When possible, IM injections should be avoided in muscles that are emaciated or atrophied because these muscles absorb medication poorly.5, Aspiration before injection and slow injection of the medication are not supported by research for vaccine administration.2 The vastus lateralis and deltoid muscle are the only two sites recommended for vaccine administration because these sites do not contain large vessels that are within reach of the needle.2 For all other medications, there is no evidence to either support or abandon the practice of aspiration before administration. PPSV23and IPV are recommended by the manufacturer to be administered by the subcutaneous or intramuscular route. Apply the safety shield and dispose in the closest sharps container. Needles should be stored in Food and Drug Administrationapproved containers or in containers that are in compliance with community guidelines. This muscle is located on the anterior lateral aspect of the thigh and extends from one hands breadth above the knee to one hands breadth below the greater trochanter. Document the medication, time, route, site, date of administration, and effect of the medication; any adverse effects; unexpected outcomes; and any interventions applied. Glynda Rees Doyle and Jodie Anita McCutcheon, Clinical Procedures for Safer Patient Care, LandmarkingVentrogluteal Administering an IM InjectionUsing Z-track, Landmarking Vastus Lateralus Administering IM InjectionUsing Z-track, Insertion of an Indwelling Subcutaneous Device aka subcutaneous butterfly, Next: 7.5 Intravenous Medications by Direct IV Route, Creative Commons Attribution 4.0 International License. Vaccine administration. All the patients were provided with the same treatment and intervention with a prolotherapy injection containing 15% dextrose, with a disposable syringe of 10 mL containing 4 mL of 15% dextrose, 1 mL of lidocaine, and 5 mL of distilled water. Use a bar code system or compare the MAR to the patients identification band. Cover injection site with sterile gauze, using gentle pressure, and apply Band-Aid as required. 17. The Needlestick Safety and Prevention Act (2) was enacted in 2000 to reduce the incidence of needlestick injury and the consequent risk for bloodborne diseases acquired from patients. Using larger-than-recommended dosages can be hazardous because of excessive local or systemic concentrations of antigens or other vaccine constituents. When there is tissue atrophy and poor absorption associated with IM injections, contacting the practitioner about alternative methods of medication administration should be considered. WebRecommended available dose formulations include 50 mg/ml strength, in 3 ml multiple dose vials or 100 mg/ml strength, in 5 ml multiple dose vials. What is the maximum safe and effective volume of oil that can be injected IM in to the delt. The injection site is in the middle of the deltoid muscle, about 2.5 to 5 cm (1 to 2 inches) below the acromion process. (2020). IM injection sites should be rotated to decrease the risk of hypertrophy. (2022). Checklist 59 outlines the steps to perform a Z-track IM injection. Verify patient using two unique identifiers and compare to MAR. A -inch, 23- to 25-gauge needle should be inserted into the subcutaneous tissue (Figures 4and 5) (4). The Z-track method creates a zigzag path to prevent medication from leaking into the subcutaneous tissue. Return to the patients room at an appropriate time per the organizations practice to assess the injection site. Deltoid muscle: This is the top, upper part of the arm. Assess baseline vital signs and the patients medical and medication history. This amount of medicine may be contained in 1 mL or in one-half (0.5) mL of the injection, depending on the strength. Inspect the skin surface over sites for bruises, inflammation, or edema. 20. Always compare MAR to the practitioners original orders to ensure accuracy and completeness. Aspiration before injection of vaccines or toxoids (i.e., pulling back on the syringe plunger after needle insertion but before injection) is not necessary because no large blood vessels are present at the recommended injection sites, and a process that includes aspiration might be more painful for infants (22). The vastus lateralis muscle is the preferred site for administration of immunizations to newborns, infants, toddlers, and children up to 3 years old. The muscle is thick and well developed. The ventrogluteal site is free from blood vessels and nerves, and has the greatest thickness of muscle when compared to other sites (Cocoman & Murray, 2008; Malkin, 2008; Ogston-Tuck, 2014a). Place a clean swab or dry gauze between your third and fourth fingers. If a needle hits the sciatic nerve, the patient may experience partial or permanent paralysis