IM Injection-SON-TH 16/03/2006 16:47 Page 1

Clinical Practice

IM injections:
THE ADMINISTRATION of intramuscular
injections is a common nursing interven-
tion in clinical practice.1 This article aims
to, raise awareness in relation to the injec-
tion sites used for intramuscular injection

How’s your
and, to highlight best practice in relation
to IM injection administration.
The importance of good injection tech-
nique cannot be understated. It should
not be forgotten that among potential
complications of IM injection are abscess,

technique?
cellulites, tissue necrosis, granuloma, mus-
cle fibrosis, contractures, haematoma and
injury to blood vessels, bones and periph-
eral nerves.2 Although IM injection is a
commonplace nursing practice, there is a
dearth of guidelines for nursing staff in
this area.3,4 It has been outlined that there
are no working policies or procedures on
Good injection technique can mean the administering injections to which nursing
difference between less pain and injury. staff can refer.3 Furthermore, the technique
and preparation by certain staff may not
Angela Cocoman and John Murray explain be substantiated by evidence.4
Sites of the thigh (Rectus femoris and
Vastus lateralis)
The uptake of drugs from the thigh
Giving an IM injection into the Vastus lateralis site region is slower than from the arm but
faster than from the buttock, thus facilitat-
❚ To find the thigh injection site, make an
ing better drug serum concentrations
imaginary box on the upper leg. Find the groin.
One hand’s width below the groin becomes the than is possible with the gluteal muscles.5
upper border of the box The thigh may be utilised when other
sites are contraindicated or by clients who
❚ Find the top of knee. One hand’s width above Vastus Lateralis
administer their own medication, as it is
the top of the knee becomes the lower border
Rectus Femoris readily available in the sitting or lying back
of the box
position. However, the main disadvantage
❚ Stretch the skin to make it tight
is that injections in the Rectus femoris site
❚ Insert the needle at a right angle to the skin may cause considerable discomfort.6
(90°) straight in This site can be used for infants, children
❚ Up to 2ml of fluid may be given into this site and adults. Needle length used is usually
2.5cm or less.
The dorsogluteal site
IM injection into the Gluteus medius site (buttock) This site is commonly referred to as the
outer upper quadrant and is contraindi-
❚ Find the trochanter. It is the knobbly top
cated in children.
portion of the long bone in the upper leg
The presence of major nerves and blood
(femur). It is the size of a golf ball Gluteus Maximus vessels, the relatively slow uptake of med-
❚ Find the posterior iliac crest. Many people ication from this site compared with
have ‘dimples’ over this bone others and the thick layer of adipose tis-
Greater Trochanter
❚ Draw an imaginary line between the two sue commonly associated with it, makes
bones Sciatic Nerve this site problematic.7 The sciatic nerve
❚ After locating the centre of the imaginary and superior gluteal artery lie only a few
line, find a point one inch toward the head. centimetres distal to the injection site,
This is where (X) to insert the needle thus great care needs to be taken to iden-
❚ Stretch the skin tight tify landmarks accurately. Palpating the
❚ Hold the syringe like a pencil or dart. Insert the needle at a right angle to the skin ileum and the trochanter is important;
using visual calculations alone can result
❚ Up to 3ml of fluid can be given in this site
in injection being placed too low and

