Running head: INJECTION SIGHTS
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Evidence-Based Intramuscular Injection Sights vs. Dorsogluteal Injection Sight
Kelli J. Koop
Ferris State University
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INJECTION SIGHTS
Introduction
In current healthcare settings, intramuscular (IM) injections are considered a basic
skill performed in everyday practice by registered nurses. For most nurses, IM injections
are simple tasks executed without much concentration or thought. Contrary to belief,
history has proven IM injections to be complicated and potentially harmful to the patient.
Prior to performing an IM injection, there are many nursing considerations and
assessments to complete.
In the past, there were four evidence-based intramuscular injection sights:
dorsogluteal, ventrogluteal, vastus lateralis and deltoid. For many years, the most popular
injection sight was the dorsogluteal. Today, there are many studies on the pros and cons
for each intramuscular injection sight. Though not adopted by all nurses, there has been
evidence-based research that has suggested and proven the dorsogluteal sight to be
dangerous and no longer considered an appropriate injection sight.
Evidence-Based Practice
Healthcare practices and skills are evolving every day. New evidence-based
research discoveries are slowly being implemented into healthcare policies and standards.
Though evidence-based practices (EBP) are crucial to patient safety and success, most
clinical decisions are made by traditional practices and personal preferences (Cocoman,
pp.1171, 2010). Research shows there can be anywhere from an eight to thirty year
deficit between evidence-based discoveries and implementation into the healthcare
settings (Hauck, pp. 665, 2013). There are many factors that contribute to the
discrepancy: lack of access to EBP research and skills to evaluate and integrate the
research into practice, lack of technical skills, and negative attitudes (Hauck, pp. 665,
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2013). Though it is the nurse’s responsibility to learn the skills, it falls on administration
leaders to introduce EBP research.
Registered nurses have a busy career, especially with the current nursing shortage,
which makes it difficult for them to find time to read about new practices and skills.
Time-consuming and difficult research for evidence-based articles increase the chance
nurses will ask other co-workers for information or advice before researching new EBPs.
It is essential that administrative leaders provide easy access to these resources to
encourage initiative in their nurses to research and find EBPs on their own.
Learning and perfecting new skills take time and effort nurses have little to none
of by the end of the workday. Skill labs should be required for all nurses during work
hours if they are expected to perform new skills in the practice setting. For example, if
the ventrogluteal sight is the best but most unfamiliar injection sight, workshops need to
be available so nurses can become skilled at administering them. This will not only
increase technical skills, but also create positive attitudes about EBPs by increasing the
nurse’s comfort and confidence in the new skills. Nurses need to be evolving with the
new EBPs if they expect to provide the best healthcare possible.
Evidence-Based Injection Sights
According to Taylor, the deltoid is one of four intramuscular sights and the most
popular for vaccine injections. It is located in the upper arm. This sight does come with
risks, a misplaced injection could cause damage to the radial nerve or artery. In order to
find the correct placement, palpate for the acromion process and axilla. Next, form a
triangle on the lateral aspect of the upper arm in-between the acromion process and axilla
and inject into the middle of the triangle. No more than one milliliter should be injected
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into this sight (Taylor, pp. 753, 2011).
As stated by Taylor, the vastus lateralis injection sight is located at the mid thigh.
This sight is one of the preferred sights because it has no large nerves or blood vessels to
damage. This sight is also the largest, allowing for multiple injections at the same sight.
To locate the injection location, divide the thigh into thirds horizontally and vertically,
placing the needle in the outer middle section. This injection sight is used most often on
infants and children because the muscles at the other injection sights are poorly
developed (Taylor, pp.753, 2011).
According to Taylor, the ventrogluteal injection sight is suggested to be the ideal
injection sight, although no evidence-based research has proven this to be true. This sight
provides a large muscle mass with little subcutaneous tissue (fat tissue) and very little
blood vessels and nerves, perfect for intramuscular injections. In order to find its location,
place the palm of the hand on the greater trochanter, placing the index finger on the
anterosuperior iliac crest and extending the middle finger dorsally along the iliac crest.
This forms a triangle in-between the fingers, and the needle is injected centrally. Use the
right hand on the patient’s left hip and the left hand on the patient’s right hip. Though this
sight is one of the preferred locations, it is the least used due to unfamiliarity (Taylor, pp.
752-753, 2011).
Dorsogluteal Injection Sight
The dorsogluteal, according to Taylor, is traditionally the most favored
intramuscular injection sight for most nurses. The location of this injection sight is
described as the upper-outer quadrant of the buttocks. Nurses could be more precise by
visually cutting the first quadrant into four sections again and using that upper-outer
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quadrant section (Taylor, pp. 753-754, 2011).
