I Hit A Bone!! - page 6

Oh, wow... I hit a bone! I was injecting an older, thin lady with 0.5mL pneumococcal vaccine IM in deltoid. I used a #23, 1 inch. needle. After seeing the client, my instructor told me to insert 1/2... Read More

  1. by   bagwash
    It's interesting to read this thread. I was always taught to dart the needle in (and to bunch up the muscle first) and I've always found patients tend to consider my IMIs less painful than other injections they've had. But when I started working in an Eating Disorders ward, my manager told me that good injection technique (on any kind of pt) meant you do not bunch up the muscle but pull it taut between thumb and forefinger of the other hand, almost flattening the muscle and then push the needle in. I watched her do this on one of our pts and it looked painful to me. It's hard giving IMIs to anorexices because they usually have a complex about anyone seeing their buttocks (scrawny as they are) so prefer to have IMIs in the deltoid--where there is practically no muscle (let alone any fat!) at all. We're talking about girls/women who weigh, at best, less than 50 kg, often less than 40kg and sometimes just on 30 kg.

    It's awful to give IMIs knowing they are going to be painful. I always go for a smaller needle but then feel anxious that perhaps it hasn't gone properly into what muscle they do have. One of the older RNs (thankfully no longer on the ED ward!) told me confidently that it was OK to give IMIs in the bicep. I queried this and pointed out where the bicep was, just in case she had meant the deltoid, but no, she meant the bicep. This woman used to be a nurse educator! She assured me "you can give an IMI in any muscle so long as you don't hit a nerve or blood vessel". I guess her sense of anatomy is pretty lousy as the radial nerve runs right over the biceps, apart from other reasons not to give it there, like it being too small.

    As for breaking needles off, we had a pt in the general psych area who'd become dependant on prescribed opiate injections (we call it pethedine, I think you guys in the US call it demerol) for "spasms" which her doctor was silly enough to believe required such an extreme remedy. She had self-injected large amounts for years and at one point, supposedly broken off a large part of a needle in her arm. As a result she'd developed a truly horrible infection, mostly caused by a common bug carried by cats and dogs and also present in the soil (can't remember which one). It had wreaked appalling damage to her lower arms (somehow spreading to the other one), to the point where she looked as if she'd been attacked by a wild animal. It smelt terrible as well. Perhaps the self-neglect associated with long term drug dependance had a lot to do with it, but she ended up being assessed as needing partial amputation.

    Her doctor never would face up to the fact that he'd helped her become a chronic drug addict, and he continued to prescribe the meds in large amounts while she was in our hospital. She had only to ring him complaining of the spasms for him to call the RN and insist she be given extra prn IMI opiates. These spasms were supposedly a psychosomatic, PTSD-associated result of self-defensive flailing of the arms following satanic abuse, believe it or not. Unfortunately her doctor did believe it, with pretty tragic results. Disclaimer: I'm not suggesting the woman lied about being abused, by the way --though I have grave doubts about the whole "satanic abuse epidemic" of some years back--only that the spasm story was way too out there to be taken literally).
    Last edit by bagwash on Nov 24, '06
  2. by   DaFreak71
    I recall reading a study about a year ago that actually examined if IM medication was reaching the muscle in people of varying sizes. The study concluded that in people who had excess fat in the gluteal regions, they were not receiving the proper amount of medication since most of it ended up in the fat layer. This study made it clear in my mind that you must select a needle size that is appropriate for your patient. If they have more fat...bigger needle; less fat...smaller needle. The goal of IM is to get it into the muscle.

    With regard to the question of whether experience or textbook technique is more desirable, I would have to come down on the side of the textbook or related studies. Nursing is suppose to be evidence based, meaning that we do things in a particular way in order to achieve the intended result. I see many flaws in the "halfway" line of thought. First of all, how do you know the needle is indeed going in only halfway? My guess is that you are merely estimating it. Furthermore, how do you arrive at the conclusion that "halfway" is in the muscle? This estimation technique does not offer any conclusive evidence that the medication being given is reaching its target area. Based on evidence, the correct manner in which to give an IM (and this refers to the textbook manner, since it is evidence based) is to select a needle of appropriate size and sink it in with a darting motion of the wrist. Stopping halfway might make the RN feel as if they have more control of the needle, but without knowing if you've actually entered the muscle or stopped short of it, you are taking a risk of your patient not getting the needed medication.

