IM/Rhogam Injection Gone Wrong?

[cougSN]

Hi,

So even though my nurse assured me that I did it in the correct location and I talked to another trusted nurse who said I was fine, I just wanted everyone's opinions. I am a senior in a BSN program in my practicum in OB and today I gave my first Rhogam injection NOT in the deltoid. In the clinic, I did one in the deltoid and this is the first one I gave in the gluteal muscle. In my BSN program, we were taught to give gluteal injections in the ventrogluteal area (trochanter as a landmark, anterior superior iliac crest, blah blah....). I "confirmed" with my nurse that I give it in the "hip" when she told me to give it and she said "well, you give it in the upper outer quadrant of the buttock". I wasn't about to start controversy or anything so I went with it and she said "also, I never really aspirate injections" and so I was like, okay, if this is the guidance she is giving me, then I will go with it. She watched me earlier aspirate on a vaccination and the shot took a little longer than I think she would have liked, so this is why she said this.

Either way, I went into the patient's room (in postpartum unit), my nurse came in with me, I gave the injection in the upper outer quadrant, as she said, and I did not aspirate, as she said. The patient did not jump or even move during the injection, so I assumed all was well and okay, did not see much, if any blood when I pulled the needle out.

A while later (after being in and out of her room several times), we go back into the room to check on her, she is walking around the room, no problem and she says "by the way, I have this sharp pain on my left hip" (same side as the injection). My nurse double checked the site with me (and confirmed I put it in the correct spot, according to where I placed the bandage) asked her to describe the pain and she said it was "sharp pain", she felt like it might have been in her bone (I did not hit her bone, I am sure of it) she rated it an 8-9/10. We asked her to walk and she walked just fine and was even walking around the room when we came in.

My paranoia is that I did not give it in the correct location and have caused her sciatic damage or because I did not aspirate, I got it in her vein and this pain she is feeling is a function of hitting her vein. She requested pain relief for it, so we gave her oxycodone for it (because of the outrageous number). Later, we went back in, my nurse said "how is your hip?" and she said "it's fine, better".

Anybody have any suggestions or can anyone else further put my mind at ease about this situation? I feel as though I may not be able to sleep tonight very well because I am so worried about it. I am afraid I have done some damage and will be in trouble for it, and I have 8 hours of practicum left before I am offcially graduted. Help, please!! I really appreciate it.

[Elvish, BSN, DNP, RN, NP]

Some injections you give people are going to hurt worse than others, and everyone's reaction to an injection is going to be different. I got a Bicillin shot in my dorsoglute once and couldn't sit for days!

Having said that - I ALWAYS give my Rhogams in the ventroglute. There are no major blood vessels or nerves in that spot and in most adults, relatively the same amount of subcutaneous fat. Having given it in the dorsogluteus, it's possible you may have hit a nerve, and that could be why she was having that pain. But, I would not be terrified of getting in trouble nor losing sleep over it. I'd chalk it up to a lesson learned. I understand that fear of not wanting to make waves, especially when working with someone who may have been doing this type of nursing longer than you've been alive. But if there is a next time, you would be within your bounds to say, "I've been taught that ventrogluteus is the place to give IM injections for XYZ reasons. I'm not comfortable with dorsogluteus." That's not making waves, that's protecting yourself.

If you are really in doubt, check the package insert that comes with the Rhogam. That will generally tell you where the safe injection spots are. But if you are not comfortable doing something, do not be afraid to speak up.

ETA - I moved this into the Ob/Gyn forum. :)

[danamobile]

I was in a similar situation myself as a student, and I find a lot of the older nurses have not been shown the ventral gluteal landmarking (that I've experienced). Like the other poster said, stick with your guts, and you will have the courage to speak up for what you've learned-- it may be different, but if you have the reasoning behind it, you can judge for yourself-- is this good practice, or is this BEST practice?

.. and ALWAYS aspirate, otherwise, how else will you know you are not giving it IV? Don't lose any more sleep over it :) You sound like me.. I lose sleep all the time, and its just not necessary!!!!!

[roser13, ASN, RN]

Always, always, always, aspirate!!!

[CEG]

IM injections can be pretty painful if you haven't had one lately. If she tended to rate her pain high, then very likely was the pain from the IM injection.

If we were concerned about an IV injection I think she would be having more severe systemic symptoms so I think localized muscle pain means you can forget about that.

It's very tough to be in the middle. I teach OB clinicals and I typically go with my students to observe any procedures, it is also on my license! So don't hesitate to ask your instructor to run interference for you if necessary.

BTW I also use the deltoid. You can always ask the patient where they want it also. If they have had it several times they will probably have a preference.

You'll be fine! It shows that you are doing well if you are taking the time to post here and look back over your own performance. Worry about the NCLEX instead;)

[RN-BS1972]

it comes with experience for one thing and you will learn over time that every one patient is different, different pain tolerance (anxiety increases pain remember that too) etc.

When in doubt give it in the vastus lateralus and remember to do it at a 90 degree angle it is the meatiest part and you shouldn't hit a nerve. Glucagon is Im also and when used in emergencies I dont think about aspirating.

[RN-BS1972]

there may be a question on boards that asks the correct way to give an IM and if 90 degree angle is one of the answers pic that one

[BigBub1000]

I'm not sure you should put such specific information on here. But it sounds like the shot was ok.

Next time, you have to aspirate. On IM's, you have to make sure you're not in a blood vessel. Your teacher is wrong. Just do it, don't say anything or question it or discuss it, just say, after the fact, if you are queried about it," Oh, sorry, I'm just used to aspirating on an IM. By the way, if you don't aspirate, how do you know you're not in a blood vessel?" And make her explain why she is deviating from standard practice and probably from hospital P&P. Do as you were taught and what you know is right.

As for her pain being excessive - everyone is different. I think you were right to believe her. How is the site now? How is she?

[cougSN]

You think I gave away too much info? Well, now that you mention it, it is pretty specific and I don't know how to delete the post. I'm sorry, I was just trying to be thorough so everyone would understand the situation. Does anyone know how to delete a post?

[littleneoRN]

Our hospital policy states that aspirating with an IM injection is not supported by the evidence. Our policy now states that aspiration is acceptable if it makes the nurse feel better, but research shows no benefit. Just throwing that out there....

[Lacie, BSN, RN]

Contrary to another posters response "older" nurses were not taught VENTROGLUTEAL injections landmarks? We were taught the same as newer nurses in this regard so yes we were taught. I always give my IM's in the ventrogluteal as most programs donot advocate the use of the dorsalgluteal any longer due to complications. Personally I dont think you did anything wrong so hang in there and breath. In the future you may want to just do a quick double check with your clinical instructor if another nurse is telling you to do something in a manner of which either you have question of the appropriateness or if differing from the way you have been instructed. At least until you graduate and then go with your own gut. Right now your career in school depends on you following your instructors direction. Smile and you did right in questioning.

[JaneyW]

Hip pain is different from sciatic pain. There are lots of pains and aches after childbirth--and also after an IM injection. Like Lacie said--breathe. I'm sure everything is fine. You will probably always questions everything you do. Eventually you learn to get to sleep.