I Hit A Bone!!

VickyRN, MSN, DNP, RN · Nov 23, 2006

As a student. It seems to me that the "correct" way to give an injection, is to use aseptic technique, locate one of the proper sites, use one of the proper needle gauges and lengths for the individual patient, and to end with the injection going into the layer that it is supposed to. Z-tracking, air locking, darting or semi-darting or going in at a 90 or 87.5 degree angle etc.... all of that is up to the nurse as long as the aforementioned requirements for the injection have been completed by one of the MANY correct ways.

I agree with you. We also need to take into account the weight and muscular build of a patient. For instance, with a female client under 125 lbs, you should not use the deltoid to give a Depo-Provera injection. You must use the dorso-gluteal or ventrogluteal site instead.

missninaRN · Nov 24, 2006

We did a flu shot clinic this week and were given only one size of needles and the syringes were the kind that retract after they are injected.

I hit bone on two different people. I told my instructor about it but she didn't say anything about checking the bevel for a missing tip. After reading this thread I'm now worrying that I left a needle tip in a patient.

How much force does it take to break the tip off a needle? Would a patient eventually feel it in their arm? I hate to think that someone might get an MRI some day and not know that there is a piece of metal in them.

jill48, ASN, RN · Nov 24, 2006

When did I say slowly??? I said "gently"
I am not trying to offend with this question, I'm really not, but since Brian started tweaking things the "years experience" is missing. Have you been nursing long enough to know that many things we do are not textbook? It doesn't make it wrong, not at all. There are many things that, in the real world, are not done the way the textbooks taught in school. I remember my instructors telling us "When you graduate you'll learn the real world way of doing things but this is how you need to do it to graduate and pass your boards." And it's not just my school that said that, there are two schools of nursing in this county plus two in the next county and I've dealt with students from all three during their clinicals. They are told the same thing by their instructors.
Starting IV's......I remember my text showing one way and one way only to dress a fresh IV site. Do I it that way? No. Do other nurses do it that way? Some do, most don't. Does that mean the ones of us who don't are wrong? Of course not!!!!
You are entitled to your opinion, not faulting you for that at all, but for you to say that the textbook way is the only way, and in the manner that you have ---- I picture you glaring at me with your hands on your hips ---- is the fastest way to offend.

I don't take offense to your questions. I would question that too. To answer your question, I have 11 years experience in both med/surg and geriatrics. I'm also in school now getting my RN and BSN. And about confusing "slowly" for "gently", I can't think of a difference between those two words when it comes to inserting a needle. Maybe I am wrong. I don't think textbook way is the only way. But in some procedures, I do believe that textbook way is still the most efficient, least painful, or more appropriate way - but that is just my opinion - I'm not saying your way is wrong or any less effective. Please do not be offended, that was not my intention. In all honesty, there are ony a few things that we still do by textbook, but it also comes down to the fact that I may have all the appropriate tools and the time that others do not have. But I'm also know to be a type A personality; I'm quite a by the book type of person, which is probably why I enjoy the paperwork aspect of the job that alot of nurses hate. :smilecoffeecup:

augigi, CNS · Nov 24, 2006

Not to mention, you can also give pneumococcal vaccine SC instead of IM if they don't have enough muscle.

TazziRN, RN · Nov 24, 2006

Olive branch accepted.

There is a difference between slowly and gently. Slowly means just that, while gently is with less force.

bagwash · Nov 24, 2006

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).

DaFreak71 · Nov 24, 2006

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.

jill48, ASN, RN · Nov 24, 2006

Olive branch accepted.
There is a difference between slowly and gently. Slowly means just that, while gently is with less force.

:kiss :icon_hug:

Gennaver, MSN · Nov 24, 2006

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.

TrudyRN · Nov 24, 2006

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?

zenman · Nov 25, 2006

>
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!

DaFreak71 · Nov 25, 2006

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!

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!