Z track for IM injections?

marshmallowstar, BSN, RN · Dec 30, 2011

Always aspirate, only takes a second or 2 and if you inject into a blood vessel you're going to be dealing with bigger problems than an agitated patient. Z track doesn't take any extra time and is helpful for keeping the injection in place for absorption.

Our safety needles auto retract or engage by sliding a lever from the side so I can't be of help there but I would think a technique that keeps stick risk low is the one to use.

OB-nurse2013, BSN, RN · Dec 31, 2011

I'm a student but have given many injections and we were told not to aspirate anymore. We also were taught the z-track method but that because of new research they are not teaching to aspirate anymore.

NICU<3RN · Jan 1, 2012

On our unit we try to do Z-track if appropriate and accessible. If it is not, and it is an emergency, we can use our judgement as to where to put the needle. While buttock is always the preferred site at our facility, if it can't be done by Z-track then we can still get it in in another buttock location. I've also seen them done on the thigh and deltoid.

Also, our facility we were taught not to aspirate because the newest evidence shows that aspiration of the needle is not necessary in IM injections.. because the location of the IM injections rarely has a blood vessel running through it. So, we don't.

Last, insanely, our facility does not always have safety needles!!! I think it's insane.. I once refused to give an IM to a screaming flailing patient on the floor for this reason. The nursing director gave it instead. I am sorry, but I am not risking getting stuck because the facility doesn't want to pay extra for them! Since that incident we have seen a rise in safety needles at our facility, and when I do use them, I try to flick them back by rubbing it on something (safer!) unless there is nothing there to flick it back with then I'll use my finger.

marshmallowstar, BSN, RN · Jan 3, 2012

hmm, I'm interested in the research. All I can find is info about immunizations and deltoid aspiration. Completely anecdotal but I once saw a charge nurse have blood return during a vastus lateralis injection. Dorsogluteal is my site of choice and I've often thought the risk would be low but that event always stuck with me. Of course I want to use evidence based practice though! Anyone have any further info on aspiration at gluteal sites?

Thanks for the update guys! We're always learning!

Meriwhen, ASN, BSN, MSN, RN · Jan 3, 2012

Hi, I just started working at a new job on a psych unit. My preceptor watched me give a IM Ativan. I have given many an injection at other facilities, so it's not a forgien thing to me. Anyway, after he and 6 other co-workers watched me give an IM into L buttock, he told me "You need to practice your injection technique". He said I have to give all IMs Z track method, and aspirate. Well, every where I've worked no one aspirates when giving a STAT emergency IM, we just get it into the patient. I would just like some feed back from some other RNs out there. Also, after giving injection do you just flick the plastic cover down over the needle with your thumb, or do you rub it on the side of bed? He does not want me pushing plastic cover down with finger. Thx for any input! I just felt really stupid.

You should ALWAYS aspirate and Z-track. It only takes an extra second or two, gets the medication to where it needs to be--and keeps it there--and can save a patient from harm. I've done it even in the worst of codes where I've had to administer multiple shots. I also do it regardless of injection site (my preferred site is the vastus lateralis)

As far as activating safety covers, I prefer to keep my fingers as far away from the needle as possible...especially given that in psych there seems to be quite a bit more than usual of Hep B/Hep C/HIV in our patient population. I would use the side of the bed/table/anything not my finger.

rotary · Mar 3, 2012

I'm a student but have given many injections and we were told not to aspirate anymore. We also were taught the z-track method but that because of new research they are not teaching to aspirate anymore.

That doesn't sound correct. It's rare to hit a vessel but it DOES happen. You definitely don't want to be injecting a long acting antipsychotic into someone's blood stream.

NICU<3RN · Mar 3, 2012

That doesn't sound correct. It's rare to hit a vessel but it DOES happen. You definitely don't want to be injecting a long acting antipsychotic into someone's blood stream.

