Competency Validator Guideline
Competency title: Intramuscular Injection
Developed by: June Levine RN MSN National Consultant Ambulatory Nursing Ben
Hudnall Memorial Trust, Rachel Conway RN MSN - KP North West Region;
Step Information:
NA
Step 1. Assesses for age appropriate care for syringe/needle
selection: Able to state the needle size differences for adults and
children
Syringe size: Adults: 1-5 ml syringe; infants and small children, 0.5-1 ml;
Needle size 22-25gauge;
Needle length: Adult, 1-1 ½ inches; Small children, 5/8 - 1 inch; For overweight children
could go up to 1 ½ inch
Step 6. If MA is giving the medication, the MA, LVN, and RN need to
explain the verification process including documentation
MA must bring medication vial or prefilled syringe, needle and medical order to the
LVN/LPN, RN or provider to have them verify how much medication will be drawn up.
Documentation must include who verified the medication administration.
Step 8. Explains procedure
Advises patient to remain still, explain where you will give injection, they will feel a little
stick and then you will remove the needle. Advise them that they will or will not feel
medicine being injected – be truthful. If child is under 14 years of age, they should be
told the same thing and emphasize that it will only hurt for a few seconds and they need
to remain still. Obtain parental assistance as needed
Step 9. Selects appropriate injection site
Site is the single most consistent factor associated with complications and injury.
Consider: Age of patient:
● Infants: vastus lateralis is the preferred site*
● Toddlers and children: vastus lateralis or deltoid (with full muscle development)
● Adults: ventrogluteal or deltoid*
Selects site free of bruises, inflammation, lesions or discoloration
Intramuscular Injection
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Ambulatory RN Residency Program
Ben Hudnall Memorial Trust 2011
August 2012
A. Which of the following age groups should not be given an IM injection in the
deltoid area?
a. 6-11 months
b. 1-2 years
c. 2-4 years
d. 3-6 years
B. The vastus lateralis site is used most often to administer medication to?
a. Adults
b. Infants
c. Adolescents
d. Elderly Patients
C. The _____ site should be used for IM injection for the toddler or child?
a. Vastus lateralis
b. Deltoid
c. Vastus lateralis or deltoid
D. The _____ site should be used for IM injection for the adult?
a. Vastus lateralis
b. Ventrogluteal
C. The general recommended length of needles to inject a vaccine in a 4-year old’s
deltoid is?
a. 1 inch
b. 5/8 inch
c. 1 ½ inch
D. What is the angle of insertion in administering an IM injection?
a. 10-15 degrees
b. 45 degrees
c. 90 degrees
d. Parallel to the skin
The presence of major nerves and blood vessels and the relatively slow uptake of
medication from the dorsogluteal site compared with other sites, added to the often thick
layer of adipose fatty tissue, makes this site problematic
Because of the location of the sciatic nerve, dorsoglutal injection site may cause
permanent or partial paralysis of the involved leg if the needle hits the involved
leg.
Intramuscular Injection
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Ambulatory RN Residency Program
Ben Hudnall Memorial Trust 2011
August 2012
Step 23 & 24. Assists patient as required, observes for reactions and
provides further instructions.
Explains how long patient would be observed for different medications common to the
practice site and this person’s licensure to give certain medications. Explains that
patient’s previous reaction to this particular medication or other medications will
influence how long they stay. Assures patient is not driving if medication will alter their
ability to drive.
Step 25 Explains documentation process.
Documents thoroughly and accurately in patients medical record (should include
medication, dosage, route, injection site, effects of medication, any follow-up instructions
date, time, name and title). If immunization must also document manufacturer, lot
number and expiration
Critical thinking/Problem Solving question(s)
NA
Step 26. How much air do you inject?
None, This is no longer a recommended practice. It can decrease the accuracy of
medication dose.
Step 27. When giving multiple injections, what is the recommended
distance between sites?
1-2 inches
Step 28. What are the possible complications of IM injections?
Giving an IM injection is not a benign procedure; there are numerous reports in the
literature of patient complications related to improperly administered IMs.
Common complications include skeletal muscle fibrosis and contracture, abscesses at
the injection site, nerve injury & gangrene. Complications due to inappropriate
administration of IM injections fall into the area of medical errors.
Step 29. Which site is the preferred site for all ages? Why?
Ventrogluteal
This site provides the greatest thickness of gluteal muscle and consists of both the
gluteus medius and gluteus minimus. It is free of penetrating nerves and blood vessels
and has a narrower layer of adipose fat of consistent thinness than is present in the
dorsogluteal site.
The dorsogluteal site often preferred has a significant risk of sciatic nerve and superior
gluteal artery – lies only a few centimeters distal to the injection site.
Intramuscular Injection
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Ambulatory RN Residency Program
Ben Hudnall Memorial Trust 2011
August 2012
The subcutaneous fat in adults in the dorsogluteal area varies from 1–9 cm varies in a
very small percentage of patients actually receiving an IM injection. The presence of
major nerves and blood vessels and the relatively slow uptake of medication from
the dorsogluteal site compared with other sites, added to the often thick layer of
adipose fatty tissue, makes this site problematic
When using this site that the upper outer quadrant be divided into four quadrants, so that
the injection is given in the outer quadrant of the upper outer quadrant, approximately 1–
2 cm below the iliac crest.
Step 30. Demonstrate how you find the landmarks for ventrogluteal
injection?
Land marking instructions: Find the trochanter (knobby top portion at the top of the femur
(leg). Find the anterior iliac crest. The iliac crest is the thick curved upper border of the
ilium, the most prominent bone on the pelvis. (You can feel the iliac crest by pushing
your hands on your sides at your waist, feeling for the bone and following it down and to
the front.)
Step 31. Describe how to administer an IM injection by Z Track?
1. After accurately land marking the injection site, displace the skin over the injection site
by pulling the skin laterally away from the underlying muscle with your non- dominant
hand (you should move the skin about 1⁄2 inch or 1 cm)
2. Hold the syringe like a pencil or dart, and insert the needle at a right angle to the skin
(90°) with your dominant hand.
3. Pull back plunger. If no blood is aspirated, depress the plunger at approximately 1ml
per 10 seconds and inject the drug slowly
4. When withdrawing the needle, release the retracted skin at the same time. This
maneuver seals off the puncture tract and traps the drug in the muscle.
Positioning: Position your right hand to patient’s left side if using the left ventrogluteal
site, or place your left hand to patient’s right side for the right ventrogluteal site. Place
the palm of your hand over the trochanter. Point your index finger toward the anterior
(front) iliac crest. Spread the second or middle finger toward the back of the iliac crest,
making a V with your fingers. The injection site is in the middle of this V, level with the
knuckles of your fingers. The thumb should always be pointed toward the front of the
patient’s body.
The literature suggests that up to 3mls of fluid may be administered into this site. It is
important to remember that, as with injections at any other site, good injection practice is
equally important at the ventrogluteal site.
Adapted from: Engstrom et al, 2000; Cocoman and Murray, 2008; United Kingdom
Psychiatric Pharmacy Group, 2009
Intramuscular Injection
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Ambulatory RN Residency Program
Ben Hudnall Memorial Trust 2011
August 2012
Interpersonal question(s):
NA
Step 32. How would you restrain a child, if needed?
Place child on parent’s lap. Give job a few minutes to calm down, Instruct parent to “hug”
child, restraining arms, with child’s head against parent’s chest.
Curriculum content:
NA
Refer to Power Point in the Curriculum
Developed August 2010, Revised August 2012,
.
Intramuscular Injection
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Ambulatory RN Residency Program
Ben Hudnall Memorial Trust 2011
August 2012