    One could argue that since we can rarely ever "truly" know if the medication has reached its target area, that either technique is acceptable. I disagree. We have to have a basis for our actions, that basis is knowledge and the knowledge comes from those who have studied and researched the best way to deliver an IM.

    It would be very interesting to be able to study the various techniques of giving an IM. I would be very interested to know if the "halfway" method is delivering the medication. The main problem I see with the "halfway" method is that it is inexact. What might look to be halfway during one IM might be more than halfway or less than halfway during the next IM. So this pretty much reduces giving an injection to a subjective method.

    If you select an appropriate size of needle, why would you ever need to estimate the halfway point for an IM? Also, if you are selecting the appropriate size of needle and combining that with choosing an appropriate injection site, I suspect that hitting bone would not very common at all.

    With regard to my credentials, I am a nursing student.
    Last edit by DaFreak71 on Nov 24, '06 : Reason: Spelling; clarification
  3. by   jill48
    Quote from TazziRN
    Olive branch accepted.

    There is a difference between slowly and gently. Slowly means just that, while gently is with less force.
    :kiss :icon_hug:
  4. by   Gennaver
    Quote from breakin_moon
    Oh, wow... I hit a bone! I was injecting an older, thin lady with 0.5mL pneumococcal vaccine IM in deltoid. I used a #23, 1 inch. needle. ...
    Any comments are appreciated.

    Hi there,

    I know, it is horrible...I did it to my own classmate!! She is such a wonderful young lady I hate that it happened.

    It taught me to not just to do something if the isntructor hasn't fully recognized my voiced concern.

    I asked the instructor about exact placement and she knodded to go "right there". Well, that was wrong! It was too high on this petite classmate of mine who is both petite and slim and zowie! I hurt her.

    Sigh, you can gaurantee I will forever remember that first IM injection.
  5. by   TrudyRN
    We have all hit bones a time or two. It is unnerving but no harm is done, apparently. Your instructor was wrong, I think, to tell a novice what she did. She should have told you to get a shorter needle, although I don't know if shorter needles exist - or if they are standard equipment, readily accessible, in an adult clinic. Does anyone know?
  6. by   zenman
    Quote from lostdruid
    <<Snip>>

    We have to have a basis for our actions, that basis is knowledge and the knowledge comes from those who have studied and researched the best way to deliver an IM.
    This (debating research and methodologies) can be another topic entirely and one I love debating with physicians. As an example...and too make it short... do we look at the research regarding lab numbers as correct or do we look at the patient? I'll quote a physician whose name I won't use, "Treat the patient, not the lab. Look at the numbers you're fed. Don't believe numbers. Are we treating numbers or are we treating her? My word of wisdom today, as everyday, is **** the numbers." This is sometimes the way of thinking of experienced physicians and nurses.

    Yes, you value the book learning but also experience. You may have "information" but do you have "knowledge?" Information is knowing H20; knowledge is being able to make it rain, lol:chuckle

    It would be very interesting to be able to study the various techniques of giving an IM. I would be very interested to know if the "halfway" method is delivering the medication. The main problem I see with the "halfway" method is that it is inexact. What might look to be halfway during one IM might be more than halfway or less than halfway during the next IM. So this pretty much reduces giving an injection to a subjective method.

    If you select an appropriate size of needle, why would you ever need to estimate the halfway point for an IM? Also, if you are selecting the appropriate size of needle and combining that with choosing an appropriate injection site, I suspect that hitting bone would not very common at all.

    With regard to my credentials, I am a nursing student.
    Yes, and you're going to be a great nurse! You make a lot of good points and you are correct. However, taking the last unit I worked on..an acute med/surg unit...if I was rushed (a given) and walked all the way to the end of the unit with a needle too long for my patient, I would not waste time going back but would insert it halfway. Ideally, I'd hopefully be more awake and select the correct size needle. But a few 12 hr pm shifts will mess you up!
    Last edit by zenman on Nov 25, '06
  7. by   DaFreak71
    Hi Zenman!
    All I have is the basics of the science part of nursing and none of the art. That is where experienced nurses come in, they combine the science (the textbook stuff) and implement it (or alter it) so that it meets the needs of that particular patient. That truly is an art! And thanks for the compliment!





    Quote from zenman
    This (debating research and methodologies) can be another topic entirely and one I love debating with physicians. As an example...and too make it short... do we look at the research regarding lab numbers as correct or do we look at the patient? I'll quote a physician whose name I won't use, "Treat the patient, not the lab. Look at the numbers you're fed. Don't believe numbers. Are we treating numbers or are we treating her? My word of wisdom today, as everyday, is **** the numbers." This is sometimes the way of thinking of experienced physicians and nurses.

