Muscles

Intramuscular injections into the gluteal region. Drug embolism: injections can be dangerous Complications during intramuscular injections

Technique for performing intramuscular injection:
Purpose: medicinal
Indications: determined by the doctor
Equipment:
1. soap, individual towel
2. gloves
3. ampoule with medicine
4. file for opening the ampoule
5. sterile tray
6. tray for waste material
7. disposable syringe with a volume of 5 - 10 ml
8. cotton balls in 70% alcohol
9. skin antiseptic (Lizanin, AHD-200 Special)
10. Covered with a sterile napkin, a sterile patch with sterile tweezers
11. mask
12. first aid kit “Anti-HIV”
13. containers with disinfectant. solutions (3% chloramine solution, 5% chloramine solution)
14. rags
Preparation for manipulation:
1. Explain to the patient the purpose and course of the upcoming manipulation, obtain the patient’s consent to perform the manipulation.
2. Treat your hands at a hygienic level.
3. Assist the patient into the desired position.
Intramuscular injection technique:
1. Check the expiration date and tightness of the syringe packaging. Open the package, assemble the syringe and place it in a sterile patch.
2. Check the expiration date, name, physical properties and dosage of the drug. Check with the assignment sheet.
3. Take 2 cotton balls with alcohol with sterile tweezers, process and open the ampoule.
4. Fill the syringe with the required amount of the drug, release the air and place the syringe in a sterile patch.
5. Put on gloves and treat the ball with 70% alcohol, throw the balls into a waste tray.
6. Use sterile tweezers to place 3 cotton balls.
7. Treat a large area of skin with the first ball in alcohol centrifugally (or in the direction from bottom to top), treat the puncture site directly with the second ball, wait until the skin dries from the alcohol.

8. Throw the balls into the waste tray.
9. Insert the needle into the muscle at an angle of 90 degrees, leaving 2-3 mm of the needle above the skin.

10. Place your left hand on the piston and inject the medicinal substance.
11. Press a sterile ball to the injection site and quickly remove the needle.
12. Check with the patient how he is feeling.
13. Take the 3rd ball from the patient and escort the patient.

Carry out infection safety measures, treat your hands at a hygienic level, dry with an individual towel

Complications

The nurse must clearly understand what complications may occur after intramuscular injections and how to avoid them. If complications arise, the nurse must know the algorithm of medical care for the patient.

So, complications after intramuscular injections may be as follows.

Needle breakage

Not often, but it does happen. The reason is strong muscle contraction due to fear of the procedure, unexpected start of injection, or improper psychological preparation of the patient.

Help: keeping calm, reassure the patient, assure him that everything will be fine. With the ! and 2nd fingers of your left hand, press down the tissue on both sides of the broken needle, squeezing it out in this way. Take tweezers with your right hand, carefully grab the tip of the fragment and remove it. The action is repeated several times. If attempts are unsuccessful, urgently call a doctor through an intermediary, remaining with the patient and reassuring him. In the future, follow all the doctor’s instructions.

Damage to the periosteum

Can occur when giving an intramuscular injection with a needle that is too long in a thin patient. Help: referral to a surgeon and implementation of his instructions. Prevention: correlate the length of the needle with the size of the patient’s subcutaneous fat layer at the site of the intended injection.

The following complications are possible with intramuscular injections:

The needle enters a blood vessel, which can lead to to embolism, if oil solutions or suspensions are introduced, which should not enter directly into the bloodstream. When using such drugs, after inserting the needle into the muscle, pull the piston back and make sure that there is no blood in the syringe.

· Infiltrates- painful compactions in the thickness of the muscle tissue at the injection site. They may occur on the second or third day after the injection. The reasons for their occurrence can be either non-compliance with the rules of asepsis (non-sterile syringe, poorly treated injection site), or repeated administration of drugs in the same place, or increased sensitivity of human tissues to the injected drug (typical of oil solutions and some antibiotics).

· Abscess- manifested by hyperemia and soreness of the skin over the infiltrate, increased body temperature. Requires urgent surgical treatment and antibiotic treatment.

· Allergic reactions to the administered drug. To avoid these complications, before administering the drug, an anamnesis is collected to determine the presence of allergic reactions to any substances. For any manifestation of an allergic reaction (regardless of the method of previous administration), it is advisable to discontinue the drug, since repeated administration of this drug can lead to anaphylactic shock.

Subcutaneous injections

Used, for example, when administering insulin.

The subcutaneous fat layer has a dense vascular network, so medicinal substances administered subcutaneously have an effect faster than administered orally - they bypass the gastrointestinal tract, entering directly into the bloodstream. Subcutaneous injections are made with a needle of the smallest diameter and up to 2 ml of medications are injected, which are quickly absorbed into the loose subcutaneous tissue without causing any harmful effects on it.

The most convenient sites for subcutaneous injection are:

· outer surface of the shoulder;

· subscapular space;

· anterior outer surface of the thigh;

· lateral surface of the abdominal wall;

· lower part of the axillary region.

In these places, the skin is easily caught in the fold and the risk of damage to blood vessels, nerves and periosteum is minimal.

· in places with edematous subcutaneous fat;

· in compactions from poorly absorbed previous injections.

