THE ADMINISTRATION of intramuscularinjections is a common nursing interven-tion in clinical practice.1 This article aimsto, raise awareness in relation to the injec-tion sites used for intramuscular injectionand, to highlight best practice in relationto IM injection administration.

The importance of good injection tech-nique cannot be understated. It shouldnot be forgotten that among potentialcomplications of IM injection are abscess,cellulites, tissue necrosis, granuloma, mus-cle fibrosis, contractures, haematoma andinjury to blood vessels, bones and periph-eral nerves.2 Although IM injection is acommonplace nursing practice, there is adearth of guidelines for nursing staff inthis area.3,4 It has been outlined that thereare no working policies or procedures onadministering injections to which nursingstaff can refer.3 Furthermore, the techniqueand preparation by certain staff may notbe substantiated by evidence.4

Sites of the thigh (Rectus femoris andVastus lateralis)

The uptake of drugs from the thighregion is slower than from the arm butfaster than from the buttock, thus facilitat-ing better drug serum concentrationsthan is possible with the gluteal muscles.5

The thigh may be utilised when othersites are contraindicated or by clients whoadminister their own medication, as it isreadily available in the sitting or lying backposition. However, the main disadvantageis that injections in the Rectus femoris sitemay cause considerable discomfort.6

This site can be used for infants, childrenand adults. Needle length used is usually2.5cm or less.The dorsogluteal site

This site is commonly referred to as theouter upper quadrant and is contraindi-cated in children.

The presence of major nerves and bloodvessels, the relatively slow uptake of med-ication from this site compared withothers and the thick layer of adipose tis-sue commonly associated with it, makesthis site problematic.7 The sciatic nerveand superior gluteal artery lie only a fewcentimetres distal to the injection site,thus great care needs to be taken to iden-tify landmarks accurately. Palpating theileum and the trochanter is important;using visual calculations alone can resultin injection being placed too low and

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50 WIN April 2006

IM injections:How’s yourtechnique?

Good injection technique can mean thedifference between less pain and injury.

Angela Cocoman and John Murray explain

Giving an IM injection into the Vastus lateralis sitez To find the thigh injection site, make an

imaginary box on the upper leg. Find the groin.One hand’s width below the groin becomes theupper border of the box

z Find the top of knee. One hand’s width abovethe top of the knee becomes the lower borderof the box

z Stretch the skin to make it tight

z Insert the needle at a right angle to the skin(90°) straight in

z Up to 2ml of fluid may be given into this site

Vastus Lateralis

Rectus Femoris

IM injection into the Gluteus medius site (buttock)z Find the trochanter. It is the knobbly top

portion of the long bone in the upper leg(femur). It is the size of a golf ball

z Find the posterior iliac crest. Many peoplehave ‘dimples’ over this bone

z Draw an imaginary line between the twobones

z After locating the centre of the imaginaryline, find a point one inch toward the head.This is where (X) to insert the needle

z Stretch the skin tight

z Hold the syringe like a pencil or dart. Insert the needle at a right angle to the skin

z Up to 3ml of fluid can be given in this site

Gluteus Maximus

Greater Trochanter

Sciatic Nerve

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injuries to other structures.8

Risks associated with an IM injection to thedorsogluteal sitel Contact with sciatic nervel Contact with the superior gluteal arteryl Too much fatty tissue – poor absorption

rates.The deltoid site

The ease of access, especially in an out-patient setting, possibly adds to thefrequency with which the deltoid site isused for IM injections. This site is used forimmunisations/non-irritating medications,hence vaccines which are usually small involume tend to be administered into the

deltoid site.9 This is a relatively small areaand muscle mass, especially in atrophiedpatients compounded by the close prox-imity of the radial nerve, brachial arteryand bony processes to this site means thatmore substantial injuries can occur.