of the leg.5 The rectus femoris is no longer considered a safe injection site because of the risk of damage to the descending branch of the lateral circumflex femoral artery and the muscle branch of the femoral nerve to the vastus lateralis.6. For screening, the HI assay was performed by thestandard Clarke and Casals technique using dengue referencestrains.11A test dilution 1:10 Take all necessary steps to avoid interruptions and distractions when preparing and administering medications. (2018). The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Needles and syringes used for vaccine injections must be sterile and disposable. Children and infants will require shorter needles. After the needle pierces the skin, use the thumb and forefinger of the nondominant hand to hold the syringe barrel while still pulling on the skin. WebDiphtheria, Tetanus, Pertussis. reduced attenuation of smallpox vaccine virus (9)]. Per the organizations practice, pull back on the plunger. A vapocoolant spray (e.g., ethyl chloride) may also be used just before injection to decrease pain. If injecting into the vastus lateralis, ventrogluteal, gluteus medius, or Knowledge of body mass can be useful for estimating the appropriate needle length (26). 5 mL. Assemble medication, non-sterile gloves, syringes, needles, and sharps container. Insert the needle with a dart-like motion. Review the patients previous verbal and nonverbal responses to injections. ACIP discourages the routine practice of providers prefilling syringes for several reasons. If the deltoid mass is large enough, give up to 2 injections into each deltoid muscle (separated by 2.5 cm). Once medication is completely injected, remove the needle using a smooth, steady motion. WebMethylprednisolone acetate injectable suspension, USP is a white to almost white colored suspension and is available in the following strengths and package sizes: 400 mg per 10 mL (40 mg/mL PACKAGE LABEL-PRINCIPAL DISPLAY PANEL-400 mg per 10 mL (40 mg/mL) - Container Label Parenteral Medication Administration. To prevent inadvertent needlestick injury or reuse, safety mechanisms should be deployed after use and needles and syringes should be discarded immediately in labeled, puncture-proof containers located in the same room where the vaccine is administered (5). There is no evidence the cream interferes with other vaccines (46-49). Deltoid or gluteal injections are both possible; the site can be chosen based on patient preference. Reweigh the patient if appropriate. For infants and younger children, if more than 2 vaccines are injected in a single limb, the thigh is the preferred site because of the greater muscle mass; the injections should be sufficiently separated (separate anatomic sites [i.e. Any factor that interferes with local tissue blood flow affects the rate and extent of drug absorption. Ask for the patients name as an additional identifier. Chapter 4: Vaccine safety. WebAugmentin (amoxicillin/clavulanic acid) is an antibiotic that is available as a 150 mg/mL strength injection. Name four techniques. Assess the patients symptoms before initiating medication therapy. In adults (but not in infants) (52), the immunogenicity of hepatitis B is substantially lower when the gluteal rather than the deltoid site is used for administration (8). Safely using sharps (needles and syringes) at home, at work and on travel. Only limited volumes can be given by intramuscular injection. Applying a colorful adhesive bandage or sticker to the injection site should be considered. To prevent contamination of the vial, make sure the patient area is clean and free of potentially contaminated equipment. With IMs, there is an increased risk of injecting the medication directly into the patients bloodstream. Colloids. The deltoid muscle has a triangular shape and is easy to locate and access, but is commonly underdeveloped in adults. Historic concerns about exposure to vaccine components are limited to non-parenteral vaccines in which some degree of environmental exposure is unavoidable (5, 8), or situations in which self-inoculation is likely due to the nature of the vaccine microbe [e.g. Providers are sometimes concerned when they have the same contraindications or precautions as their patients from whom they withhold or defer vaccine. 6. Review medication information such as purpose, action, side effects, normal dose, rate of administration, time of onset, peak and duration, and nursing implications. (d) Some experts recommend a 5/8-inch needle for men and women who weigh <60 kg, if used, skin must be stretched tightly (do not bunch subcutaneous tissue). Intramuscular injections are administered at a 90-degree angle to the skin, preferably into the anterolateral aspect of the thigh or the deltoid muscle of the upper arm, depending on the age of the patient (Table 6-2). Discard the uncapped needle (or needle enclosed in a safety shield) and the attached syringe into a puncture-proof and leakproof receptacle. 