An injection into the buttock is a fairly common medical procedure that each of us has to go through from time to time. It is better, of course, to carry out the procedure in a special medical institution, where there are qualified personnel who can give the most painful injections almost imperceptibly.

However, patients often prefer to save their own time and perform injections. Before starting self-medication, we recommend that you clarify what will happen if the injection is given incorrectly.

For most patients, such treatment passes without consequences, however, if the injection is performed incorrectly, a large number of procedures are prescribed, or due to individual characteristics the nerve is located close to the skin. In this case, the procedure can cause very painful sensations: it becomes difficult to sit, the leg goes numb, unpleasant sensations reverberate in the lower back, and other complications appear. We suggest you figure out why this happens, what to do in such a situation and how to relieve the pain.

You can alleviate your condition, reduce discomfort, if the injection site hurts a lot, if you understand the cause of these sensations. Most often there are two of them:

failure to comply with hygiene rules;
the appearance of cones. They are an extremely unpleasant and painful type of lump that appears as a result of the slow resorption of the medicine. They occur mainly when many injections are taken. How long the lump lasts depends on the measures you take.

It is important to know! If both buttocks are punctured, it is better to give intramuscular injections in the thigh or shoulder than to continue to injure the butt.

It is recommended to wipe the injection sites daily with a cotton swab soaked in medical alcohol, and at the first signs of lumps, use absorbable ointment. It is better to find out what to smear with your doctor; most often in such cases, “Alor”, “Delobene”, etc. are prescribed.

When a lump forms, massage and iodine mesh will help get rid of it. And at night it is recommended to apply all kinds of compresses. For example, a magnesium or alcohol compress, or apply a leaf of fresh cabbage (not cut). To prevent the formation of abscesses, Solcoseryl cream is used.

If the gluteal muscle at the injection site turns red, the patient’s temperature rises, but there is no lump, most likely a purulent process has begun in the body. This phenomenon indicates that an infection has entered the injured area. Eucabol (an antibacterial agent) and the already mentioned Solcoseryl jelly help relieve inflammation.

It is important to know! All of the symptoms mentioned above, plus severe pain and a feeling like someone is cutting you, may indicate the onset of an abscess.

Is it possible to swim after an injection in the buttock?

The question of whether it is possible to wash after an injection so as not to increase the likelihood of infection worries many patients. It all depends on the type of intramuscular drug being injected. These kinds of restrictions should be clarified with your doctor, he will tell you whether you should swim after this medicine, limit yourself to taking a shower, or completely refrain from import procedures.

Consequences of self-injection in the buttock

If you overcome the psychological barrier, giving yourself an injection yourself is not difficult. You just need to wipe the injection site with medical alcohol or peroxide, confidently insert the needle at an angle of 45⁰, and slowly inject the drug. However, if at least one of these actions is done incorrectly, complications can be very dangerous.

Negative consequences that occur if an intramuscular injection into the buttock hits a nerve:

, pulls his leg;
tingling, numbness;
heat;
edema;
seals;
bruises and other marks;
abscess.

If the injection is given properly, then the negative consequences of an injection into the buttock inside appear extremely rarely, although they should not be completely excluded. If you suspect that you have performed a medical procedure incorrectly, be sure to contact your doctor so that an unsuccessful injection does not affect your health.

Let's find out why the consequences of injections are dangerous.

Cones

A lump or lump at the injection site is a dense, painful swelling. It usually occurs after intramuscular injections, if the injected drug is not absorbed. You are probably wondering why such phenomena are dangerous? If appropriate measures are not taken and the lump remains 1-2 months after the end of treatment, an abscess and damage to the sciatic nerve may develop.

Reasons why seals appear:

high-speed drug administration;
short or poor quality needle;
excessive muscle tension by the patient;
injection in the middle of the buttock;
an excessive amount of medication was administered;
injection with air into the buttock;
infection;
allergy.

You will recognize that a lump has appeared by the following signs:

in case of infection: swelling, temperature, redness, pain in the lower back, buttock, pus is released;
in case of nerve injury: numbness, the injection site loses sensitivity, pain “shoots” into the lower extremities;
if air gets into the buttock during an injection (air infiltration): formation of a lump or lump.

It is important to know! Immediately after the injection, be sure to wipe the injured area with a cotton swab and alcohol, this will reduce the risk of infection.

Folk remedies that will tell you what to do if a lump forms and how to remove its consequences:

An iodine mesh applied for 3 days will help to dissolve the seal;
placing half a fresh potato on the compaction ball;
compress of chewed rye bread with sugar;
applying gauze made of alcohol or magnesium will help soften and remove old formations;
an ordinary fresh cabbage leaf helps to remove even old bumps if it is stuck with an adhesive plaster overnight;
It is recommended to apply aloe juice if there is a large lump;
kefir compress.

A qualified doctor will tell you how to treat such formations. Usually prescribed:

Vishnevsky ointment is an effective antiseptic and anti-inflammatory agent, applied for 3-4 hours. Not used when spawned;
heparin ointment. Has anti-inflammatory and analgesic effect;
troxevasin – relieves swelling and inflammation;
demexide solution - helps to dissolve and remove blood clots, reduce inflammation.

