nerve and radial artery
(Berman et al, 2008)
Client’s Position: sitting
Procedure:
• place four fingers across deltoid
muscle, with first finger at
acromion process
• top of axilla marks the lower border
• site is approximately 2 inches below the
acromion process

13.  Presence of major nerves and blood
vessels, slow uptake of
medication, thick layer of adipose tissue
(Small, 2004 as cited in Cocoman, A &
Murray, J., 2010)
 Difficult
to palpate due to thick layer of
adipose fat – from 1 cm to 9 cm
(Lachman,1963 as cited in Cocoman, A
& Murray, J., 2010)

14.  Turkishstudy with 59 women and 60
men with BMI >25kg/m2, only 98% of
women and 37% of men received a true
IM; recommends that a needle > 1.5
inches be used in women with BMI
>25kg/m2 (Zayback et al, 2007 as cited
in Cocoman, A & Murray, J., 2010)

15.  CT scans conducted by Haramati, et al
in 1994 in 338 patients, found that 20%
had calcified granulomas in the buttocks
 Damage to the sciatic nerve has been
documented in several legal cases with
financial awards (Small, 2004 as cited in
in Greenway, K., Merriman,C. &
Statham, D., 2006)

16.  Findings by Nisbett in 2006 (as cited in
Greenway, K., Merriman,C. &
Statham, D., 2006) show:
Mean thickness Probability of penetrating
IM Site of subcutaneous muscle using 21G needle
fat (35mm length)
Ventrogluteal site 19 mm 74%
Dorsogluteal site 32 mm 57%

17. - conducted in Australia in 2005 by
Wynaden, D., Landborough, I. & Chapman, R. showed
that:
A. INJECTION SITE:
 Abscess, induration, erythema, wheals, pain, hematoma
, bleeding and paralysis are largely attributed to site
and technique
 Deltoid - causes immediate and post-injection
discomfort (Wink, 1992)
 Dorsogluteal site - last choice due to damage to sciatic
nerve and superior gluteal artery (Perry & Potter, 2004)
 Ventrogluteal - safest site for administering IM
injections (Greenway, 2004; Perry & Potter, 2004); with
no documented evidence of complications (Beecroft &
Redick, 1989; Beecroft & Kongelbeck, 1994)

18. B. EQUIPMENT
 Generally, gauge 23(32mm) to gauge
21(38mm) (Chiodini, 2001; Newton, et
al, 1992)
 If client is > 91kg, use gauge 20 (50mm)
(Beyea & Nicholl, 1996; Keen, 1990)
 Regardless of method of choice, needle length
should be appropriate for the site and client’s
BMI (Belanger-Annable, 1985; Calnan, 2001;
Cockshott et al, 1982; Haramati et al, 1994;
Keen, 1983,1989; Lenz, 1983;
McConnell, 1982; Murphy, 1991;
Zuckeman, 2000)

19. C. MEDICATION VOLUME
 Deltoid – 0.5ml to 1 ml (Murphy, 1991;
Rodger & King, 2000)
 Ventrogluteal – up to 5ml (Murphy, 1991;
Rodger & King, 2000)
 If pH or tonicity of medication is different
than body fluids, choose larger muscle sites
(Murphy, 1991)

20. D. MEDICATION FORMULATION
 Pain can be associated with buffers, co-
solvents, antimicrobials, preservatives
(Brazeau et al, 1998)
 Read literature supplied with medication to
consider drug formulation

21. E. TECHNIQUES TO REDUCE DISCOMFORT
 pressure to site for 10 seconds prior to injection
(Barnhill et al, 1996; Chung, et al, 2002)
 pinch-grasp technique (Locsin, 1985)
 thumping technique (Hasan, 2001)
 Others include: give client appropriate information;
RN should be calm and confident; use drawing-up
needle; use smallest diameter needle; stretch skin;
pierce skin quickly; distract client; inject
medication slowly (Brentnell,1990; Beavis, 1999;
Campbell, 1995; Dickerson, 1992; Rodger &
King, 2000; Workman, 1999)

23. Z-track technique: for highly irritating, viscous solutions;
reduces leakage, pain and irritation to prevent seepage of
medication
IM injection at a 90 degree angle
A) skin pulled to the side
B) skin released
Note: When skin returns to its normal position after needle is
withdrawn, a seal is formed over the site

24. G. SKIN CLEANSING
 Disinfect a circular area of 2.5cm to 7.5cm
with alcohol wipe for 30 seconds and allow
to dry for 30 seconds (Newton &
Newton, 1977; Beyea & Nicoll, 1996;
Workman, 1999)
H. ASPIRATING FOR BLOOD
 Aspirate for blood for 5 to 10 seconds; if
blood appears, withdraw the needle and
repeat the process using sterile equipment
(Beyea & Nicoll, 1996; McConnell, 1982;
Workman, 1999)

25. I. ANGLE AND VELOCITY OF NEEDLE
 Less emphasis on the velocity of the needle
piercing the skin, but more on starting with
the needle closer to the skin to minimize
needle stick injury and missing the target
(Katsma & Katsma, 2000)
J. BODY POSITIONING
 Dorsogluteal site: femur-pointing inward
(toes pointing inward) relaxes the gluteus
maximus (Kruszewski et al, 1979; Rettig &
Southby, 1982)

26.  Assess BMI:
- Generally, use 32mm (23G) to 38 mm (21G) needle
- If client > 91 kgs, use 38 mm (21G) or 50mm (20G) needle
 Use drawing up needle
 Select appropriate site and proper position
 Cleanse site for 30 seconds with alcohol wipe and allow to dry
for 30 seconds
 Use Z-track technique
 Position needle close to skin
 Insert needle quickly and smoothly at 72-90 degree-angle
 Aspirate for blood
 If no blood is aspirated, inject medication slowly (1ml per
second); if blood is aspirated, withdraw needle and recommence
with sterile equipment.
 Withdraw needle smoothly and quickly
 Apply gentle pressure to site for 30 seconds
 Assess site for abnormal reaction and ensure patient comfort.

29.  Berman, A., Snyder, S., Kozier, B. & Erb, G. (2008). Fundamentals
of nursing (8th ed). New Jersey: Pearson Education, Inc.
 Cocoman, A. & Murray, J. (2010). Recognzing the evidence and
changing practice on injection sites. British Journal of
Nursing, 19(18), 1170-1174.
 Floyd, S. & Meyer, A. (2007). Intramuscular injections – what’s
best practice. Kai Tiaki Nursing, 13(6), 20-22.
 Greenway, K., Merriman,C. & Statham, D. (2006). Using the
ventrogluteal site for intramuscular injections. Learning
Disability Practice, 9(8), 34-37.
 Henkelman, W.J. (2011). Evidence-based practice and injection
techniques. Nevada RN formation, 20.
 Salmond, S. W. (2007). Advancing evidence-based practice: a
primer. Orthopedic Nursing, 26(2), 114-123.
 Wynaden, D., Landborough, I. & Chapman, R. (2005). Establishing
best practice guidelines for administration of intramuscular
injections in the adult: A systematic review of the literature.
Contemporary Nurse, 20(2), 267-277.