question about IM emergency meds from new psych RN

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Hi everyone. I did a few searches on here for this topic, and found a couple things, but the site is working too slow for me to keep searching for exactly what I wanted to ask, so I hope you'll forgive me if this has already been discussed!

I start a new job soon, in an inpatient psych facility. I'm a new grad, and this is THE job I wanted, and in the area of nursing that I love, so I feel so fortunate and excited in this job market. And also nervous, of course. My question(s) are about emergency IM meds.

1. Is the dorsogluteal site used in emergency med administration? If the person is in restraints, which site is preferred? Or is this an institutional policy thing?

2. I've not yet medicated anyone with more than 0.5ccs (delt injection per institution policy) who has had to be restrained -- do they release the restraints on one side so you can get to the back side? or the ventrogluteal? I worry about finding the right spot in an emergency!

3. Do you aspirate for blood return when you're giving an IM med to a combative patient?

4. The facility I was in before gave some injections in the deltoid -- mostly just 0.5cc Ativan, etc. Are there certain meds you wouldn't give in this spot, even if it were a small amount?

5. Say a patient is being actively combative, violent, etc. and has to be put in restraints or held to keep others safe. At what point do you offer a PRN med? Before they are restrained? After they are restrained? I've seen this all move very fast, and I know I'll be responsible for documenting it -- say the patient has already "crossed the line" of safety, verbal deescalation isn't so much an option, and has to be restrained, do you then give them the option of taking a PO PRN, or is it acceptable to "force" medicate them with rationale that they are/have been a danger to others unmedicated?

THANKS in advance. I'm feeling nervous but okay about this new role, but emergency meds is one area I'm not very confident in.

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Specializes in Peds, med/surge, nursing home, wounds.

Hi! I have worked as a nurse for a while, but only the last 2 months in psych... From what I have seen, heard, and done so far here is my scoop... (forgive my blunt terminology) The butt is the best choice to give an IM if possible because the bigger the muscle the faster the absorption. When we have a code, we have the pt usually in physical hold before the restraints are attached to the bed, and that is when we ideally give the medication- there are many people holding so it is fairly "safe". I have given 2 cc and I do pull for blood first, since the patient is being physically held, but I do try to go fast... If a patient is willing to take an injection, I go with what they choose, and alot of times I choose the arm just to make it least traumatic- they usually don't have to move from sitting to laying and they don't have to remove any clothing usually. But that is when there is no code. In the end, if you give an IM, it will get into the patient no matter where you go, so I wouldn't worry too much. As far as knowing where to out the needle- the butt, draw an imaginary cross dividing the cheek into 4 equal part and go for the middle of the upper outer square- using your fingers to know where to put the needle on the arm... Our facility doesn't have a policy about where to inject, but my advice is to make it easy on yourself and find out ahead of time which drugs can be drawn in the same syringe and which ones can't- you are much better off giving one injection over 2... We often get orders for haldol, ativan, and benadryl all at one time and we can give 2 in one syringe so you only have to give 2 IMs Hope this helps!

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Specializes in Psychiatric..

Hey..... I just qualified as an RPN in Ireland. Over here, we do 4 years psych or whatever discipline you pick (general, Intellectual disability etc) I have tons of experience in the very thing youre talking about. If it were me I'd...............

1. Dorsogluteal, easy to find, safest, and patient cannot hit you

2. Decide with your team where youre gonna IM before you go to do it.....

3. Yes, aspirate for blood......... All procedures are still valid.

4. The deltoid is ok but generally cant hold enough of the drug you want to inject.. So if you need to IM 5ml haloperidol and 2ml ativan (+ 2ml H2O)..... youre gonna hit trouble.....The dorsogluteal site is not even that big so itll take 2 Ims... But the less injections the better...... Then obviously if your patient was in plaster around his backside youd chose somewhere else.....

5. Id always ask will they take PO (liquid or tab) at least 3 times before giving an IM...its in the law here. If the person was charging a nurse, well you restrain them and ask. 3 times if nessescery while still restrained. I always talk to the patient about what happened a day or two later (or when they are well enough to) so as to deal with any ill feelings or resentment the patient might hold against me.. Youll find generally they understand but it shows respect and thats the holy grail in psych nursing.. You may meet this patient again in the same scenario, and because they know you repsect them, they may trust you and take the oral PRN instead of the whole "involuntary IM" which no one wants..

Hope I was able to help you....

Take it easy and keep a cool head!!

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Thank you both for taking time to share your experiences! If anyone else has any other insight, I'd love to hear it, too.

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Specializes in Acute Mental Health.