    Yes, you value the book learning but also experience. You may have "information" but do you have "knowledge?" Information is knowing H20; knowledge is being able to make it rain, lol:chuckle



    Yes, and you're going to be a great nurse! You make a lot of good points and you are correct. However, taking the last unit I worked on..an acute med/surg unit...if I was rushed (a given) and walked all the way to the end of the unit with a needle too long for my patient, I would not waste time going back but would insert it halfway. Ideally, I'd hopefully be more awake and select the correct size needle. But a few 12 hr pm shifts will mess you up!
    Last edit by VickyRN on Nov 25, '06 : Reason: editing of quoted post
  8. by   ns lpn
    Quote from augigi
    Most textbooks are out of date as soon as they are printed, if not before.

    A look at the current literature recommends:

    "A 1- to 1.5-inch needle should be used to give influenza vaccine to adults." (CDC guidelines)

    "Insert needle at an 80-90° angle into densest portion of deltoid muscle--
    above the level of armpit and below the acromion." (CDC website, attached)

    Thus I'd say you should choose a site with adequate muscle in which to inject it. I've also attached an interesting article about deltoid thickness in the elderly.

    Thanks for posting, the attaching article was helpfull.
  9. by   leslie :-D
    wow, i've learned a couple things by reading this thread.
    i never knew that one was supposed to bunch up muscle pre-injection.
    i always smooth it out and keep the injection site taut.
    the last thing i want to do is inject into sub q tissue when it's supposed to be muscle.
    and no, i would never standardly use a 23g on all pts to give an im.
    the emaciated, little ole' ladies get a 25g given at an angle to their deltoid.
    if i only had access to one size needle, then yes, i would guesstimate those pts with little/no muscle mass and go in halfway.

    as to technique, i bow to those with the yrs of experience vs. a textbook.
    i personally rest the heel of my dominant hand on the pt., and dart w/the wrist....i have more control this way and my pts have never complained.
    as tazzi stated, i ensure that i've penetrated the dermis and advance gently but quickly.

    as a final point, often technique has nothing to do with it.
    some of these meds are irritating to the tissue, no matter how you inject it, and it's going to hurt.

    from reading this thread, i was (inadvertently) reminded of "why nurses eat their young"....
    i recall the days of being a nsg student and/or brand, new nurse and challenging my mentors w/yrs of experience..."but the book said to do it this way!!!" and for me, there was no other way.
    well, i've come a long way and have collected a wealth of tricks that the books don't teach.
    as long as one has a sound knowledge base, there's nothing wrong with being creative in order to save time, spare pain, reduce invasiveness.

    with peace,

    leslie
  10. by   PANurseRN1
    Quote from TazziRN
    Another alternative would be to inject at an angle, rather than straight in. And don't freak out, I've hit bone many a time.
    I only ever hit bone once and that was many years ago when I was a student. Pt. was a LOL with CA. That feeling of hitting bone made me so sick I almost threw up. Thank goodness it never happened again.
  11. by   PANurseRN1
    Quote from jill48
    I'm sorry but that is just insane. Why would you dart it in til just past the dermis and then push it in gently? And just exactly how do you know when you have passed the dermal layer? The proper way to give an injection is to dart it in, there is no reason whatsoever to slow it down halfway. If there is any chance you can hit bone, then your needle is just too long. I don't understand why you would do this. My injections are so fast that my patients don't feel them half the time; after I do it, they say, "Ok, when are you going to do it?" I just did.
    Uhm, a little respect, please. I was taught to insert 1/2 way, too. Way back in the dark ages when I was a student, we didn't have the variety of needles to choose from like we do now. So it would have been totally appropriate to learn to inject 1/2 way, depending on when you went to school. (I didn't slow the injection though; I was just taught how to dart the needle in 1/2 way.)

    In any case, no need to scoff. There is usually more than one right way to do things.
  12. by   PANurseRN1
    Quote from TazziRN
    You missed the part where I said "from just above the skin". I don't dart it from across the room. I slow it down halfway because I've hit bone quite a few times by throwing darts. In darting the way you describe it you must have a certain needle length because you will drive it in almost to the hub, if not all the way. My way you don't have to. I have never hit bone using this method and my pts tell me they barely feel the needle. I also am not the only one who does this, quite a few nurses I know do, so my method can't be that insane. And who are you to say the method is not proper?
    Exactly.

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