Bruise

If the needle gets into a vessel when injecting into the buttock, it is injured and a bruise forms.
Why, after treatment, blood accumulates in the tissues at the injection site, and painful bruises remain (reasons for this phenomenon):

incorrect insertion of the needle, as a result of which the walls of blood vessels are punctured;
poor quality syringe;
poor blood clotting in the patient;
individual characteristics (close location of blood vessels to the surface);
surface input;
using an insulin syringe.

It is best for your doctor to tell you what to do and how to treat the bruise. Special drugs (troxevasin, heparin ointment, traumeel and others) help to get rid of this phenomenon. There are also folk recipes that tell how to remove painful formations (the same cabbage leaf, honey or rye compress). However, they can only be used if a bruise just appears, but the following symptoms are not observed:

throbbing pain;
big boss;
heat;
edema.

Abscess

This phenomenon is one of the most dangerous post-injection complications. What an abscess looks like can be seen in the photo below. It is an inflammatory, purulent formation, the treatment of which is an extremely responsible and important step.

How to determine that you have an abscess (complication symptoms):

increased sweating;
weakness;
body temperature up to 40⁰ C;
loss of appetite;
painful redness and swelling at the injection site.

Because of the danger of such a phenomenon, rather than treating an abscess after an injection, it is better to check with a qualified physician, whom you should contact after detecting symptoms. Self-medication in this case is not acceptable.

Seal

A slight hardening that forms at the injection site is quite common. As a rule, no special treatment is required if it appears. It is recommended to simply inject into the other buttock until the lump goes away.

The tips below will tell you how to remove hardening after injections:

iodine mesh is the most popular way to cure compaction;
vodka compress on skin previously lubricated with cream;
cabbage leaf and others.

In addition to folk remedies, traditional medicine will also tell you how to treat such problems. The doctor explains what to do and how the lumps dissolve; usually in this case, ointments for inflammation and swelling that have antiseptic and analgesic properties are prescribed.

Numbness of the buttock

When the buttock and thigh go numb after an injection, many do not take this phenomenon seriously. However, if the feeling appears and does not go away for a long time, you should sound the alarm, asking your doctor what to do and how to treat this phenomenon. After all, a numb thigh or numb leg may indicate an abscess or nerve injury.

Inflammation

A most dangerous symptom indicating the onset of suppuration; when it appears, mandatory treatment is required. Only a doctor can tell you what to do in this case, after conducting an appropriate examination and taking the necessary tests. Based on them, the physician determines how to treat the patient.

Purulent inflammation symptoms:

red spot on the skin;
the injection site becomes hot, body temperature rises significantly;
painful sensations when pressing;
External and internal fistulas are formed (in advanced cases).
How to relieve inflammation:
stop administering the injectable medication until the complication is treated;
physiotherapeutic procedures;
dynamics control;
use of specialized medications.

Infiltrate

Infiltration is a hardening formed at the injection site due to improper injection, violation of hygiene rules, or for other reasons. Treatment in this case occurs as with the appearance of cones (seals).

Why does blood bleed after an injection in the buttock?

If after performing the injection blood starts to flow (sometimes it flows quite strongly, like a stream). Why is this happening? Most likely, a needle inserted under the skin made a hole in the vessel.

This phenomenon may be an accident or caused by the individual characteristics of the body (close proximity of blood vessels to the skin). When injecting the corners, it is recommended to pull the syringe corkscrew slightly towards you; if blood is drawn in, you should not continue the injection.

Allergic reaction to an injection in the buttock

If the patient is allergic, administering an allergen drug to him can have the most dire consequences, including anaphylactic shock.

You should immediately seek qualified help if:

a burning sensation appeared after an injection in the buttock;
the injection site in the buttock itches;
Itching appeared on the buttocks after injections.

Intramuscular injection is the most common and simplest. However, if performed incorrectly, complications of intramuscular injections can arise, which can be avoided if the manipulation is performed correctly.

Features of the procedure

Careful preparation is necessary before injection. It will not only allow you to give the injection correctly, but will also reduce the risk of complications. It’s worth starting with theoretical skills that allow you to administer intramuscular injections. How to properly give an injection in the buttock and thigh? For convenience, the entire manipulation is divided into stages.

Stage 1. The equipment for performing the injection is prepared. Prepare a syringe, medications, alcohol and 4 cotton balls or disposable alcohol wipes. You will definitely need a container in which the cotton wool and syringe will be placed before and after the injection.

Stage 2. The ampoule is disinfected and the medication is collected. Take an ampoule of medicine and carefully read the label, check the volume, dosage, and expiration date. Then take an alcohol wipe and wipe the ampoule with it at the opening site. Next, the medicine is collected. During this, it is necessary to ensure that the needle does not touch the walls of the ampoule. After removing the needle from the ampoule, a cap is put on it.

Stage 3. An alcohol wipe is taken and the injection site is treated with it, from the center to the periphery. Then another napkin is taken and the injection site is treated again, but with a smaller diameter. This is necessary to avoid complications of intramuscular injections in the form of inflammation.

Stage 4. Take a syringe, lift the needle up and, without removing the cap, release the air from it. Then the cap is removed and the injection is performed with a sharp movement at a right angle. The drugs are administered slowly, with equal pressure on the syringe plunger.

