Deltoid injection

Landmarks for the deltoid muscle are the acromion process and the axillary line. Insert the needle at a point two to three finger widths (1 to 2 inches) below the acromion process, above the axillary line in the middle of the triangular-shaped deltoid muscle in the midline of the lateral aspect of the arm.

Vastus lateralis injection

Landmarks for the vastus lateralis muscle are the head of the greater trochanter and the knee. Insert the needle into the middle third of the muscle at least one hand width below the greater trochanter and one hand width above the knee in the anterolateral aspect of the leg.

Ventrogluteal injection

Landmarks for the ventrogluteal muscle are the head of the greater trochanter and the anterior superior iliac spine. Place the heel or the palm of your hand on the head of the greater trochanter with your thumb pointing toward the patient’s abdomen. Extend your index finger up to the anterior superior iliac spine then spread your other fingers back along the iliac crest. Insert the needle in the “V” formed between your index and third fingers.

Determining maximum volume of injection, gauge, and length of needle

Overall, the site you use, the age and size of the patient, and the medication you administer all determine the maximum volume of the injection and the gauge and length of the needle. If the total volume to be administered exceeds the maximum volume recommended for a particular site, split the injection into two or more smaller injections and give them at different sites.

For the deltoid muscle of an average adult or adolescent, give up to 1 mL of medication with a ⅝-inch to 1-inch needle. Do not use the deltoid site for infants and toddlers younger than 3 years. For preschoolers and older children, use a ⅝-inch needle for giving an IM injection in the deltoid.

For the vastus lateralis muscle in an average adult or adolescent, give up to 3 mL of medication with a 18- to 25- gauge, 1- to 1½-inch needle for oil based or viscous solutions. Use a 22- to 27-gauge, 1- to 1½-inch needle for aqueous solutions. For infants, give up to 1 mL with a 1-inch needle; for small infants, give up to 0.5 mL with a ⅝-inch needle. This is one of the preferred sites for infants.

For the ventrogluteal muscle of an average adult, give up to 3 mL of medication with an 18- to 25-gauge, 1- to 1½-inch needle for oil-based or viscous solutions. Use a 22- to 27- gauge, 1- to 1½-inch needle for aqueous

solutions. For infants, give up to 1 mL with a ½- to 1-inch, 21- 25-gauge needle; for small infants, give up to 0.5 mL with a ?-inch, 21- 25-gauge needle. For toddlers, give up to 2 mL with a 1-inch, 21- 25-gauge needle. For children age 3 and older, give up to 2 to 3 mL with a 1-inch, 21- 25-gauge needle. For adolescents, give up to 3 mL with a 1- to 1½-inch, 21- 25-gauge needle. This is the preferred site for administering irritating or oily solutions to patients of any age.

If you have used a needle to draw up medication for an intramuscular injection, change the needle to a clean, dry needle for the injection to prevent tissue irritation or damage.

 

References

Bindler, R. C., & Ball, J. W. (2003). Clinical skills manual for pediatric nursing: Caring for children (3rd ed.). Upper Saddle River, NJ: Pearson Education, Inc. pp. 55-57.

Perry, A. G., & Potter, P. A. (2006). Clinical nursing skills and techniques (6th ed.). St Louis, MO: Elsevier Mosby. pp. 697, 699, 723-729.

Smith, S. F., Duell, D. J., & Martin, B. C. (2008). Clinical nursing skills: Basic to advanced skills (7th ed.).Upper Saddle River, NJ: Pearson Education, Inc. pp. 603-604, 617-621.

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Injections

Subcutaneous (SQ)

Review medication orders, and check for drug allergies. Wash hands, and put on gloves. Identify client by checking armband. Use 1 - 3 cc syringe and 23 - 25 gauge, 1/2 - 5/8 inch needle. Maximum amount of fluid to

administer SQ is 1 cc. Choose site: abdomen, lateral and anterior aspects of upper arm or thigh, scapular area of

back, or upper ventrodorsal gluteal area. Note: Avoid areas of bony prominence, major nerves, and blood vessels.

Figure 10: Sites for routine subcutaneous injections. (Avoid umbilicus area.) Source: Smith et al., 2000, p. 387. 

Wipe with alcohol in a circular motion to cleanse. Allow to dry. Pinch skin between finger and thumb. Spread taut if client has substantial cutaneous tissue. Insert needle at 45° or 90° angle depending on body size of client: 90° if obese; 45° if average

weight. If client is very thin, gather skin at area of needle insertion and administer at 90° angle.

Figure 11: Insert needle at 45° or 90° angle into tissue for subcutaneous injection. Source: Smith et al., 2000, p. 387. 

Release the subcutaneous tissue, and aspirate prior to injecting medication (except insulin or heparin).

Inject medication slowly, remove needle quickly, and gently massage site with alcohol swab. Do not massage after the administration of heparin.

Intramuscular (IM)

Review medication orders, and check for drug allergies. Wash hands, and put on gloves. Identify client by checking armband. Use 3 cc syringe and 20 - 23 gauge, 1 - 2 inch needle. Maximum amount of fluid should be

determined by client's muscle mass and site to be injected. Use 2 inch needle with obese client to ensure that medication is injected into a large muscle.

If amount to be injected for adults is > 5 cc or children > 3 cc: divide dose into two syringes to administer.