I've worked as a psych nurse for just about 1.5 yrs now and have done hundreds of IM's. When you put a pt in restraints there are normally people helping. Most don't go willingly. Our Security will ask where we want to give it and then help us get a good position. Gluteal is good especially with some of the thicker meds and there are certain meds that can't go in the deltoid. It's usually a hectic time but they are safe in 4pnts so take your time. I have had to give in legs, delts, and gluts. It's difficult when the pt is struggling but security is really good about safety. Congratulations and good luck!!

Yes, always aspirate! It will come quickly and easily and is a habit with me now.

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Specializes in Acute Mental Health.

Also, when I notice someone escalating, I ask if they need a prn. I have also suggested a prn and pointed out behaviors that lead me to believe they would benefit from taking one or more. I just came off of a very violent couple of days. The hardest thing for me to learn, was and is, using restraints. If a pt assaults another pt and then walks, on their own, to the seclusion room, is willing to take a prn, and tells me they will not hurt anyone else, I can't put them in restraints. It's difficult to seperate your feelings at times. There are many legalalities surrounding the use of restraints. The first is it's your license. The next is the use of least restrictive means first. which is for me prns and 'time outs' It can get frustrating. My cna's usually want the restraints and explaining legal stuff gets old. Educate yourself on your states regs. Many facilities will throw their nurses' under the bus in a hearbeat if and when something goes wrong.

I worked hard for my license and I would like to keep it for many many years to come.

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Specializes in Hospice, corrections, psychiatry, rehab, LTC.

As far as IM injections in restraint situations, go for whatever you can hit. Your patient will not be cooperative, and likely will be thrashing around on the bed. I have used every IM site imaginable depending upon the circumstances. I try not to use the deltoid, because the smaller muscle means that the medication will sit there longer rather than doing the job you want it to do.

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Specializes in Psych.

That's so interesting @irishpsychintern that you have to, by law, ask a pt. 3x to take something po. I'm sure that gets old in a code situation.

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Specializes in Psych.

@manchmal All very good questions to be asking ahead of time, as in the moment it can be very high-adrenaline. Know that the first few times you might shake a little and be nervous about giving a shot with 10 people standing around. I always hate when staff has someone down on the floor and I'm drawing up. The Ativan seems to take forever in that moment, lol! But over time you will do this very frequently, and you will get better each time. Also, you will see many different techniques, does NOT mean they are the right way to do it. Learn the right way(as you are doing), try the right way, and determine what works best for you. In these situations sometimes things are a bit tweaked and oh the positions you will contort yourself into in order to safely give an injection to the patient, and not your peers, who are in very close quarters with you, lol!

Also @chevyv had some very good advice and I can totally relate to what was said about other staff just wishing you would put restraints on right away. It can be tough but usually it comes down to "I have a license to worry about, so we are doing it this way." Really does take patience!

Good luck with your new career @manchmal:)

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Specializes in Psychiatric..
That's so interesting @irishpsychintern that you have to, by law, ask a pt. 3x to take something po. I'm sure that gets old in a code situation.

No never... the law is the law... If you dont do it, in my books, youre abusing the patients rights which in turn, I feel, is abusing the patient. Ireland has a shocking (not near as strong a word as needed) history in psychiatric care. Its a disgrace. I could talk to you for hours about it and you would honestly have difficulty believing that it ACTUALLY happened in the last century never mind the last 20 years. So I feel strongly about "little" things like asking 3 times before IM. It could be you or I someday is how I always look at it.

Anyhow, peace out :)

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Specializes in Psych.

Yes, America has quite the nasty psych history as well, so I believe what you are saying completely. One of the reasons I went into psych nursing was because I saw how horribly people with psychiatric illness have been treated, and unfortunately still are in some places. Even our fellow nurses, who aren't in psych, have been known to look down their nose at our chosen profession, and oftentimes our patients.

It's great that there are now laws against the barbaric treatment that you are referring to and newer forms of "treatment" are available.

Would you mind a dialogue about general psych care in Ireland vs. the States, i.e. what are your restraint policies, does it vary by facility or is government mandated, etc? I find it quite interesting, would love to hear the comparisons, and would welcome the opportunity to possibly institute change for the better.

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Specializes in Psych.

When I started I was always taught gluteal because if you get them safely on their stomach it is easier to hold them still. Also if you are in the deltoid there is a risk of them flinging their arm up (almost had my first needle stick from that). Not sure the official stand on this but I was also taught to get the med in them anyway possible and that can also mean through clothing. (unless it's jeans or something very heavy)

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