Download Administering intramuscular and subcutaneous injections in

Continuing Education Module 19: Child Health
Administering intramuscular and
subcutaneous injections in children
Sound clinical judgement and individualised assessment is essential to ensure safe
practice when administering injections to children, writes Naomi Bartley
Table 1
Children and nurses often view the administration of injections
as a traumatic procedure. Nurses aim to avoid administering
injections to children unnecessarily. However, certain medications may only be administered by injection, as alternative routes
are not viable or may not facilitate absorption.1 Correct injection
technique can reduce complications, injury and discomfort for
the child.
Recent years have seen a reduction in the use of intramuscular
injections in particular. The introduction of alternative analgesia
techniques, such as epidurals, intravenous infusions, and patient
and nurse controlled analgesia has reduced the volume of injections administered. Despite this, the administration of injections
remains a fundamental nursing practice and children’s nurses
need to update their knowledge and skills.
Necessary skills for good injection technique include knowledge of: anatomy and physiology; pharmacology; suitable
injection sites and injection techniques for children; clinical holding; and effective communication skills.
Evidence-based nursing guidelines for the administration of
both intramuscular (IM) and subcutaneous (SC) injections were
created within Our Lady’s Children’s Hospital to support best
practice and safe administration of medication.
Individual child assessment
The nurse should initially assess whether an injection is the
optimum route for the child. There is no universal agreement
on optimum injection site, needle size or injectable volumes,
therefore, children’s nurses must recognise the importance of
individual child assessment and clinical judgement to ensure
best practice when administering IM and SC injections to children (see Table 1).
An injection is the percutaneous introduction of a medicine via
needle and syringe but may also involve newer devices, such as
an auto-injector2 (see Table 2).
An IM Injection is a method of administering medication
directly into muscle tissue.1 The rate of medication absorption is
faster than the SC route and muscles tolerate a greater volume of
fluid3 (see Table 3).
An SC injection delivers medication below the epidermis and
dermis layers into subcutaneous tissue1. The rate of absorption
is slower than the IM route, as SC tissue has less blood supply.4
SC injections are often self-administered by the child or given by
a family member or caregiver. Education and support are vital.
Some children use an automatic injection device when administering an SC injection (see Table 4).
Injection sites for children
Individual assessment is recommended to select the appropri-
Intramuscular injection sites*
The deltoid
This is easily accessible but not recommended for repeated
injections or large volumes due its small muscle mass
Land marking this site:
• Expose the arm completely from shoulder to elbow
• Two finger widths down from acromion process; the bottom
edge is at an imaginary line drawn from axilla
• Injection site is 3-5cm below the acromion process
The vastus lateralis
This stretches from the greater trochanter of the femur to the
lateral condyle of the knee. It is an ideal site as it is easily
accessible, a large muscle mass and has no major blood
vessels or nerves in the area4
Landmarking this site:
• Identify greater trochanter and lateral femoral condyle.
Identify the muscle position
• Divide the muscle into thirds. Middle third is the injection
site, in the upper lateral quadrant of the thigh
Subcutaneous injection sites
• Upper thigh, abdomen, upper arm and buttocks1
• Abdomen is the preferred site as medication is absorbed
more quickly and uniformly and less affected by exercise8
*Important: The gluteus maximus muscle is not recommended for
IM injections in children, due to the potential for damage to the
nearby sciatic nerve and gluteal artery1
ate injection site for children and use of the correct injection site
is a major factor in limiting complications.5 When identifying an
injection site, position the child to allow relaxation of the limb.
Factors to consider
Child
• Size/age: the muscle should be accessible, well-perfused, welldeveloped and able to tolerate the volume of the medication.1,3
For IM injections, the vastus lateralis is recommended for children under two years of age.3 For children over three years, the
deltoid may be more appropriate6
• Child/parent’s preference: Encourage involvement, when appro-
Sponsored by an unrestricted grant from Nurofen for Children
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Clinical Focus 2012
Table 2
Use of auto-injectors
• Used with SC injections only
• Needle angle will be 90 degrees
• Single-use product
• Refer to the manufacturer’s instructions as various products are
available
• Can assist in reducing fears associated with injection
Table 3
priate. Research has shown that children who are sitting up and
infants who are held by their parents appeared to experience
less pain during injections7
• Child’s position: Correct positioning may minimise anxiety or
discomfort1 and assist in accurate landmarking of the site. Consider the child’s ability to maintain the required position safely.3
Medication
• Frequency of injections – sites must be rotated to avoid fibrosis
of the injection site
• For the administration of more than one injection, use separate
sites. If using one limb, allow a distance of 25mm between sites
to reduce local reactions6
• Type of medication and specific manufacturer’s instructions for
administration.
