IM injections

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Okay, I feel really old right now. I am an LPN working on my BSN and just finished working a free flu clinic in Boston with some of my fellow students. When I went to school the first time around we were taught to draw up the medication to be injected, tap out the bubbles get the correct dose and then add up a 0.1 ml air bubble. The theory was that when the syringe was inverted and the medication was injected, the bubble would float to the top, and would be injected last. This worked as a stopper to keep any of the injected fluid from leaking back out. Apparently this is not done anymore, and when I googled "method intramuscular injection" one of the sites popped up and said that leaving an air bubble was an old method that was used during the time of re-usable syringes and should be discontinued because it would alter the amount of medication administered. Anyone as "old" as me?

Y'all have made some good points. As a student, you need to go with what your instructor wants or if there is an institution policy, which I doubt, go with that, but in reality it probably doesn't make a lot of difference.

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Hi. I was just wondering if anyone had been involved in implementing best practice guidelines for IM injections?

I am specifically looking at IM injections in children.

If you are happy to share what your workplace does, that would be wonderful. I will acknowledge anything that anyone shares as I am currently writing best prac guidelines for this.

Thanks

Jenny

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We were taught to draw up the med and measure without bubbles, of course. Then pull back the plunger to allow 0.2ml of air for a regular injection, and 0.5ml for a Z track injection.

When giving the Z track, leave the needle in the skin for 10 seconds to allow it to absorb and not track back out the needle hole as much (to prevent loss of medication and irritation to the tissue).

The extra air bubble was to push all of the medication out of the syringe, and to push it into the tissue further.

Also taught to use a 1 1/2 inch needle for regular IM injections, and a 2 inch needle for the Z track (deep IM) injection. (I rarely use a 2 inch needle, however, and I never leave the needle in the skin for more than a couple of seconds. We were taught to use the 2 inch needle with the Z track method when administering Vistaril and Iron (was it Imferon?) injections. Our instructor told us the Vistaril was irritating, and the Imferon could leave a permanent stain on the skin if too short of a needle.

I was also taught to aspirate insulin, and now we are taught not to do that. Methods change over time, but slowly it seems.

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Specializes in Med/Surg, Ortho.

That is the way i learned,, only we use .2cc bubble. No matter,, but fab4fan is right about the rational behind using the bubble. It clears the full dose from the needle and helps move the medication into the intended tissue rather than leaving some to come out as you withdraw the needle into the subcutaneous tissue.

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Thanks for the 2 replies since yesterday regarding IM injections. I have completed a literature review of this area before I write my best rpractice guidelines.

Much of the literature I have read states that the air bubble is an outdated practice.

Also interestingly the literature seems to recommend using the Z track method for IM injections now.

I would be interested in anyomne else's ideas and practice.

Thanks.

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Specializes in Rehab.

We were told that the only time we are to use the 0.1mL air-lock is for Heparin. And, in our class, aspirating Insulin is a no-no.

But, that's just us.

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Specializes in Education, Acute, Med/Surg, Tele, etc.

Us here learned no bubble, and it is interesting to hear of this (I recall if proper z is done, you close up the way it would go out). Makes sense, I just had never heard of it in my circles...(which doesn't suprise me..LOL!) Heck, I have patients that must have watched too many TV med shows and think if you do not squirt med out the needle before a shot...you will kill them by adding air to their heart...LOL! I just say "oh okay Quincy!" (well maybe more in my head with certain clients! LOL!)

We also say no no to aspiration of insulin. But then again at my current workplace we don't have another Nurse to check your draw which still to this day tweeks me out (I liked having another nurse check!).

Oh now I am so curious about this...I will ask around to my fellow RN's and see if they practice using air...I guess we just never discussed it...great post!

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Oh, I forgot that step to displace the tissue when giving a Z track injection as opposed to just sort of pinching up or securing the tissue in a normal IM inject. This is also to prevent backtracking of the medication into the subq. tissue.

We don't aspirate insulin or heparin anymore.

We do massage insulin, but not the heparin. Is that pretty much the majority now?

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Thanks again. I am enjoying reading the posts that people written. Correct as you say that the literature states that the Z track closes off the track that the medication is given kind-of sealing it.

I am also interested in the following:

(1)Feedback on locating the ventrogluteal site versus thbe dorsogluteal site. This is in the view that the Ventroglutaeal site is thought to be safer, without risk to the sciatic nerve. There is a lot of literature about this.

(2)The angle of giving an IM injection. Literature that I have read recommends a 90 degree angle. However at a course I went to recently on immunisations, we were told a 60-70 degree angle. It is a contentious issue.

(3)whether nurses swab the injection site first with an alcohol swab. literature i have read states that this is not neccesary unless it is visibly dirty.

I look forward to your responses.

Jenny

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Specializes in Education, Acute, Med/Surg, Tele, etc.

Well I do ventro because I too fear the sciatic nerve hit...I have had it happen to me personally and it damaged it perm! So some experience there as well as one hit to the bone (oh that sensation then pain still haunts me..it is fresh in my mind!).

Wow, but to explain how I do it...I would have to show. I use my hand and put my thumb on the furthest felt area of protrube of the front hip (I am too tired today for exact anatomy here..sorry..LOL! LONG DAY TODAY!) and my pinkie to the furthest area I can reach towards the back trying to stay fairly in line with my thumb. Then I set my mark between the middle and ring finger with my eyes. I feel the area to make sure how much muscle tissue I am dealing with (in other words a check to make sure I am not going to ding off the bone!) wipe and 'z' it and go for it. I have yet to have anyone complain, which is a real feather in my cap since I am very sensitive to any screw ups in this area (since I was so injured!).

I am also quite a dart...I set my mark, make sure visually and palpate, and boom...wipe, Z, dart and go. This seems to help me..but choosing your needle length is the art of a good dart! (medics normally choose too long actually, guage by palpation...I work with the VERY elderly and usually have more skin to worry about vs fat!)

And alcohol swipes...not using them would be against my grain really...too use to it. So I still use them..but I am polite enough to wait till there is no more visual wetness from the wipe, because..OUCH that can feel like a burn to sensitive folks (or some not so sensitive either!). I also follow that rule in SQ from multiple diabetics telling me that is what bugs them most...that wipe and burn!

Who else likes ventroglute

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I use the ventrogluteal 90% of the time. I also was taught you are less likely to hit nerve, vessel, or bone here. Another thing, just a slight tilt, if at all, and you can inject.

It is my experience that more nurses have trouble finding the correct site for a deltoid injection than elsewhere. (They just don't realize they are giving it in the wrong site.)

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I like the Ventrogluteal site because of it's safety but i am continually amzed at the number of nurses who know nothing about that site. I always make a point to explain to patients before I use that site so they don't wonder if I know what I am doing.

About 10 years ago I worked in a local ER PRN. It was not a good working environment and was probably one of the worst places I have ever seen for frank staff hostility. During my orientation process the charge nurse told me she didn't think I was cut out for working in an ER. I looked at her and asked "how in the world could you think that? I work 2 12 hour shifts a week in XXXX hospital (a nationally known level 1 trauma center) and I am in charge on both nights!

She told me their standards must be much higher than XXXX hospital because the nurses had noticed me using very poor technique in several tasks. When I asked who said it and what tasks, she said she had been told that two different nurses observed me giving IM injections and I obviously didn't know what I was doing....

What was I doing???

I was using the ventrogluteal site instead of the dorsogluteal and I always (even now) use a z-track style with IM injections...

I had to try my hardest to keep from laughing in her face but I told her I understood they might not know about the VG site but that it was very safe and I brought in documentation the next day to support its use.

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