Stage 5. After administering the drug, the needle is sharply removed, and an alcohol pad is applied to the injection site.

Where to inject

To avoid complications, it is not enough to know exactly how intramuscular injections are carried out, how to do them correctly in the thigh, buttock - this is no less important.

To perform an injection into the buttock, it is necessary to “divide” it into four squares. The injection is performed in the upper outer square.

For injection into the thigh, its anterior surface is also divided into four parts. The injection is made in the outer upper corner.

If the procedure is performed incorrectly, various complications of intramuscular injections arise.

Infiltrate

Signs of pathology are the presence of compaction and severe pain at the injection site. Infiltrates occur due to a violation of the method of drug administration, when using underheated oil solutions, as well as with multiple injections into the same place.

To avoid infiltration, it is necessary to carefully select the injection site, alternate the buttocks, and also monitor the temperature of the injected drugs and perform the manipulation correctly.

If complications arise from intramuscular injections in the form of infiltration, then you should apply a heating pad to the sore spot or make a warm compress. The iodine mesh helps to speed up the resorption of the seal.

Abscess

If the rules of asepsis are violated, an abscess appears. This is a purulent inflammation with a clear boundary. Signs of pathology are pain, redness of the skin over the abscess with a clear boundary, as well as increased body temperature.

To avoid the appearance of an abscess, it is necessary to follow the rules of asepsis. However, in cases where a complication has arisen, surgical treatment is prescribed by opening and draining the cavity.

Needle breakage

In rare cases, post-injection complications during intramuscular injections can be caused by needle breakage. This occurs due to severe muscle spasm during the procedure, due to a poor-quality needle, and also due to the insertion of the needle all the way to the cannula. To avoid needle breakage, it is inserted into the tissue to a depth of no more than 2/3 of its length. The patient must lie down during the procedure.

If the needle breaks, use tweezers to remove it. There are times when the fragment goes too deep into the tissue and cannot be removed. In this case, surgical extraction is performed.

Emboli

Another possible complication with intramuscular injection is air and oil embolism. The signs of pathology are similar. During the procedure, oil or air enters the vessel and travels through the bloodstream to the pulmonary vessels. As a result, suffocation occurs, leading to the death of the patient.

Oil embolism occurs due to the solution entering the vessel during intramuscular injection. To avoid this, during the injection the solution should be administered in a two-step manner.

Preventing air embolism helps to follow the rules for administering drugs intramuscularly, namely, carefully displacing the air from the syringe.

Nerve damage

If the injection site is chosen incorrectly or when the needle passes close to the nerve trunk, neuritis or paralysis of the limb may occur. To prevent this from happening, it is necessary to carefully select injection sites.

Hematoma

Careless intramuscular injection can cause a hematoma. Prevention of formation is the use of sharp needles for intramuscular injection and adherence to manipulation techniques.

Treatment of complications of intramuscular injections in the form of hematomas occurs by applying to the injection site. To speed up the resorption of the hematoma, you can apply various ointments recommended by your doctor.

When performing an intramuscular injection, it is necessary not only to know the theory of the manipulation itself, but also to be able to apply the acquired knowledge in practice. Compliance with all standards will avoid complications.

Article 498. Workman B (1999) Safe injection techniques. Nursing Standard. 13, 39, 47-53.

In this article, Barbara Workman describes the correct technique for intradermal, subcutaneous, and intramuscular injections.

Goals and intended learning outcomes

As knowledge of nurses' daily nursing practice procedures increases, it is prudent to review some routine procedures.

This publication provides an overview of the principles of intradermal, subcutaneous and intramuscular injections. It is shown how to choose the correct anatomical injection site, consider the possibility of drug intolerance, as well as the special needs of the patient, which may affect the choice of injection site. Aspects of patient and skin preparation are covered, as well as equipment features, and ways to reduce patient discomfort during the procedure.

The main purpose of the article is to encourage nurses to critically reconsider their own injection technique, based on the principles of evidence-based medicine, and provide effective and safe care to the patient.

After reading this article, the nurse should know and be able to:

Determine safe anatomical areas for intradermal, subcutaneous and intramuscular injections;
Identify muscles - anatomical landmarks for performing intramuscular injections, and explain why they are used for this;
Explain the basis of this or that method of treating the patient’s skin;
Discuss ways to reduce patient discomfort during injection;
Describe the nurse's actions aimed at preventing injection complications.

Introduction

Giving injections is a routine and perhaps the most common job a nurse does, and good injection technique can make this procedure relatively painless for the patient. However, technical skill without understanding the manipulation exposes the patient to unnecessary risk of complications. Giving injections was originally a medical procedure, but with the invention of penicillin in the 1940s, nursing duties expanded significantly (Beyea and Nicholl 1995). Currently, most nurses perform this manipulation automatically. As nursing practice is now becoming evidence-based, it is only logical review this fundamental procedure from the perspective of evidence-based medicine.

Drugs are administered parenterally because they are usually absorbed faster than from the gastrointestinal tract, or, like insulin, they are destroyed by digestive enzymes. Some drugs, such as medoxyprogesterone acetate or fluphenazine, are released over a long period of time and require a route of administration that ensures continuous absorption of the drug.