Volume of injection
This is poorly researched for children. Individual assessment
of the child and the medication is essential. 9 For IM injections,
0.5-2ml may be injected depending on the age and size of the
child.3 The Z-track technique can reduce pain and prevent complications associated with IM injections. This technique avoids
potential back flow of medication as the needle track is sealed
Table 4
Administering an IM injection
Consider correct route
IM route appropriate
for this child?
If not suitable, do
not administer
injection
Select correct site
Individually assess each
child
0-12 months: Vastus lateralis
Older child: Vastus lateralis/deltoid
Three years plus: Deltoid
Refer to clinical
nurse manager
and medical
team
Administering a SC injection
Consider correct route
SC route appropriate
for this child?
Select correct site
Individually assess each
child
Prepare child/family
Prepare child/family
Needle guage:
All ages: 23-25 gauge
Bleeding disorders: 23 gauge
Select correct needle
length. Individually
assess each child
Needle length:
All ages: 25mm
Very small infants/pre-term babies:
Consider shorter length
Prepare medication
Administer IM injection
• Inject medication to densest portion of muscle
• Inject at a 90º angle
• Aspirate for five seconds. Discard if blood is present
• Inject medication slowly (10 sec/ml)
•Prepare
Leave needle
in place for 5-10 seconds after injecting medication
medication
• Remove needle swiftly
• Apply gentle pressure with sterile gauze. Do not rub
• Use Z-track technique if possible
Reassure and praise child
Assess child
Child Health Oct GT TH.indd 2
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Refer to clinical
nurse manager
and medical
team
Infant: Consider buttocks
Older child: Thigh, abdomen,
upper arm
Ensure rotation of sites
Needle guage:
16mm length for all ages
or insulin syringe
Prepare medication
Administer SC injection
• Gently bunch/lift up skin
• Inject at a 45º or 90º angle
– 90º angle insertion: recommended for all ages
– 45º angle insertion: if needle length is greater than 8mm or for
children
little subcutaneous tissue
Preparewith
medication
• Avoid squeezing the skin too tightly
• Inject medication slowly and release skin
• Leave needle in place for 5-10 seconds after injecting medication
• Remove needle swiftly
• Apply gentle pressure if any evidence of bleeding
Reassure and praise child
Assess child
Document procedure
40
Select correct needle
Prepare
length.
Individually
assess each child
If not suitable, do
not administer
injection
Document procedure
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Clinical Focus 2012
Table 5
Table 6
Z-track technique
• Gently pull/displace the skin with your non-dominant hand, 1cm
laterally from the land marked injection site. This displaces the
tissues prior to injection3
• Hold this position until the medication is administered and the
needle is removed
• After removing the needle, release the pull on the skin. This seals
the medication within the muscle layer and prevents medication
leakage3
off after injecting the medication.3 It is useful for medication that
may stain the skin, such as iron (see Table 5).
Potential complications
The majority of complications are associated with IM injections,
but complications may occur after any type of injection. These
may be due to local trauma from the injection itself or from the
medication.10 Adverse events may be due to incorrect site, inappropriate injection depth or rate of injection. 9 Complications
include:
• Pain
• N erve damage, tissue necrosis, intramuscular haemorrhage,
abscess, allergic reaction, needle phobia
• Granuloma, intravascular injection, cellulitis
• Muscle fibrosis with repeated use of the same site
• M edication errors with use of low dose syringes (measure in
units not millilitres).
Updating knowledge and skills
Children’s nurses are encouraged to update their knowledge
and skills in relation to the practice of administering injections.
Sound clinical judgement and individualised assessment is essential to ensure safe practice. The information within this article is
based on Nursing Guidelines on the Administration of IM and SC
injections within Our Lady’s Children’s Hospital, Crumlin.
