Steps

Rationale/Points of Emphasis

1 Verify the order with the child’s medical record, including calculation of appropriate dose, and check for allergy to drug; if present, do not administer drug and notify the prescriber.

Detects possible transcription errors.

caREminder

Question whether another less traumatic route than IM injection is equally effective and can be used.

2 Perform hand hygiene.

Reduces transmission of microorganisms.

3 Obtain medication and read the label to verify with the order. Check for expiration date; if expired, do not administer.

To decrease chance of medication error, patient, route, dose, frequency, and time to be administered must be verified each time a medication is given.

caREminder

Bring medication to room temperature before administration. Cold medication causes increased discomfort when injected.

4a Check the amount of medication to be administered to determine syringe size and appropriateness for the child. Limit volume according to the age of the child and the size of the muscle used (see Table 62-1 ).

Large volumes of medication injected into a small muscle can result in leakage of medication out of the muscle and muscle atrophy.

4b Use a low-dose 1-mL syringe to give volumes <0.5 mL.

Ensures dosage accuracy.

5 Choose appropriate needle length for the site and muscle size (see Table 62-1 ). Select gauge based on what is available for the appropriate needle length for the child and medication viscosity. Usually, a 22- or 23-gauge needle is appropriate, but viscous medication requires a larger bore/smaller gauge needle.

The needle must be long enough to enter the muscle mass. Minimizes injury to the tissue and leakage into the subcutaneous tissue. Larger gauge needles have a narrower bore and thus produce a jet under higher pressure, which causes more damage to the tissue.

6a Draw up the medication in the medication room. Draw up correct amount of medication into the syringe.

The sight of the needle can increase the child’s anxiety.

6b If there is a large volume of medication, more than one injection may need to be given.

Medications must be measured accurately because a small error in amount could result in dangerous dosage variation.

Do not draw up additional air into the syringe because clearing the needle of air can affect dose administered.

caREminder

Use a filter needle to draw medication up from an ampule or rubber-topped vial and change to appropriate-sized needle before injection. This prevents small particles such as glass or other substances from entering the syringe.

7 Don gloves.

Standard precaution to reduce transmission of microorganisms.

8 Verify medication with electronic record or take medication record and syringe with medication to the child to administer. Verify the child’s identity by comparing name on medication (if verified electronically) or on medication record with child’s identification band and any other patient identifier required by the institution.

Ensures proper identification of the child.

9 Evaluate the child’s muscle mass and choose the most appropriate site (Figure 62-1). If multiple injections are to be given, rotate injection sites.

Decreases risk for complications associated with giving IM injections, which may result from inappropriate site selection. Rotating sites reduces potential of tissue damage.

Figure 62-1 Steps for locating intramuscular injection sites in children. (A) Ventrogluteal. Place your index finger on the anterior superior iliac spine, middle finger on the superior iliac crest, and your palm on the greater trochanter (use your right hand for the child’s left hip and vice versa). Inject into center of the “V” formed by the index and middle fingers. (B) Vastus lateralis. First, identify the middle third of the femur. Next, identify the area between two imaginary lines drawn from the greater trochanter to knee—one line midanteriorly and one midlaterally. Injection site is located between the lines in the middle third of the midlateral anterior thigh. Flexing the knee may promote relaxation of the muscle. (C) Deltoid. Identify site about two fingerbreadths below acromial process and just above axilla. Inject into upper third of deltoid muscle. (D) Dorsogluteal. Not recommended in children younger than 5 years of age or those with insufficient muscle mass. Place child on abdomen and have him or her point the toes inward. Draw an imaginary line between the posterior superior iliac spine and the greater trochanter. Inject in the upper outer region above this line into the gluteus medius muscle.

Vastus lateralis is the preferred site for children younger than 7 months. For children older than 7 months, consider the ventrogluteal. Do not give in operative sites, wounds, or an extremity that has a pathologic process. The vastus lateralis is a relatively large muscle in infants, free from major blood vessels and nerves. The ventrogluteal muscle has a fairly consistent layer of adipose tissue (increasing deposition of medication into the muscle) and is free from nerves and major blood vessels. Avoiding areas of impaired tissue integrity avoids further tissue damage or potential spread of infection.

KidKare Give the child choices of the injection site, as appropriate (e.g., which leg or side), to help give the child some control of the situation. Evaluate the use of nonpharmacologic interventions: distraction (storytelling, blowing bubbles), cold therapy, manual pressure (apply with noninjection hand thumb for 10 seconds before injection), and other means that may help decrease perception of pain sensation (see Chapter 7 ).

10 Position and hold the child securely.

Positioning may help relax the muscles, causing less pain (e.g., for ventrogluteal injection, place child on his or her side with upper leg flexed and over top of lower leg). Holding securely decreases chance of injury from child’s movement; even cooperative children have a tendency to move during injections.

caREminder

Family members should not be responsible for securing the child but may remain to give support.

11 Cleanse the site with antiseptic wipe and allow to dry.

Decreases microorganisms and minimizes pain at the site of injection.

12a Insert the needle quickly at a 72- to 90-degree angle. Aspirate to check for blood; if present, remove needle, replace with a sterile one, and start over. Rapidly inject the medication. Withdraw the needle and apply pressure over the site with a dry cotton ball or gauze.

Facilitates needle entry into the muscle. Aspiration was historically thought to prevent intravenous or intra-arterial medication administration but there is little research to support this. Ipp, Taddio, Sam, et al. (2007) found that rapid administration of vaccines without aspiration was less painful than slow administration with aspiration; no adverse effects were reported. Alcohol over an injection site may sting and prolong bleeding.

caREminder

For caustic medication, such as iron, use the Z-track method, which helps prevent leakage of medication into subcutaneous tissue, decreasing pain and other complications.

12b To inject using the Z-track method: Use a new sterile needle. Pull the skin with your nondominant hand laterally or downward away about ½ inch (1.25 cm) from the injection site; insert the needle into the muscle at a 90-degree angle at the site where you initially placed your finger to displace the skin. Aspirate for blood return; if blood is aspirated, discontinue the procedure; if no blood appears, inject the drug slowly. Wait 10 seconds, if possible, before withdrawing the needle; withdraw the needle slowly. Release the displaced skin and subcutaneous tissue to seal the needle track.

Using a new needle avoids medication being on the outside of the needle and coming in contact with tissue as the needle is inserted. Pulling the skin and subcutaneous layers displaces them out of alignment with the underlying muscle to trap the drug in the muscle after the structures return to their normal position. Waiting before withdrawing the needle after injection helps ensure dispersion of the medication.

Do not recap needle; dispose of syringe and needle in a sharps container to reduce chance of needle-stick injuries.

13 Place adhesive bandage over site.

Young children may feel that their insides will leak out the injection site if a bandage is not used.

KidKare Use character or fun bandages to comfort the child.

14 Dispose of needle, syringe, and waste in appropriate receptacle. Remove gloves and perform hand hygiene.

Prevents needle-stick injuries. Reduces transmission of microorganisms.

15 Comfort the child and have the family member comfort the child after the injection.

Promotes positive relationship and decreases longterm negative effects of painful procedures.

KidKare Giving the child a sticker or other reward can help promote comfort.

16 Return to the room a short time later for positive interaction with the child. Assess for signs of adverse reaction to medication.

Playing or other fun activities will help the child not associate the nurse with only painful procedures. Provides opportunity to further evaluate the child’s physical and emotional response to the procedure.