There are four main characteristics of an injection: injection site, route of administration, injection technique and equipment.

Intradermal route of administration

The intradermal route of administration is intended to provide local rather than systemic action to drugs and is typically used primarily for diagnostic purposes, such as allergy and tuberculin tests, or for the administration of local anesthetics.

To perform an intradermal injection, a 25G needle with a cut upward is inserted into the skin at an angle of 10-15°, exclusively under the epidermis, and up to 0.5 ml of solution is injected until the so-called “lemon peel” appears on the surface of the skin (Fig. 1). This route of administration is used to perform allergy tests, and the injection site must be marked to monitor the allergic reaction over a certain period of time.

The sites for intradermal injections are similar to those for subcutaneous injections (Figure 2), but they can also be performed on the inside of the forearm and under the collarbones (Springhouse Corporation 1993).

When conducting allergy testing, it is important to ensure that a shock kit is readily available should the patient experience a hypersensitivity reaction or anaphylactic shock (Campbell 1995).

Rice. 1. “Lemon peel”, which is formed during intradermal injection.

IMPORTANT (1):
Review the symptoms and signs of anaphylactic reactions.
What will you do if you have anaphylactic shock?
What drugs are you using that can trigger an allergic reaction?

Subcutaneous route of administration

The subcutaneous route of drug administration is used when slow, uniform absorption of the drug into the blood is necessary, with 1-2 ml of the drug injected under the skin. This route of administration is ideal for drugs such as insulin, which require a slow, steady release, are relatively painless and are suitable for frequent injection (Springhouse Corporation 1993).

In Fig. 2 shows places suitable for performing subcutaneous injections.

Traditionally, subcutaneous injections are performed by inserting a needle at a 45-degree angle into a fold of skin (Thow and Home 1990). However, with the introduction of shorter insulin needles (5, 6 or 8 mm in length), insulin injections are now recommended with the needle inserted at a 90 degree angle (Burden 1994). It is imperative to fold the skin in order to separate the fatty tissue from the underlying muscles, especially in thin patients (Fig. 3). Some studies using computed tomography to track the direction of injection needle movement have shown that sometimes subcutaneous injections inadvertently introduce the drug into the muscle, especially when injecting into the anterior abdominal wall in thin patients (Peragallo-Dittko 1997).

Insulin administered intramuscularly is absorbed much more quickly, and this can lead to unstable glycemia, and possibly even hypoglycemia. Hypoglycemic episodes can also occur if the anatomical site of injection changes, since insulin is absorbed from different sites at different rates (Peragallo-Dittko 1997).

For this reason, insulin injection sites should be constantly changed, for example, the shoulder or abdomen is used for several months, then the injection site is changed (Burden 1994). When a patient with diabetes is admitted to the hospital, it is necessary to look for signs of inflammation, swelling, redness or lipoatrophy at the sites where insulin was administered, and be sure to note this in the medical records.

Aspiration of the contents of the needle during subcutaneous injection is currently considered inappropriate. Peragallo-Dittko (1997) reports that puncture of blood vessels before subcutaneous injection is very rare.

Educational materials for patients with diabetes do not contain information about the need for aspiration. It has also been noted that aspiration before heparin administration increases the risk of hematoma formation (Springhouse Corporation 1993).

Intramuscular route of administration

When administered intramuscularly, the drug ends up in a well-perfused muscle, which ensures its rapid systemic effect and the absorption of fairly large doses, from 1 ml from the deltoid muscle to 5 ml in other muscles in adults (for children, these values should be divided in half). The choice of injection site should be based on the patient's general condition, age, and the volume of drug solution to be administered.

The intended injection site should be examined for signs of inflammation, swelling and infection, and injection of the drug into areas of skin damage should be avoided. Likewise, 2-4 hours after the procedure, the injection site should be examined to ensure that there are no adverse events. If injections are repeated frequently, the injection sites should be marked so that they can be changed.

This reduces patient discomfort and reduces the likelihood of complications such as muscle wasting or sterile abscesses due to poor drug absorption (Springhouse Corporation 1993).

IMPORTANT (2):
When hospitalizing patients with diabetes, special medical records must be maintained.
How do you mark injection rotation sites?
How do you monitor the suitability of the injection site?
Discuss this with your colleagues.

Rice. 2. Anatomical areas for intradermal and subcutaneous injections. Red dots are sites for subcutaneous and intradermal injections, black crosses are sites for intradermal injections only.

Rice. 3. Grasping a fold of skin when performing a subcutaneous injection.

Older and malnourished people have less muscle mass than younger, more active people, so before performing an intramuscular injection, it is necessary to assess whether there is sufficient muscle mass for this. If the patient has little muscle, the muscle can be folded before injecting (Fig. 4).

Rice. 4. How to tuck a muscle in debilitated or elderly patients.

There are five anatomical sites suitable for intramuscular injections.

