IM Injections

[mcneillmama3, BSN, RN]

I am a Registered Nurse and have been practicing nursing for the past 12 years in different arenas: coronary care units, long term care, and now long term care insurance case management. I work flu clinics on the side in October and November. This is where I need some advice.

When I was in nursing school and throughout my career, I was always taught to aspirate for blood return when giving an IM injection(except for Z track injections) Is this still true? When I went through this year's flu shot orientation, I was told that this was not done anymore and that aspirating could cause tissue trauma.

I also have a question regarding BD's Integra Retractable needles. On the BD training website it shows and states that it is perfectly safe and acceptable to retract the needle as soon as you have administered the injection and while the needle is still in the patient's arm. This prevents the nurse from an accidental needle stick while removing the needle from the patient's deltoid. I was told that this was dangerous to the patient.

My question is how is activating the retractable needle while it is in the patient's arm any different from a nurse removing the needle herself? Either way the needle is withdrawn from the patient's muscle-either by the mechanical safety device or by a nurse removing the needle without activating the safety device. I thought the entire premise was to ensure that a nurse doesn't suffer an accidental needle stick which is possible if you were to remove the needle from the client and then press the plunger to retract the needle. This makes no sense at all.

If there are any seasoned nurses out there who could help me with this, I would greatly appreciate it.

[K+MgSO4, BSN]

just curious I Z track all if my IMI's? What ones are you not Z tracking? and I always aspitate :)

Cant help you with the other part sorry I have never used the system you discussed.

[Lacie, BSN, RN]

According to the CDC guidlelines you dont have to aspirate on Immunizations ONLY in relation to IM (except in the meds requiring z-track usually related to iron injections). Data shows no reason to require this on IMMUNIZATIONS only. Reason being it's very unlikely to hit a major vessel particularly in the Deltoid area if following the proper landmarks. Also in the end if you do see a little bit of blood (usually capillary) then an expensive med is being discarded and in addition the patient has to undergo a second stick. Pretty much this is the basis for thier decision. I dont aspirate on deltoid injections for immunizations but I do for all other IM meds.

Your question about the BD syringes - jmo it may state you can do this but I wouldnt take the chance an something mechanical going wrong. I would remove from pt then retract. Also be careful when adding air before drawing up your med as it's easy to cause the needle to retract. Hope this helps :)

[morte, LPN, LVN]

i think the rationale about not aspirating is that it matters not .....in this case.....the retractable needles, i would do as you say, push the plunger and allow it to retract the needle....what is the rationale that it causes damage?

[justiceforjoy]

We were taught to always aspirate IM injections. Always. And to always leave the needle in for 10 seconds after the injection has been given. We only z-track on viscus medications and iron preps (or any other meds that could potentially stain the skin).

With retractable needles, we are encouraged to keep the needle from retracting until we remove the needle manually, then allow it to retract as soon as it exits the skin. We are taught this because the force has been known to cause needless pain in some patients.

[morte, LPN, LVN]

We were taught to always aspirate IM injections. Always. And to always leave the needle in for 10 seconds after the injection has been given. We only z-track on viscus medications and iron preps (or any other meds that could potentially stain the skin).

With retractable needles, we are encouraged to keep the needle from retracting until we remove the needle manually, then allow it to retract as soon as it exits the skin. We are taught this because the force has been known to cause needless pain in some patients.

1) what is the rationale for this

2) where does this info come from, if you are giving an injection and follow thru on the plunger it is going to retract in the same plane it went in,,,,now if you are standing there counting to 10, in all likelyhood it will not, and i could see this causing pain

[mcneillmama3, BSN, RN]

I worked with a very good ER nurse once, who said that he always Z tracked all of his injections using a very long spinal needle and always using the gluteus muscle. He said that this caused the least amount of pain to the patient and less of a risk of medication seeping out of the muscle in to the tissues.

Normally I don't Z track medications unless they are viscous(such as Prolixin which is delivered in sesame seed oil, very thick) or leakage of the medication would cause tissue damage, such as iron shots. If I am not sure whether a medication should be Z tracked or not, I consult my drug book which tells you under nursing implications or administration directions.

Most of your IM injections don't need to be Z tracked, such as flu vaccines, demerol, or Antibiotics.

I wasn't aware that an air bubble could cause the retractable needles to malfunction, because I normally would draw up a .2-.3cc air lock for patients with very large deltoid muscles as the medication tends to squirt back out of the needle track upon removal of the needle. Now I am going to wonder if a customer really got a full dose of the flu vaccine if I see medication leak out of the needle site.

Thanks for the immediate feed back. This is a great site.

[Lacie, BSN, RN]

http://www.immunize.org/genr.d/issue297.htm#n1

the centers for disease control and prevention (cdc) has issued an online summary of the seven major changes made by the advisory committee on immunization practices (acip) in the new "general recommendations on immunization,"

"previous versions of the general recommendations have recommended aspiration (i.e., gently pulling back on the plunger to check for blood before injection) prior to injection, particularly before intramuscular injection. no data exist to document the necessity of this procedure. the 2002 cdc general recommendations on immunization does not recommend aspiration before injection."

http://uqconnect.net/signfiles/archives/posts00462-464-aspiration.txt

http://www.cdc.gov/vaccines/ed/epivac07/epivac07-faqs.htm#admin

hope this helps :)

[morte, LPN, LVN]

I worked with a very good ER nurse once, who said that he always Z tracked all of his injections using a very long spinal needle and always using the gluteus muscle. He said that this caused the least amount of pain to the patient and less of a risk of medication seeping out of the muscle in to the tissues.

Normally I don't Z track medications unless they are viscous(such as Prolixin which is delivered in sesame seed oil, very thick) or leakage of the medication would cause tissue damage, such as iron shots. If I am not sure whether a medication should be Z tracked or not, I consult my drug book which tells you under nursing implications or administration directions.

Most of your IM injections don't need to be Z tracked, such as flu vaccines, demerol, or Antibiotics.

I wasn't aware that an air bubble could cause the retractable needles to malfunction, because I normally would draw up a .2-.3cc air lock for patients with very large deltoid muscles as the medication tends to squirt back out of the needle track upon removal of the needle. Now I am going to wonder if a customer really got a full dose of the flu vaccine if I see medication leak out of the needle site.

Thanks for the immediate feed back. This is a great site.

what is the reasoning for that?

[PAERRN20]

Why would you leave the needle in for 10 seconds after injecting? I've never heard of this and that seems awfully long.

[justiceforjoy]

I think the rational was since the muscle is more dense, we want to ensure that the medication is staying put before giving the medication an exit route through the skin by taking the needle out. Same reason why we apply pressure to the site - prevent medication back flow.

For the retraction of the needle, it's what we've witnessed thus far. The same pts complain about the needle being removed when we allow it to retract while still in the skin, but they don't complain when we remove it manually and then allow it to retract. Maybe it's just for the dalteparin injections we've been giving (as students).

On that note, do you experienced nurses ever landmark your IMs? Or do you just assume where the needle goes based on experience?

[cookienay]

To Justice- to answer your questions regarding landmarking IMs...I have been practicing for 17 years and I still landmark EVERY IM injection. Good practice, takes 3 seconds. The reason is (especially with obese patients) is that fat distribution varies among patients and this way you can be more assured you are getting to the right anatomical location. However, landmarking a 500 pound patient is not without its difficulties. :)