This sight, however, has been proven by evidence-based research to be potentially
harmful for the patient. There are many harmful complications that could occur if the
sight is not properly landmarked. The sciatic nerve and gluteal artery are located only a
few centimeters from the dorsogluteal sight (Cocoman, pp. 1171, 2010). If a nurse
accidentally deviated slightly outside the quadrant, the needle could hit the sciatic nerve
or gluteal artery causing a variety of effects, such as minor motor/sensory abnormalities
or even complete paralysis of the leg (Small, pp. 288, 2004).
Another complicated issue with using the dorsogluteal injection sight is the
anatomy of the location. The buttock area commonly has a thick layer of subcutaneous
tissue ranging from one to nine centimeters (Cocoman, pp.1171, 2010). This creates the
problem of administering the medication into the correct location, the gluteal muscle. In
one study of two hundred and thirteen patients, only five to fifteen percent received an
accurate intramuscular injection (Cocoman, pp. 1171, 2010). Also, with Americans
becoming increasingly obese, patients will have a thicker layer of subcutaneous tissue in
the buttocks. This will decrease the chances even more of giving a proper intramuscular
injection in the dorsogluteal sight. Suggestions have been made to increase the length of
the needle to better bypass the subcutaneous tissue, but this will likely increase the risk
for harm and discomfort to the patient (Cocoman, pp. 1171, 2010).
Nursing Considerations
When administering an intramuscular injection, there are many issues to address.
Nurses should only perform intramuscular injections after an individualized assessment
for an appropriate sight (Small, pp. 291, 2004). One of the most important issues is
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deciding on the correct sight and locating appropriate landmarks and boundaries.
Traditionally in the practice setting, the injection sight is chosen by using the nurse’s or
patient’s personal preference. This is not an evidence-based practice. The nurse should
assess the patient fully, including weight and muscle mass, before choosing an
appropriate injection sight. If the patient has too much subcutaneous tissue at the sight,
the medication might not reach the muscle and cause future complications. On the other
hand, if the patient’s muscle is underdeveloped, the injection could cause serious damage
and pain to the patient.
After the injection sight has been chosen, “it is important to be able to identify
anatomic landmarks and site boundaries and use an accurate, careful technique when
administering intramuscular injections” (Taylor, pp. 751, 2011). Inaccurate positioning of
the needle could cause a number of harmful and painful problems to the patient, such as
an abscess, cellulitis, tissue necrosis, granuloma, muscle fibrosis and contracture,
hematoma, and injury to blood vessels, bones and peripheral nerves (Small, pp. 287,
2004). Experienced nurses might not use landmarks and site boundaries anymore because
of the belief that they have enough experience to “eye-ball” the sight; again, this is not
evidence-based practice and could cause harm to the patient as well as to the nurse’s
career.
Conclusion
Though the dorsogluteal injection sight has evidence-based research proving to be
harmful, it is still being used to this day. Evidence-based practice is not being
implemented into healthcare settings as efficiently as it should be. The amount of
responsibility nurses have for patient care and safety is increasing everyday, making it
INJECTION SIGHTS
more and more important for nurses to use evidence-based practices.
The dorsogluteal injection sight should be discontinued and the promotion of the
ventrogluteal, vastus lateralis, or deltoid sights should be encouraged. To avoid
complications for all intramuscular injection sights, nurses must know the anatomy,
advantages and disadvantages of each injection site, and be able to accurately identify
anatomic landmarks and boundaries (Small, pp. 294, 2004). Incorporating evidencebased practice will create successful nursing practice and patient outcomes (Hauck, pp.
673, 2013).
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References
Hauck, S., Winsett, R. P., & Kuric, J. (2013). Leadership facilitation strategies to
establish evidence-based practice in an acute care hospital. Journal Of Advanced
Nursing, 69(3), 664-674. doi:10.1111/j.1365-2648.2012.06053.x
Small, S. (2004). Preventing sciatic nerve injury from intramuscular injections: literature
review. Journal Of Advanced Nursing, 47(3), 287-296. doi:10.1111/j.13652648.2004.03092.x
Cocoman, A., & Murray, J. (2010). Recognizing the evidence and changing practice on
injection sites. British Journal Of Nursing, 19(18), 1170-1174. Retrieved from
http://illiad.ferris.edu.
Taylor, C., LeMone, P., Lillis, C., & Lynn, P. (2011) Fundamentals of Nursing: The Art
and Science of Nursing Care. Wyoming: Lippinocott Williams & Wilkins.