16. Retrieved February 11, 2023, https://www.ismp.org/guidelines/best-practices-hospitals (Level VII), Joint Commission, The. WebIn the elderly population, the mean daily volume was 1340 mL (range 6981708 mL) or a bolus of 500 mL over 26 hour) for a mean total of 5 days (.2521 days). For example, varicella vaccine should be discarded if not used within 30 minutes after reconstitution, whereas MMR vaccine, once reconstituted, must be kept in a dark place at 36F to 46F (2C to 8C) and should be discarded within 8 hours if not used. (2021). Retrieved February 11, 2023, from, Lilley, L.L., Rainforth Collins, S., Snyder, J.S. Assess injection site for pain, bruising, burning, or tingling. Have the patient perform several return demonstrations of medication preparation to validate learning. 18. Syringes that are prefilled by the manufacturer and activated (i.e., syringe cap removed or needle attached) but unused should be discarded at the end of the clinic day. Jun 9, 2012. Compare Mar to the patients wristband and use two patient identifiers to confirm patient. 3. Reactions may include anaphylaxis, anaphylactic shock, and neurologic deficits.10 Vaccine adverse event reporting is monitored by the Centers for Disease Control and Prevention. Position the ulnar side of the nondominant hand just below the site and pull the skin laterally. This method can be used if the overlying tissue can be displaced (Lynn, 2011). Safe Patient Handling, Positioning, and Transfers, Chapter 6. Oral typhoid capsules should be administered as directed by the manufacturer. Select needle length based on age, weight, and body mass. Aspiration in injections: Should we continue or abandon the practice? To help relax the muscle, the patient is asked to lie flat, supine, with the knee slightly flexed and foot externally rotated or to assume a sitting position. The smallpox/monkeypox vaccine (Jynneos) is primarily administered by the subcutaneous route but in some circumstances is administered by the intradermal route. Alternate sites and use appropriate needles for deep intramuscular injection. How can you make an injection less painful for a patient? Anatomically safe sites for intramuscular injections: A cross-sectional study on young adults and cadavers with a focus on the thigh. Remove the needle at the same angle at which it was inserted. Refer to agency policy regarding specifications for infants, children, adolescents, and immunizations. Intramuscular Injection: To avoid the danger of subcutaneous fat atrophy, it is important to ensure that deep intramuscular injection is given into the gluteal site. Remove the needle cap by pulling it straight off. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html, https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jan2023.pdf, https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=16265, https://www.cdc.gov/vaccines/pubs/pinkbook/safety.html, https://www.cdc.gov/vaccines/hcp/admin/admin-protocols.html, https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html. Use of a topical refrigerant (vapocoolant) spray immediately before vaccination can reduce the short-term pain associated with injections and can be as effective as lidocaine-prilocaine cream (51). Needle-shielding or needle-free devices that might satisfy the occupational safety regulations for administering injectable vaccines are available in the United States (12-13). If the subcutaneous and muscle tissue are bunched to minimize the chance of striking bone (19), a 1-inch needle or larger is required to ensure intramuscular administration. Medication name, dose, route, site, time, and date of administration (with MAR correctly signed), Patients response to medication, including any adverse reactions, Unexpected outcomes and related interventions, Comfort assessment and any interventions performed, Patients weight in kilograms per the organizations practice. The syringe has markings from 10 to 100. Instruct the patient and a family member to observe for effectiveness of the medication and adverse reactions and to report ineffectiveness of the medication and adverse reactions to the practitioner. After the needle pierces the skin, use the thumb and forefinger of the non-dominant hand to hold the syringe. WebDeltoid Muscle Administer vaccine using either a 1-mL or 3-mL syringe.5/8 in (16 mm) Use a 22- to 25-gauge needle. Nakajima, Y. and others. Vaccine recommendations and guidelines of the ACIP: Vaccine administration. For women who weigh 152-200 lbs (70-90 kg) and men who weigh 152-260 lbs (70-118 kg), a 1- to 1.5-inch needle is recommended. St. Louis: Elsevier. The capsules should not be opened or mixed with any other substance. Stay with the patient for several minutes and observe for any allergic reactions. Insert the needle into the V formed between your index and middle fingers. Hepatitis B administered by any route other than intramuscular, or in adults at any site other than the deltoid or anterolateral thigh, should not be counted as valid and should be repeated (9). 