Position client, and locate site using appropriate anatomical landmarks. Wipe site with alcohol in a circular motion to cleanse. Allow to dry. Spread skin taut, and insert needle at 90° angle with quick, dartlike action.

Figure 12: Insert needle at 90° angle for intramuscular injections. Source: Smith et al., 2000, p. 394. 

Aspirate, and observe for blood. (If blood appears, remove and discard needle). Inject medication slowly, remove needle quickly, and gently apply pressure to site with dry,

sterile 2 x 2 gauze. Do not massage injection site.

Deltoid (Upper Arm)

Use if volume is 0.5 - 1 cc, but not more than 3 cc. Use a 23 gauge, 1 inch needle. Client may be positioned sitting, standing, supine, or prone. Locate site by measuring 2 - 3 fingerbreadths below the acromion process on the lateral midline

of the arm.

Figure 13a: The deltoid muscle of the upper arm, used for intramuscular injections. Source: Kozier et al., 2000, p. 785. 

Figure 13b: The upper arm can be used for both intramuscular (IM) and subcutaneous (Sub Q) injections. Source: Smith et al., 2000, p. 387. 

Administer in nondominant arm when possible.

Dorsogluteal (Upper Outer Quadrant)

Use if volume is 1 - 3 cc, but less than 5 cc. Use a 20 - 23 gauge, 1-1/2 inch needle. Do not use this site in children < 2 yr or emaciated clients. Position client in side-lying or supine position, with knee flexed on injection side, or prone with

toes pointed inward to rotate femur. Locate site by palpating the posterior iliac spine where the spine and pelvis meet. Imagine a

line from the posterior iliac spine to the greater trochanter. Administer medication above imaginary line at midpoint.

Figure 14a: The dorsogluteal site for intramuscular injections. Source: Kozier et al., 2000, p. 785. 

Figure 14b: Locate greater trochanter to identify dorsogluteal site. Source: Smith et al., 2000, p. 395. 

Figure 14c: Locate posterosuperior spine of iliac crest. Source: Smith et al., 2000, p. 395. 

Figure 14d: Draw imaginary line between trochanter and iliac spine. Source: Smith et al., 2000, p. 395. 

Figure 14e: Inject medication directly into dorsogluteal site at 90° angle. Source: Smith et al., 2000, p. 395.

Ventrogluteal

Use if volume is 1 - 3 cc. Use a 20 - 23 gauge, 1-1/2 inch needle. This is the preferred site for adults and children < 7 mo. Position client in supine lateral position. Locate site by placing the hand with heel on the greater trochanter and thumb toward umbilicus.

Point to the anterior iliac spine with the index finger (forming a "V"). Injection of medication is given within the "V" area.

Figure 15a: The ventrogluteal site for intramuscular injections. Source: Kozier et al., 2000, p. 784. 

Figure 15b: Identify greater trochanter, and place palm at site. Source: Smith et al., 2000, p. 397.

 

Figure 15c: Place palm on greater trochanter, and point to anterior iliac spine. Source: Smith et al., 2000, p. 397. 

Figure 15d: Inject medication at 90° angle within "V" area. Source: Smith et al., 2000, p. 397.

Anterolateral Thigh (Vastus Lateralis)

Use 22 - 25 gauge, 5/8 - 1 inch needle. This is the preferred site for infants and children < 7 mo. Position client in supine or sitting position. Locate by identifying the greater trochanter and lateral femoral condyle. Injection site is the

middle third and anterior lateral aspect of the thigh.

Figure 16a: The vastus lateralis site of the right thigh, used for intramuscular injections. Source: Kozier et al., 2000, p. 785. 

Figure 16b: The vastus lateralis muscle of the upper thigh. Source: Kozier et al., 2000, p. 784. 

Figure 16c: Identify greater trochanter and lateral femoral condyle. Source: Smith et al., 2000, p. 396. 

Figure 16d: Select site using middle third and anterior lateral aspect of thigh. Source: Smith et al., 2000, p. 396. 

Figure 16e: Inject medication at 90° angle directly into muscle. Source: Smith et al., 2000, p. 396.

Z-Track Method

Discard needle after medication is drawn up, and use new needle for injection to minimize tissue staining or irritation.

Use this method when administering injection in ventrogluteal or dorsogluteal sites. Displace skin to one side (laterally) before inserting needle.

Figure 17: Z-track is used to prevent backflow of medication into subcutaneous tissue. Source: Smith et al., 2000, p. 398. 

Insert needle at 90° angle, aspirate, and administer if no blood is present. Withdraw needle before releasing skin.

Intradermal

Review medication orders, and check for drug allergies. Wash hands, and put on gloves. Identify client by checking armband. Use a tuberculin or 1 cc syringe and 25-27 gauge, 3/8 - 5/8 inch needle. Amount to be injected

is usually 0.01 - 0.1 cc. Choose site: dorsal forearm, upper back or upper chest.

Figure 18: Body sites commonly used for intradermal injections. Source: Kozier et al., 2000, p. 780. 

Wipe site with alcohol in a circular motion to cleanse. Allow to dry. Insert needle, with bevel facing upward, at angle of 10 - 15°. Advance needle until entire bevel is under skin. Slowly inject medication to form small bleb.

Figure 19: Inject solution to form wheal on skin. Source: Smith et al., 2000, p. 386. 

Withdraw needle quickly, and pat site gently with sterile 2 x 2 gauze pad. Do not massage area.

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