I Hit A Bone!! - page 2
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
Nov 22, '06Joined: Jul '06; Posts: 22I did the same thing in a similar situation, pneumococcal vaccine, thin, elderly lady, IM needle, 1 inch, 23 guage. I felt a sickening "thud", like chewing aluminum foil, and the poor woman jumped. She said "That one hurt more than the other one", I had just given her a flu vaccine in her other arm. I just said "I'm sorry", and she said that was okay.
Once you give a lot of IM injections, you can kind of estimate where the patient's muscle may be, and adjust appropriately. But, it's pretty hard to only go in so far when you have to inject the needle in like a dart so it doesn't hurt as much.
I worked in a flu clinic as an LPN, and wow, I learned a lot that day.
Nov 22, '06Occupation: med/surg/ortho RN Joined: Oct '01; Posts: 2,617; Likes: 161When i was in school i observed an RN giving a IM injecction to a frail elderly man. She gave the shot in the thigh and hit the bone. The needle came out BENT. Any instructor would have been proud though, i kept my poker face on, UNTIL i got to post conference!!!
Nov 22, '06Specialty: 4 year(s) of experience in Occupational Medicine, Orthopedics ; From: US ; Joined: Nov '06; Posts: 152; Likes: 19I got to administer 21 flu shots in one day at an assisted living facility. There were a couple of times when I thought for sure it was next to impossible to inject into the miniscule amount of muscle available. Sometimes you just have to give yourself a break. You won't do everything perfect...
What would be a shame is if you hit the bone, then gave it no other thought and went on your merry way. But instead you CARE. I say; Give yourself a break.
Nov 22, '06Joined: Mar '06; Posts: 223; Likes: 16What do you do if you pull the needle out and realise the tip broke off in the patient?
Nov 22, '06Occupation: Nurse Educator Specialty: 16 year(s) of experience in Gerontological, cardiac, med-surg, peds ; From: US ; Joined: Mar '01; Posts: 12,037; Likes: 6,470Quote from tigress_8207Notify the physician ASAP.What do you do if you pull the needle out and realise the tip broke off in the patient?
Nov 22, '06Joined: Feb '06; Posts: 127; Likes: 19When I was in school I had a few teachers tell us they hit bone when they were first learning but they also followed this with a lecture on choosing the right size needle and site. Since the pt was not harmed just use this as a learning experience and I bet next time you will do better. Sounds like your instructor needs a refresher in IM injections.
Nov 22, '06Occupation: PMHNP From: US ; Joined: Dec '03; Posts: 2,918; Likes: 1,548Quote from jill48What is your rationale for thinking that the instructor was wrong?I bet you freaked out!!! I know I would have. You should have got a shorter needle, and pinching the skin and pulling it up helps to because it increases the distance. But in my 11 years as a nurse I have never heard of inserting a needle halfway. Your instructor is wrong. You poor thing. What did the patient do? Did you know right away what had happened?
Nov 22, '06From: US ; Joined: Jul '04; Posts: 1,071; Likes: 1,013here's an abstract i just ran across, will have to get the article:
jama. 1997 jun 4;277(21):1709-11. [color=#336699]links
determination of deltoid fat pad thickness. implications for needle length in adult immunization.
objective: to measure deltoid fat pad thickness and determine the optimal needle length for deltoid intramuscular immunization in healthy adults. design, setting, and participants: prospective study of 220 healthy health care workers (126 women, 94 men) at the mayo medical center, rochester, minn. main outcome measures: deltoid fat pad thickness determined by high-resolution ultrasound scanning, weight, height, and mid-deltoid arm circumference. results: we found a highly significant difference between women and men in deltoid fat pad thickness, with women having a thicker deltoid fat pad (11.7 vs 8.3 mm; p<.001). women had a greater deltoid skin-fold thickness than men (34.7 vs 17.2 mm, p<.001) and an equal body mass index. according to the ultrasound findings, a standard 16-mm (5/8-in) needle would not have reached 5 mm into muscle in 17% (16/94) of men and 48.4% (61/126) of women in this study. conclusions: among healthy adults of the age range we studied, the following needle lengths appear to be appropriate for true deltoid intramuscular immunization: for men across the weight ranges we studied (59-118 kg), use of a 25-mm (1-in) needle would result in at least 5 mm of muscle penetration in all subjects. for women who weighed less than 60 kg, a 16-mm (5/8-in) needle would be sufficient to achieve muscle penetration of 5 mm. for women between 60 and 90 kg, a 25-mm (1-in) needle would be sufficient, and women greater than 90 kg would require a 38-mm (1.5-in) needle to ensure intramuscular administration.