10. You can review and change the way we collect information below. Retrieved February 11, 2023, from https://www.cdc.gov/vaccines/hcp/admin/admin-protocols.html, Kroger, A., Bahta, L., Hunter, P. (2023). Clinical Procedures for Safer Patient Care by Glynda Rees Doyle and Jodie Anita McCutcheon is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted. For vaccinations in adults, this is usually a 2225-gauge needle which is 1 The anterolateral thigh can also be used (25). Use a 22- to 25-gauge needle. Aqueous solutions can be given with a 20 to 25 gauge needle; oily or viscous medication should be administered with 18 to 21 gauge needles. A 38mm (1 1/2 inch) length needle may be required for women over 90 kg (200 lbs) for a deltoid IM injection. WebYou can administer 1, 2, or 3 injections per deltoid, spaced at least 1" apart. Live, attenuated injectable vaccines (e.g., MMR, varicella, yellow fever) and certain non-live vaccines (e.g., meningococcal polysaccharide) are recommended by the manufacturers to be administered by subcutaneous injection. The dorsogluteal site should be avoided for intramuscular injections. Upon injection, if a patient complains of radiating pain or a burning or a tingling sensation, remove the needle and discard. Rodgers, D. Wilson (Eds. The needle gauge for intramuscular injection is 22-25 gauge. Hold this position until the medication is injected. There may be exceptions for specific medications. Can you give 1.5 ml in deltoid? For all intramuscular injections, the needle should be long enough to reach the muscle mass and prevent vaccine from seeping into subcutaneous tissue, but not so long as to involve underlying nerves, blood vessels, or bone (15,19-22). These cookies may also be used for advertising purposes by these third parties. The injection site is generally three finger widths below, in the middle of the muscle. The width of the muscle used extends from the mid-line of the thigh to the mid-line of the outer thigh. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them. Changing needles between drawing vaccine from a vial and injecting it into a recipient is not necessary unless the needle has been damaged or contaminated (11). This technique, pulling the skin laterally before injection, prevents medication leakage into subcutaneous tissue, seals medication in the muscle, and minimizes irritation.5 To use the Z-track method in an adult, the appropriate-size needle is attached to the syringe, and an IM site is selected. Covering prevents infection at the injection site. Select the appropriate site for injection based on the patients age, muscle tissue mass, and medication volume and viscosity. The ventrogluteal site involves the gluteus medius and minimus muscles and is a safe injection site for adults and children.5 This site provides the greatest thickness of gluteal muscle, is free of penetrating nerves and blood vessels, and has a narrower layer of fat. Explain the procedure and the medication, and give the patient time to ask questions. With your nondominant hand, pull the skin taut. Patient complains of localized pain, bleeding, or continued burning at injection site, indicating potential injury to nerve or vessels. Hold syringe between thumb and forefinger on dominant hand as if holding a dart. Assess for any factors that may contraindicate an IM injection. Children weighing less than 30 kgDose is based on body weight and must be determined by your doctor. If possible, a topical analgesic should be applied to the injection site with sufficient time allowed for peak action before the IM injection. Adults and children weighing 30 kilograms (kg) or more0.3 to 0.5 milligram (mg) injected under the skin or into the muscle of your thigh. Providers should address circumstances in which dose(s) of these vaccines have been administered subcutaneously on a case-by-case basis. The needle is inserted at a 90-degree angle perpendicular to the patients body, or at as close to a 90-degree angle as possible. Intramuscular (IM) injections deposit medications into the muscle fascia, which has a rich blood supply, allowing medications to be absorbed faster through muscle fibres than they are through the subcutaneous route (Malkin, 2008; Ogston-Tuck, 2014a; Perry et al., 2014). Use a quick, darting motion when inserting the needle. The maximum amount of medication