It is important to limit volume of med-ication based upon size of muscle, ie.0.5-2ml.The ventrogluteal site

The Ventrogluteal site provides thegreatest thickness of gluteal muscle (con-sisting of both the gluteus medius andgluteus minimus), is free of penetratingnerves and blood vessels, and has a nar-

rower layer of fat of consistent thinnessthan is present in the dorsogluteal.10

The ventrogluteal site has come toattract significant attention in the nursingliterature and there is wide agreementthat this site is the preferable site for intra-muscular injection.2 There is a dearth ofresearch in this area in Ireland as to theextent to which the ventrogluteal site isused.Administrating an IM injection

There is a large research base for nurs-ing practice to be guided by in relation tothe administration of intramuscular injec-tions and it is the responsibility of nurseeducators to ensure that appropriatelyinformed guidelines are devised.4

It has been suggested4 that the follow-ing points should be incorporated intoclinical guidelines:l IM injections should be administered in

the Ventrogluteal region whenever pos-sible

l The medication should be administeredwith a needle long enough to reach themuscle without penetrating underlyingstructures

l The patient should be positioned so asto relax the muscle

l The ‘Z track’ technique should be usedat all times (see diagram).These measures should ensure optimal

nursing care for patients.

Angela Cocoman is mental health lecturer at DCUand John Murray is a community mental health nursefor Water ford Mental Health Services (HSE SouthEastern Area)

References1. Greenway K. Using the ventral gluteal site forintramuscular injection. Nursing Standard 2004; 18 (29):39-422. Small SP. Preventing sciatic nerve injury fromintramuscular injection: literature review: J AdvancedNursing 2004; 47(3): 287-2963. MacGabhan L. A comparison of two depot injectiontechniques. Nursing Standard 1996; 11(52): 33-374. McGarvey MA. Intramuscular injections: a review ofnursing practice for adults. All Ireland J Nursing &Midwifery 2001; 1(5): 185-1935. Newton M, Newtown DW, Fudin J. Reviewing the bigthree injection routes. Nursing 1992; 22: 34-426. Berger KJ, Williams MS. Fundamentals of Nursing:Collaborating for Optimal Health. Appletone Large:Connecticut, 19927. Bolander VR. Sorenson & Luckmann’s Basic Nursing,A Psychophysiological Approach (3rd ed.) Saunders:Philadelphia, 19948. Kozier et al.Techniques in Clinical Nursing (4th ed).Sage: California, 19939. Mallett J, Bailey C.The Royal Marsden NHS Trust Manualof Clinical Procedures (5th ed.) Blackwell Science: London,199610. Zelman S. Notes on the techniques of intramuscularinjection. Am J Med Sc 1961; 241: 47-5811. Rodger MA, King L. Drawing up and administeringintramuscular injections: a review of literature.J Advanced Nursing 2000; 31(3): 574-582

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Giving an IM injection into the deltoid sitez Find the knobbly top of the arm (acromion

process)

z The top border of an inverted triangle istwo finger widths down from the acromionprocess

z Stretch the skin and then bunch up themuscle

z Insert the needle at a right angle to theskin in the centre of the inverted triangle

Caution: This is a small site – give only1-2ml or less of fluid in this site

Achromial Process

Brachial Artery

Radial Nerve

Z Tracking technique

(A) (B) (C)

Giving an IM injection into the ventrogluteal sitez Find the trochanter. It is the knobbly top

portion of the long bone in the upper leg(femur). It is about the size of a golf ball

z Find the anterior iliac crest

z Place the palm of your hand over thetrochanter. Point the first or index fingertoward the anterior iliac crest. Spread thesecond or middle finger toward the back,making a ‘V’. The thumb should always bepointed toward the front of the leg. Alwaysuse the index finger and middle finger to make the ‘V’

z Give the injection between the knuckles on your index and middle fingers

z Stretch the skin tight

z Hold the syringe like a pencil or dart. Insert the needle at a right angle to the skin (90°)

z Up to 3ml of fluid may be given in this site7

Anterior Superior Iliac Crest

Location of Gluteus Medius

Injection Point(between the knuckle of the index and middle finger)

Greater Trochanter

An intramuscular injection is designed to deposit medications deep into muscle tissue

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