Teaching best-evidence: Deltoid intramuscular injection technique

Abstract

Intramuscular injection of vaccines and medications into the deltoid muscle is a long-established nursing practice. The deltoid muscle is the preferred site for intramuscular injections to adult clients in community settings, as it requires minimal, generally socially-acceptable, exposure of the client's body, and is easily accessible to the professional administering the injection. Nursing students learning to administer deltoid intramuscular injections raise excellent questions about deltoid intramuscular injection technique, in particular around landmarking technique, the use of bunching or flattening technique, and selection of needle length. Surprisingly little empirical evidence to guide the nurse, or to answer student questions about, administering deltoid intramuscular injections was found in the nursing and allied health literature. This article examines deltoid intramuscular injection practice with particular emphasis on teaching nursing students best practice.

Evidence calls for practice change in intramuscular injection techniques

“…Nurses and providers need to keep current on evidence-based changes in injection techniques and offer appropriate education to other healthcare workers including MAs. [4,49] If properly trained in IM injections, the percentage of successful IM injections could increase from 52% to 72%. [20] Review of nursing textbooks reveals variations in intramuscular (IM) injection site recommendations and techniques.…”

“…[30,34] These guidelines for large or obese patients currently recommend using 1-1.5-inch needles for patients 260+ pounds. [4,5,30,34] Even though worldwide injection practices are based on these guidelines, there is increasing evidence validating IM injections with a 1.5-inch long needle may not be reaching muscle, especially in females exceeding a BMI of 30. [2,11,35] Additionally, educational texts may vary in their instructional information related to injection practices.…”

“…[1][2][3] Instructions for IM injection technique vary in literature and in nursing texts, including guidelines for weight and gender, injection site, needle gauge and length, bunching or stretching the skin, aspiration, and z-track method. [4,5] As an example, educational texts offer inconsistencies in IM injection practices pertaining to z-track technique. To reduce medication leakage out of the muscular tissue onto the skin post injection, z-track method (displacing the skin) has been recommended by many nursing texts and the literature for decades.…”

“…[18] In addition to practice variation, evidence reveals other factors leading to ineffective IM injections including injection depth, especially in obese populations, limited IM injection education and varying information from reputable resources. [4,11,19] …”

Best vaccination practice and medically attended injection site events following deltoid intramuscular injection

“…The needle over and under penetration medically attended injection site event data presented in this review may reflect errors in either the selection of an appropriate length needle 83,84 and/or injection technique (angle of needle insertion 85 and whether the muscle was 'bunched' or 'flattened' prior to injection 86 ).…”