Naomi Bartley is a clinical placement coordinator at Our Lady’s Children’s Hospital,
Crumlin, Dublin
References:
1. Ford L, Maddox C, Moore E, Sales R. The safe management of medicines for children. In:
Practices in Children’s Nursing: Guidelines for Community and Hospital. Churchill Livingstone, Edinburgh, 2010: 417-45
2. World Health Organisation. WHO Best Practices for Injections and Related Procedures
Toolkit. WHO, Geneva, 2010
3. Barron C, Hollywood E. Drug administration. In: Clinical Skills in Children’s Nursing.
Oxford; Oxford University Press, 2010: 147-81
4. Barrett G, Fletcher T, Russell T. Fundamental aspects to safe administration of medicine.
In Fundamental Aspects of Children’s and Young People’s Nursing Procedures. London;
Quay Books, 2007: 123-80
5. Wynaden D, Landsborough I, McGowan S et al. Best Practice Guidelines for the Administration of Intramuscular Injections in the Mental Health Setting. Int J Mental Health
Nursing, 2006; 15(3): 195-200
6. National Immunisation Advisory Council. Immunisation Guidelines for Ireland. 2010
Available at http://www.immunisation.ie/en/Downloads/NIACGuidelines/
PDFFile_15498_en.pdf
7. Taddio A, Ilersich AL, Ipp M, Kikuta A, Shah V. Physical interventions and injection techniques for reducing injection pain during routine childhood immunisations: systematic
review of randomised controlled trials and quasi-randomised controlled trials, Clinical
Therapeutics, 2009; 31: Supplement B: 48-76
8. Royal Children’s Hospital. Diabetes Manual, 2011. Available at: http://www.rch.org.au/
diabetesmanual/manual.cfm?doc_id=2733
9. Malkin B. Are techniques used for intramuscular injection based on research evidence?
Nursing Times 2008; 104(50-51): 48-51
10. Barron C, Cocoman A. Administering intramuscular injections to children: what does
the evidence say? J Children’s and Young People’s Nursing 2008; 2(3): 138-44
11. Parboteah S. Safety in practice. In Foundations of Nursing Practice, Making the Difference. Hampshire; Palgrave Macmillan, 2002
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General principles for the administration of
injections
Preparation of medication
• Gather equipment in advance
• Decontaminate hands before and after the procedure
• S elect syringe size as similar as possible to medication
volume to ensure accurate dosage
• Select needle length and gauge according to individual child
assessment
• C hange needles after drawing up medication, so a clean
needle is used for administration. This reduces tissue
irritation, pain and inadvertent administration of foreign
particulate matter1
Administering the injection
• A dminister all medication as per local policy and ABA
guidelines
• Use non-dominant hand to secure the injection site and use
dominant hand to inject the medication
• Hold syringe firmly between thumb and forefinger, with heel
of the hand resting on the thumb of the non-dominant hand
• Skin disinfection is not required – use soap and water if
necessary. Children who are immunosuppressed do require
skin disinfection. Allow the chlorhexidine/alcohol swab
40 seconds to dry prior to injection
• F or heparin or insulin injections, avoid alcohol swabs as
alcohol may interfere with these medications11
• Insert needle smoothly and swiftly to avoid trauma
• If possible, leave needle in place for 5-10 seconds after
injecting medication to allow tissue expansion and
medication absorption
• A pply gentle pressure with sterile gauze. Do not rub the
site as this may cause discomfort and/or interfere with
medication absorption1
Injections for infants
• Administer oral sucrose two minutes prior to and during the
procedure to reduce pain
• Providing a carbohydrate containing drink one to two minutes
prior to injection can reduce pain6
• Offer a soother if appropriate
Children with bleeding disorders
• S eek expert advice before administering injections to
children with thrombocytopenia, bleeding disorders or those
on anticoagulants
• Use a 23 gauge needle
• Consider administering medication by SC injection
• Apply pressure with sterile gauze to the injection site for
1-2 minutes after the injection6
After the injection
• Dispose of equipment as per local policy
• Assess child during and after the procedure
• Document the procedure
• Refer any adverse events to medical team as appropriate
• Provide verbal or written advice to the child/parent/carer
• Ensure clothing at the site is not too tight to reduce
discomfort
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