pmid: 9169899 [pubmed - indexed for medline]
Nov 22, '06Occupation: "Birth Center" Staff Nurse Specialty: Ante-Intra-Postpartum, Post Gyne ; From: US ; Joined: Jul '05; Posts: 3,067; Likes: 2,035I have been doing injections for five years and I have never hit a bone, but I hear that when it happens there is no questioning what has happened. I am surprised that your instructor did not have you place it some where else. The deltoid is the smallest muscle for injecting. Her leg or glut would have been a much better place.
Life goes on. I remember I was giving and injection in the thigh once and right after the woman got a big red area around the injection sight. The FNP told me to give her an inflammatory, and explained that when I pulled out I did not rub out her muscle quick enough and some of the medication came to the surface of the skin and caused some irritation. Now when giving an IM I have my 4 by 4 right there and I rub the second the needle comes out (unless it is a medication you are not suppose to rub of course) you learn by doing, even if you do not do it perfectly the first time. Hitting a bone is not the end of the world.
Nov 22, '06Joined: Apr '06; Posts: 20; Likes: 1The instructor should have asked me what other site would have been more suitable, with more muscle, for that particular client. Otherwise, she should have instructed me to get a shorter needle. That could have been prevented in the correct manner, not by sticking the needle slowly in until it is in 50% of the way. Also, she didn't look at the bevel of the needle, or instruct me to do so. There is nothing in any of my textbooks about hitting bone.
Quote from zenmanWhat is your rationale for thinking that the instructor was wrong?
Nov 22, '06Occupation: Happily in Nursing Education! Specialty: 13 year(s) of experience in Education, Acute, Med/Surg, Tele, etc ; From: US ; Joined: Oct '04; Posts: 2,757; Likes: 415Man, even when I had instructors, or even now with other RNs...I chose my needle length and guage by MY comfort level. I worked with geri's for four years...some have little to no fat in their arms (I called them the feather weights..one breese and whoosh they float away) and I used small needles.
As far as what to use..there is no universal really...you will learn to eyeball it! If you feel you hit a bone, then when you withdraw the needle, look at the end and see if you 1. have the entire needle and it didn't break. 2. check the lumen to see if you have any bone matter in it (that would have occulded your injection). 3. watch that bleeding...if you did puncture the bone it could bleed a little longer needing a bit more direct pressure.
Don't get upset at yourself though, it happens! I have done it at least once (I called it the ricochet...bounced off the bone) and nothing bad happened. Just use this as a good learning experience in helping you choose a good sized needle (especially with elderly..they can be tricky!!!) and fine tune your dart .
BTW..with elderly there are a few things to consider...skin tone and condition (some are like jello, some rip to the touch, some are tough), pain levels and if they are low especially ( I have had elderly jump higher than any kid getting a shot and almost broke a needle once on one!). Cognitive level (one, consent to have shot is important, and two..they could be shocked and jump or hit ya! Trust me...one got me once for a insulin shot..talk about a small needle that could break...it bent but didn't break). And really feel for that muscle and use that mental guage...those muscles can be quite stringy if not used often..or feel like butter like you described! I pick a nice beefy one, and I basically clamp on to it and put in the injection.
For elderly that may not be congnitive enough to understand or remember 2 second after what you are doing...bring another person in to help calm and hold the pt if needed. That is what saved me both times I had a potential needle break I described above!
Anywhoooooooo...don't be scared now...just remember. You did fine..just get to fine tune things a bit
Nov 22, '06Joined: Apr '06; Posts: 20; Likes: 1Thanks for all of the great tips! I will remember them all.
Nov 22, '06Occupation: full-time student Specialty: Looking for a career in NICU ; Joined: Oct '06; Posts: 1,020; Likes: 82Quote from Hellllllo NurseOk, I have to ask..what happens if it breaks off?I've hit a bone a couple of times. When this happens, look at the bevel after you pull the needle out to make sure the bevel tip did not break off in the pt.