Actually.. according to the Centers for Disease Control/US Dept. Health and Human Services "Because there are no large blood vessels in the recommended sites, aspiration before injection of vaccines (i.e., pulling back on the syringe plunger after needle insertion but before injection) is not necessary" (p. D-10).

Link: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/appdx-full-d.pdf

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, eds. 12th ed. Washington DC: Public Health Foundation, 2011.

LadyLovelilocks · Mar 3, 2012

I find this discussion to be really informative and interesting. In school I was taught that most IM medications are not given via Z-track, only certain irritating ones (compazine was one). They did not recommend using the deltoid for any z-tracks because of the small size of the muscle. Finally, I was taught to leave the needle in the site for 10 seconds after administering a z-track (the rationale was that it would allow the medication to settle, but it seems dangerous in an emergency situation with a volatile patient). At your facilities, do you regularly use z-track for all IMs, including in the deltoid? Also, do you practice the "10 second wait" before removing the needle?

As far as aspiration, I know the CDC no longer recommends aspiration when providing vaccinations, but I have not heard anything definitive about non-vaccination IMs. I wouldn't be surprised if the aspiration policy changes in the future, though (I've heard rumors that SQ shots used to require aspiration, and I've seen a few older nurses aspirate for SQ injections).

MBauerRN · Mar 19, 2012

I was just discussing this topic with some of my coworkers. Some nurses have observed new nurses giving IMs without z track and you could literally see the medication running out of their body as the needle retracted.

phattass, BSN, RN · Mar 20, 2012

I've given more long-acting IM's then there are people in Iceland. Each semester I get new students and each semester someone has new methods they have been taught. Some semesters I have two differing methods coming at me from new students in the same class.

I follow the protocols from where I'm working. I still swab with alcohol (wasn't that supposed to stop like eight years ago), I z-track when possible (been back and forth and back again on that one over the years) I wait with the needle in for as long as the patient (or I) can tolerate it, if it's safe to do so (again, over the years this has went back and forth...usually between five and ten seconds IF possible) and I ALWAYS aspirate. I've drawn up blood only twice with aspiration.

I have had about four incidences where the pt spurts blood following injection and have seen quite a few injections where the long-acting oozes out if given without z-track. (Been seeing a lot more bleeding with consta). I've also seen blood spurt across the room and onto the face and arms of the nurse....with no noticable "error" in administration.

As for "flicking" safety needles...it depends on the situation. You, the safety of your co-workers and the safety of the patient are all huge factors. I've see a nurse flick and the liquid flew right into her eye off the needle as she engaged the safety mechanism. I've seen too many needle-stick injuries, both with and without the safety syringes (though most during the transition period with new safety syringes).

I've done a lot of different methods while in a seclusion room with way too many bodies trying to gain control. In some cases you do what is safest..right or wrong....sometimes that will mean a finger flick, sometimes the bed, sometimes dumping it into the metal prep tray uncapped. It's really hard to do by the book when you have six to ten people in a dog-pile but that is when you have a great chance of an injury.

I'd be up on what the facility protocol says and follow that. If the policy is clearly outdated, then it may be time to discuss new protocols. Protocols for long-acting injections need to be specific, as they are not the same as injecting other medications or vaccines.

Good luck and play safe!

brillohead, ADN, RN · Mar 21, 2012

I find this discussion to be really informative and interesting. In school I was taught that most IM medications are not given via Z-track, only certain irritating ones (compazine was one). They did not recommend using the deltoid for any z-tracks because of the small size of the muscle. Finally, I was taught to leave the needle in the site for 10 seconds after administering a z-track (the rationale was that it would allow the medication to settle, but it seems dangerous in an emergency situation with a volatile patient). At your facilities, do you regularly use z-track for all IMs, including in the deltoid? Also, do you practice the "10 second wait" before removing the needle?

I can't imagine any patient, other than an unconscious one, being cool with you leaving a needle stuck in them for an extra ten seconds....