In Fig. Figure 5(a-d) details how to identify the anatomical landmarks of all these regions. These anatomical areas are:

The deltoid muscle on the shoulder, this area is used primarily for administering vaccines, particularly the hepatitis B vaccine and ADT toxoid.
The gluteal region, the gluteus maximus muscle (upper outer quadrant of the buttock), is a traditional site for intramuscular injections (Campbell 1995). Unfortunately, there are complications when using this anatomical area, damage to the sciatic nerve or superior gluteal artery is possible if the needle insertion point is incorrectly determined. Beyea and Nicholl (1995) cite data from several investigators who used computed tomography and confirmed the fact that even in moderately obese patients, injections into the gluteal region more often result in the drug ending up in adipose tissue rather than in muscle, which certainly slows down the absorption of the drug.
The gluteal anterior region, gluteus medius muscle is a safer way to perform intramuscular injections. It is recommended because there are no major nerves or vessels, and there are no reports of complications due to damage to them (Beyea and Nicholl 1995). In addition, the thickness of the fat tissue here is more or less constant at 3.75 cm compared to 1-9 cm in the gluteus maximus region, suggesting that a standard 21 G (green) IM needle would end up in the gluteus medius.
Lateral head of the quadriceps femoris muscle. This anatomical site is most commonly used for injection in children and carries the risk of inadvertent injury to the femoral nerve with subsequent muscle wasting (Springhouse Corporation 1993). Beyea and Nicholl (1995) suggested that this area is safe in infants up to seven months of age, after which it is best to use the upper outer quadrant of the buttock.

Rice. 5a. Determining the position of the deltoid muscle.

The densest part of the muscle is determined as follows: a line is drawn from the acromion process to a point on the shoulder at the level of the armpit. The needle is inserted approximately 2.5 cm below the acromion process to a depth of 90º.

The radial nerve and brachial artery should be avoided (Springhouse Corporation 1993).

You can ask the patient to place the hand on the thigh (as models do during shows), which makes it easier to find the muscle.

To identify the gluteus maximus muscle: the patient can lie on his side with his knees slightly bent, or with his big toes pointing inward. If the legs are slightly bent, the muscles are more relaxed and the injection is less painful (Covington and Trattler 1997).

Rice. 5b. Determination of the outer upper quadrant of the buttock.

Draw an imaginary horizontal line from the beginning of the intergluteal gap to the greater trochanter of the femur. Then draw another imaginary line vertically in the middle of the previous one, and at the top laterally is the upper outer quadrant of the buttock (Campbell 1995). The muscle that lies in it is the gluteus maximus muscle. If you make a mistake during the injection, you can damage the superior gluteal artery and sciatic nerve. The typical volume of fluid to administer in this area is 2-4 ml.

Rice. 5c. Definition of the anterior gluteal region.

Place the palm of your right hand on the greater trochanter of the patient's left thigh (and vice versa). Use your index finger to feel the upper anterior iliac crest and move your middle finger back to form a V (Beyea and Nicholl 1995). If you have small hands, this may not always be possible, so simply move your hand toward the ridge (Covington and Trattler 1997).

The needle is inserted into the gluteus medius muscle in the middle of the V at a 90º angle. The typical volume of drug solution to be administered in this area is 1-4 ml.

Rice. 5d. Identification of the lateral head of the quadriceps femoris and rectus femoris muscles.

In adults, the lateral head of the quadriceps femoris muscle can be identified on the palm below and lateral to the greater trochanter, and on the palm above the knee, in the middle third of the quadriceps femoris muscle. The rectus femoris muscle is located in the middle third of the anterior thigh. In children and elderly or malnourished adults, this muscle may sometimes need to be folded to ensure sufficient depth of injection (Springhouse Corporation 1993). The solution of the drug is 1-5 ml, for infants - 1-3 ml.

The rectus femoris muscle is part of the anterior quadriceps muscle and is a site rarely used for injection by nurses but is often used for self-administration of medications or in infants (Springhouse Corporation 1993).

IMPORTANT (3):
Learn to identify anatomical landmarks for each of these five intramuscular injection sites.
If you are used to injecting only into the upper outer quadrant of the buttock, then learn to use new areas and regularly improve your practice.

Methodology

The pain from the injection depends on the angle of insertion of the needle. When injecting intramuscularly, the needle should be inserted at an angle of 90° and make sure that the needle reaches the muscle - this will reduce the pain from the injection. A study by Katsma and Smith (1997) found that not all nurses insert the needle at a 90° angle, believing that this technique makes the injection more painful because the needle passes quickly through the tissue. Stretching the skin reduces the likelihood of needle damage and improves the accuracy of drug administration.

To insert the needle correctly, place the hand of your non-working hand and stretch the skin over the injection site with your index and middle fingers, and place the wrist of your working hand on the thumb of your non-working hand. Hold the syringe between the pads of your thumb and index finger, this is how you can insert the needle accurately and at the desired angle (Fig. 6).

Rice. 6. Method of performing intramuscular injection, needle injection angle 90º, anterior gluteal region.

There has been little research on this topic in the UK, so nurses may have very different injection skills and techniques (MacGabhann 1998). The traditional technique for performing intramuscular injections was to stretch the skin over the puncture site to reduce the sensitivity of the nerve endings (Stilwell 1992) and quickly prick the needle at a 90° angle to the skin.

However, a review of the literature by Beyea and Nicholls' (1995) indicated that the use of the Z-technique results in less discomfort and fewer complications than the traditional technique.