for a single injection is generally 1 ml. Several of the newer devices have been approved by FDA for use with specific vaccines (33). Assemble medication, non-sterile gloves, alcohol swabs, syringes, needles, and sharps container. The vial must be accessed in the immediate patient area to reduce environmental contamination by vaccine virus. In addition, any factors that impair blood flow to the local tissue will affect the rate and extent of drug absorption. For older children and adults, the deltoid muscle can be used for more than one intramuscular injection. Sites for intramuscular injections include the ventrogluteal, vastus lateralis, and the deltoid site. Leaving the needle in place allows the medication to be displaced. Evidence does not support use of antipyretics before or at the time of vaccination; however, they can be used for the treatment of fever and local discomfort that might occur following vaccination. Locate correct site using landmarks, and clean area with alcohol or antiseptic swab. After needle pierces skin, continue pulling on skin with non-dominant hand, and at the same time grasp lower end of syringe barrel with fingers of non-dominant hand to stabilize it. 23. Bloodborne diseases (e.g., hepatitis B, hepatitis C, human immunodeficiency virus [HIV]) are occupational hazards for clinicians and other health-care providers. Movement of the needle once injected can cause additional discomfort for the patient. The needle is inserted at a 90-degree angle; this varies from the angle used for subcutaneous and intradermal injections (Figure 1).undefined#ref2">2,5 The appropriate needle length is determined by the patients weight and age and the amount of adipose tissue in the chosen injection site.2,7 The needle must be long enough to reach the muscle tissue, but not too long to present the risk of hitting underlying neurovascular structures or bone.2, IM injections should be administered so that the needle is perpendicular to the patients body or as close to a 90-degree angle as possible.2 IM injection sites should also be rotated to decrease the risk for hypertrophy. The needle goes into your skin. If the patient expresses concern regarding the accuracy of a medication, the medication should not be given. The barrel holds the medicine and has markings on it like a ruler. Use of longer needles has been associated with less redness or swelling than occurs with shorter needles because of injection into deeper muscle mass (16). The ventrogluteal site is a safe injection site for adults and children receiving irritating or viscous solutions and is the site of choice for administering IM injections to adults. Source: Adapted from Minnesota Department of Health and Immunize.org. Look up how many MLs can I inject intramuscular into my deltoid the first 3 results will give you 3 different answers, somewhere between there. 7. Place safety shield or needle guard on needle and discard syringe in appropriate sharps container. 26. Webinjection-site reactions occurred in 1% of treatment courses or 7% of patients treated with one 5-mL injection and in 4.6% of treatment courses or 27% of patients treated with two Retrieved February 11, 2023, from. The Z-track method can be used (except with infant vaccination where skin is compressed) provided that the overlying tissue can be displaced. Recognize and immediately treat respiratory distress and circulatory collapse, which are signs of a severe anaphylactic reaction. Obtain the medication, check the practitioners order, verify the expiration date, and inspect the medication for particulates, discoloration, or other loss of integrity. When in doubt about the appropriate handling of a vaccine, vaccination providers should contact that vaccines manufacturer. For adults, the deltoid muscle is recommended for routine intramuscular vaccinations (23) (Figure 3). This step confirms the correct identity of the patient. Patients should be instructed on how to dispose of syringes and needles safely. If no blood appears, inject the medication slowly. Locate correct site using landmarks, and clean area with alcohol or antiseptic swab. Monitor the patient for adverse and allergic reactions to the medication. Cookies used to make website functionality more relevant to you. Avoid muscles that are emaciated or atrophied; they will absorb medications poorly. The technique of IM injections has changed over the past years due to evidence-based research and changes in equipment available for the procedure. ), Centers for Disease Control and Prevention (CDC). 15. Compare MAR to patient wristband and use two patient identifiers to confirm patient. 16. 