I Hit A Bone!!

[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. After seeing the client, my instructor told me to insert 1/2 of the needle. It went in her skin like butter - all the way. I heard a pop sound. My instructor stated "you didn't go in half the way." I have administered numerous IM injections, mostly in the deltoid and ventrogluteal sites without any complications. I thought I was doing a great job - until this! I'm thinking I should have gotten a shorter needle, or chosen a different site. I don't know if I can just stick the needle in 50% of the way.

Any comments are appreciated.

[ns lpn]

Most textbooks are out of date as soon as they are printed, if not before.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.

[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

[PANurseRN1]

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.

[PANurseRN1]

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.

[PANurseRN1]

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.