Z-method

This technique was originally proposed for the administration of drugs that stain the skin or are strong irritants. It is now recommended for intramuscular administration of all medications (Beyea and Nicholl 1995) as it is thought to reduce pain and the likelihood of drug leakage (Keen 1986).

In this case, the skin at the injection site is pulled down or to the side (Fig. 7). This moves the skin and subcutaneous tissue by about 1-2 cm. It is very important to remember that this changes the direction of the needle and may not hit the right place.

Therefore, after determining the injection site, you need to find out what muscle is under the superficial tissue, and not what skin landmarks you see. After injecting the drug, wait 10 seconds before removing the needle to allow the drug to be absorbed into the muscle. After removing the needle, release the skin. The tissue over the injection site will seal the deposit of the drug solution and prevent leakage. It is believed that if the limb is moved after injection, absorption of the drug will be accelerated as blood flow will increase at the injection site (Beyea and Nicholl 1995).

Rice. 7. Z-method.

Air bubble technique

This technique was very popular in the USA. Historically, it was developed during the days of glass syringes, which required the use of an air bubble to ensure that the dose of the drug was correct. Dead space in the syringe is no longer considered necessary because plastic syringes are calibrated more accurately than glass syringes and this technique is no longer recommended by manufacturers (Beyea and Nicholl 1995).

Recently, two dummy (slow-release oil solution) studies were conducted in the UK (MacGabhann 1998, Quartermaine and Taylor 1995) comparing the Z-technique and the air-bubble technique to prevent solution leakage after injection.

Quartermaine and Taylor (1995) suggested that the air bubble technique was more effective in preventing leakage than the Z-technique, but the results of MacGabhann (1998) were inconclusive.

There are questions regarding the accuracy of dosing when using this technique, since the dose of the drug in this case can be significantly increased (Chaplin et al 1985). Further research into this technique is required as it is considered relatively new in the UK. However, if it is used, the nurse must ensure that she is administering the correct dose to the patient and that the technique is used exactly as recommended.

Aspiration technique

Although aspiration is not currently recommended for guidance during subcutaneous injections, it should be used for intramuscular injections. If the needle mistakenly enters a blood vessel, the drug can be inadvertently injected intravenously, sometimes resulting in an embolism due to the specific chemical properties of the drugs. When administering the drug intramuscularly, the contents of the needle should be aspirated within a few seconds, especially if thin, long needles are used (Torrance 1989a). If blood is visible in the syringe, it is removed and a fresh drug is prepared for injection in another place. If there is no blood, the drug can be injected at a rate of approximately 1 ml per 10 seconds, this seems a little slow, but allows the muscle fibers to move apart to properly distribute the solution. Before removing the syringe, you must wait another 10 seconds, and then remove the syringe and press the injection site with an alcohol wipe.

There is no need to massage the injection site as this may cause leakage of the injection site and skin irritation (Beyea and Nicholl 1995).

Leather processing

Although cleansing the skin with an alcohol wipe prior to parenteral procedures is known to reduce bacterial counts, there is controversy in practice. Rubbing the skin to administer subcutaneous insulin predisposes the skin to hardening under the influence of alcohol.

Previous studies suggest that such wiping is not necessary and that lack of skin preparation does not lead to infectious complications (Dann 1969, Koivisto and Felig 1978).

Some experts now believe that if the patient maintains cleanliness, and the nurse strictly follows all standards of hygiene and asepsis during the procedure, then disinfection of the skin when performing an intramuscular injection is not necessary. If skin disinfection is practiced, the skin must be rubbed for at least 30 seconds, then allowed to dry for another 30 seconds, otherwise the entire procedure is ineffective (Simmonds 1983). In addition, injecting before the skin is dry not only increases soreness, but also may introduce live bacteria from the skin into the tissue (Springhouse Corporation 1993).

IMPORTANT (4):
What recommendations do you have for pre-injection skin treatment at your facility?
Find out what recommendations there are for insulin injections.
Are these recommendations consistent with the research evidence cited in the article?
What will you do?

IMPORTANT (5):
Imagine that you are observing a student who is about to perform his first injection. What tips or advice will you use in this case to help the student develop proper injection skills?

Equipment

Intramuscular needles should be long enough to reach the muscle, with at least a quarter of the needle remaining above the skin. The most common needles used for intramuscular injections are 21 gauge (green) or 23 gauge (blue), ranging from 3 to 5 cm in length. If the patient has a lot of fatty tissue, intramuscular injections require longer needles to reach the muscle. Cockshott et al (1982) found that the thickness of subcutaneous fat in the gluteal region in women can be 2.5 cm greater than in men, so a standard 21 G injection needle with a length of 5 cm reaches the gluteus maximus muscle in only 5% of women and 15 % of men!

If the needle has already pierced the rubber cap of the bottle, then it will become dull, and in this case the injection will be more painful, since the skin has to be pierced with greater force.

The size of the syringe is determined by the volume of solution injected. For intramuscular administration of solutions in volumes less than 1 ml, only small-volume syringes are used to accurately measure the required dose of the drug (Beyea and Nicholl 1995). To administer solutions of 5 ml or more, it is better to divide the solution into 2 syringes and inject into different areas (Springhouse Corporation 1993). Pay attention to the tips of the syringes - they have different purposes.