2. Additional information about implementation and enforcement of these regulations is available from OSHA. (2022). Inactivated influenza vaccine is immunogenic when administered in a lower-than-standard dose by the intradermal route to healthy adult volunteers. Small muscles absorb small volumes. 14. Collaboration with the practitioner helps determines which methods will help best reduce pain before injection. Subcutaneous injections may be administered into the upper-outer triceps area of an infant if necessary. Intramuscular (IM) injections have been associated with adverse effects and pain, and this route of medication injection should be used as a last resort. WebFaro particip en la Semana de la Innovacin 24 julio, 2019. The act directed OSHA to strengthen its existing bloodborne pathogen standards. Intramuscular injections are Centers for Disease Control and Prevention (CDC). Don non-sterile gloves and prepare the patient in the correct position. Rotavirus, adenovirus, cholera vaccine, and oral typhoid vaccines are the only vaccines administered orally in the United States. Let the patient know there may be mild burning at the injection site. Hand hygiene prevents the transmission of microorganisms. 20. Explain the risks related to the procedure, including hematoma formation, nerve injury, and allergic reaction to the medication. The revised standards became effective in 2001 (2). Jet injectors prevent needlestick injuries to health-care providers (2) and can overcome improper, unsterile reuse and other drawbacks of needles and syringes in developing countries (9, 38-39). Assess for factors such as muscle atrophy, reduced blood flow, skin condition, and circulatory shock. An IM injection may require a longer and larger-gauge needle to penetrate deep muscle tissue. Use the correct needle length based on the patients gender and weight. Take the medication to the patient at the right time according to the six rights of medication safety and perform hand hygiene. Thanks. Assess the patients knowledge regarding the medication to be received. Move dominant hand to end of plunger. WebLocate the deltoid injection site, as described above. 2. Complications with IM include muscle atrophy, injury to bone, cellulitis, sterile abscesses, pain, and nerve injury (Hunter, 2008; Ogston-Tuck, 2014a). Once medication is completely injected, remove the needle using a smooth, steady motion. The length will be shorter for infants and children; see agency guidelines. IM .. Haemophilus influenzae type b (Hib) 0.5 mL IM Hepatitis A (HepA) 18 yrs: 0.5 mL IM 19 yrs: 1.0 mL Hepatitis B 70% isopropyl swab for 30 Unused syringes that are prefilled by the manufacturer and activated (i.e., syringe cap removed or needle attached) should be discarded at the end of the clinic day. Rarely, an adverse reaction occurs after immunizations. More research is needed to investigate the practice of aspiration before administering an IM injection with medications other than vaccines.8 The recommended route and site for each vaccine is included in the manufacturers instructions for use.2. Only give injections that are less than 0.5 mL into the deltoid. The site provides the greatest thickness of gluteal muscles, is free from penetrating nerves and blood vessels, and has a thin layer of fat. Perform hand hygiene before patient contact. Upon injection, if a patient complains of radiating pain, burning, or a tingling sensation, remove the needle and discard. For intramuscular injections (use a 22- to 25-gauge needle for all ages): For subcutaneous injections (use a 23- to 25-gauge needle for all ages): Subcutaneous injections are administered at a 45-degree angle, usually into the thigh for infants younger than age 12 months and in the upper-outer triceps area of people age 12 months and older. Engineering controls means controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate orremove the bloodborne pathogens hazard from the workplace). (b) Note that prefilled syringes of High-Dose Fluzone have a volume of 0.7 cc and the recommended volume of administration is 0.7 ccs. Use your thumb and index finger to stretch the skin around the injection site. The IM site is used for medications that require a quick absorption rate but also a reasonably prolonged action (Rodgers & King, 2000). The site involves the gluteus medius and minimus muscle and is the safest injection site for adults and children. WebFor a well-developed adult, no more than 3 ml of medication should be administered in a single IM injection because the muscle tissue does not absorb it well in larger volumes. Cover injection site with sterile gauze, using gentle pressure, and apply Band-Aid as required. Place safety shield on needle and discard syringe in appropriate sharps container. Want to create or adapt OER like this? Assess the patient for specific contraindications to receiving IM injections and advise the practitioner accordingly.