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Clinical Practice

Giving an IM injection into the deltoid site

❚ Find the knobbly top of the arm (acromion Achromial Process
process)
❚ The top border of an inverted triangle is
two finger widths down from the acromion rower layer of fat of consistent thinness
process than is present in the dorsogluteal.10
The ventrogluteal site has come to
❚ Stretch the skin and then bunch up the
muscle attract significant attention in the nursing
literature and there is wide agreement
❚ Insert the needle at a right angle to the Brachial Artery
that this site is the preferable site for intra-
skin in the centre of the inverted triangle
Radial Nerve
muscular injection.2 There is a dearth of
Caution: This is a small site – give only research in this area in Ireland as to the
1-2ml or less of fluid in this site extent to which the ventrogluteal site is
used.
Administrating an IM injection
Giving an IM injection into the ventrogluteal site There is a large research base for nurs-
❚ Find the trochanter. It is the knobbly top Anterior Superior Iliac Crest ing practice to be guided by in relation to
portion of the long bone in the upper leg Location of Gluteus Medius the administration of intramuscular injec-
(femur). It is about the size of a golf ball tions and it is the responsibility of nurse
❚ Find the anterior iliac crest Injection Point educators to ensure that appropriately
(between the knuckle of the
❚ Place the palm of your hand over the informed guidelines are devised.4
index and middle finger)
trochanter. Point the first or index finger It has been suggested4 that the follow-
Greater Trochanter ing points should be incorporated into
toward the anterior iliac crest. Spread the
second or middle finger toward the back, clinical guidelines:
making a ‘V’. The thumb should always be ● IM injections should be administered in
pointed toward the front of the leg. Always the Ventrogluteal region whenever pos-
use the index finger and middle finger to make the ‘V’ sible
❚ Give the injection between the knuckles on your index and middle fingers ● The medication should be administered

❚ Stretch the skin tight with a needle long enough to reach the
muscle without penetrating underlying
❚ Hold the syringe like a pencil or dart. Insert the needle at a right angle to the skin (90°)
structures
❚ Up to 3ml of fluid may be given in this site7 ● The patient should be positioned so as
to relax the muscle
Z Tracking technique ● The ‘Z track’ technique should be used
at all times (see diagram).
These measures should ensure optimal
nursing care for patients.
Angela Cocoman is mental health lecturer at DCU
and John Murray is a community mental health nurse
for Water ford Mental Health Services (HSE South
Eastern Area)

References
1. Greenway K. Using the ventral gluteal site for
intramuscular injection. Nursing Standard 2004; 18 (29):
(A) (B) (C) 39-42
2. Small SP. Preventing sciatic nerve injury from
intramuscular injection: literature review: J Advanced
An intramuscular injection is designed to deposit medications deep into muscle tissue Nursing 2004; 47(3): 287-296
3. MacGabhan L. A comparison of two depot injection
injuries to other structures.8 deltoid site.9 This is a relatively small area techniques. Nursing Standard 1996; 11(52): 33-37
Risks associated with an IM injection to the and muscle mass, especially in atrophied 4. McGarvey MA. Intramuscular injections: a review of
nursing practice for adults. All Ireland J Nursing &
dorsogluteal site patients compounded by the close prox- Midwifery 2001; 1(5): 185-193
● Contact with sciatic nerve imity of the radial nerve, brachial artery 5. Newton M, Newtown DW, Fudin J. Reviewing the big
three injection routes. Nursing 1992; 22: 34-42
● Contact with the superior gluteal artery and bony processes to this site means that 6. Berger KJ, Williams MS. Fundamentals of Nursing:
● Too much fatty tissue – poor absorption more substantial injuries can occur. Collaborating for Optimal Health. Appletone Large:
Connecticut, 1992
rates. It is important to limit volume of med- 7. Bolander VR. Sorenson & Luckmann’s Basic Nursing,
The deltoid site ication based upon size of muscle, ie. A Psychophysiological Approach (3rd ed.) Saunders:
Philadelphia, 1994
The ease of access, especially in an out- 0.5-2ml. 8. Kozier et al.Techniques in Clinical Nursing (4th ed).
patient setting, possibly adds to the The ventrogluteal site Sage: California, 1993
9. Mallett J, Bailey C.The Royal Marsden NHS Trust Manual
frequency with which the deltoid site is The Ventrogluteal site provides the of Clinical Procedures (5th ed.) Blackwell Science: London,
used for IM injections. This site is used for greatest thickness of gluteal muscle (con- 1996
10. Zelman S. Notes on the techniques of intramuscular
immunisations/non-irritating medications, sisting of both the gluteus medius and injection. Am J Med Sc 1961; 241: 47-58
hence vaccines which are usually small in gluteus minimus), is free of penetrating 11. Rodger MA, King L. Drawing up and administering
intramuscular injections: a review of literature.
volume tend to be administered into the nerves and blood vessels, and has a nar- J Advanced Nursing 2000; 31(3): 574-582

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