Gloves and auxiliary materials

Some facilities have policies that require the use of gloves and aprons when administering injections. It should be remembered that gloves protect the nurse from patient secretions and from developing drug allergies, but they do not provide protection from needlestick injuries.

Some nurses complain that it is uncomfortable for them to work with gloves, especially if they initially learned to perform this or that manipulation without them. If a nurse works without gloves, then you need to be careful and make sure that nothing gets on your hands—neither medications nor patients’ blood. Even clean needles must be disposed of immediately; under no circumstances should they be re-capped; needles should only be disposed of in special containers. Be aware that needles can fall from injection trays onto the patient's bed, which can result in injury to both patients and staff.

To protect overalls from splashes of blood or injection solutions, you can use clean disposable aprons; this is also useful in cases where a special sanitary regime is required (to prevent the transfer of microorganisms from one patient to another). You need to carefully remove the apron after the procedure so that any dirt that gets on it does not come into contact with the skin.

IMPORTANT (6):
Make a list of all the ways that help reduce the pain of injections. Compare with Table 1.
How can you incorporate more ways to reduce injection pain in your practice?

Table 1. Twelve Steps to Making Injections Painless

1	Prepare the patient, explain to him the essence of the procedure, so that he understands what will happen and strictly follows all your instructions
2	Change the needle after you have drawn up the medication from the vial or ampoule, and make sure it is sharp, clean, and of sufficient length.
3	In adults and children over seven months of age, the site of choice for injection is the anterior gluteal region
4	Position the patient so that one leg is slightly bent - this reduces pain during the injection
5	If you are using alcohol wipes, make sure your skin is completely dry before injecting.
6	You can use ice or a freezing spray to numb the skin, especially for young children and patients who have a phobia of needles.
7	Use the Z-technique (Beyea and Nicholl 1995)
8	Change sides of injections and note this in your medical records
9	Pierce the skin carefully, at an angle of close to 90 degrees, to prevent pain and tissue displacement
10	Gently and slowly inject the solution at a rate of 1 ml per 10 seconds so that it is distributed into the muscle
11	Before removing the needle, wait 10 seconds and pull the needle out at the same angle as you inserted.
12	Do not massage the injection site after it is completed, just apply pressure to the injection site with a gauze pad

Pain reduction

Patients are very often afraid of performing injections because they assume that it will hurt. Pain usually occurs due to irritation of pain receptors in the skin or pressure receptors in the muscle.

Torrance (1989b) provided a list of factors that can cause pain:

Chemical composition of the drug solution
Injection technique
Rate of drug administration
Volume of drug solution

Table 1 lists ways to reduce pain from drug injection.

Patients may have severe needle aversion, fear, and anxiety, all of which significantly increase injection pain (Pollilio and Kiley 1997). Good technique for performing the procedure, adequate information to the patient and a calm, confident nurse are the best way to reduce the pain of the procedure and reduce the patient’s reaction. Behavior modification techniques may also be used, especially when the patient is undergoing long-term treatment and sometimes requires the use of needle-free systems (Pollilio and Kiley 1997).

Numbing the skin with ice or cooling sprays prior to the injection has been suggested to reduce pain (Springhouse Corporation 1993), although there is currently no research evidence to support the effectiveness of this technique.

Nurses should understand that patients may even experience syncope or fainting after routine injections, even if they are otherwise healthy. It is necessary to find out whether this has happened before, and it is advisable that there is a couch nearby on which the patient can lie down - this reduces the risk of injury. Most often, such fainting occurs in adolescents and young men.

Complications

Complications that develop as a result of infection can be prevented by strict adherence to aseptic techniques and thorough hand washing. Sterile abscesses can result from frequent injections or poor local blood flow. If the injection site is swollen or the area of the body is paralyzed, the drug will be poorly absorbed and such areas should not be used for injection (Springhouse Corporation 1993).

Careful selection of the injection site will avoid nerve damage, accidental intravenous injection and subsequent embolism from drug components (Beyea and Nicholl 1995). Systematic rotation of the injection site prevents complications such as injection myopathy and lipohypertrophy (Burden 1994). The appropriate needle length and use of the anterior gluteal region for injection allows the drug to be injected precisely into the muscle, and not into the subcutaneous fat. The use of the Z-technique reduces the pain and skin discoloration associated with the use of some medications (Beyea and Nicholl 1995).

Professional responsibility

If the drug is administered parenterally, there is no way to “return” it. Therefore, it is always necessary to check the dose, the correctness of the prescription, and ask the patient his last name so as not to confuse the prescription. So: the right medicine for the right patient, in the right dose, at the right time, and in the right way - this will help avoid medical errors. All drugs must be prepared exclusively according to the manufacturer’s instructions; all nurses must know how these drugs work, contraindications to their use and side effects. The nurse must assess whether the drug can be used in the patient at this time (UKCC 1992).

conclusions

Safely administering injections is one of the primary functions of the nurse and requires knowledge of anatomy and physiology, pharmacology, psychology, communication skills, and practical experience.

There are studies that prove the effectiveness of injection techniques in preventing complications, but there are still “blind spots” that need more research. This article focuses on research-proven techniques so that nurses can incorporate these procedures into their daily practice.

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