1. Intramuscular Injections IM’s
Chapter 22 Perry & Potter

2. Review – IV Fluids Order: ½ NS @ 125cc/hr Drop factor: 15 gtt/ml
Drop rate:
31.25 gtt/min (31-32)
125 cc/hr x 15 gtt/ml = (31-32)
60 min
Order: D5 ½ 100 ml/hr
Drop factor: 10 gtt/ml
16.6 gtt/min (16-17)

3. Review – IV Medications
Order: Maxeran 10 mg IVPB ½ hour ac meals
Available: 10 mg/ml
Further dilute: 50 ml NS, infuse over 15 min
What is the rate:
200 ml/hr
50 ml X ? = 200 ml/hr
15 min min
What is the drip rate (drop factor 15 gtt/ml):
50 gtt/min

4. Order: Pantoprazole 40 mg IV now Available: 40 mg vial
Reconstitute with 10 ml NS (final concentration 4 mg/mL). Reconstituted solution may be given intravenously (over 2 minutes) or may be added to 100 mL D5W, NS, or LR (for 15- minute infusion).
Stable in D5W, LR, NS.
Y-site administration: Incompatible: Midazolam, zinc.
How much do you add to the minibag:
10 ml
What is the rate:
440 ml/hr
What is the drip rate with drop factor of 15 gtt/ml:
110 gtt/min (this will be difficult to count)

5. What would you do? Reason for primary infusion & reason for IV med
Primary line: NS with 40 meq 75 ml/hr
Order: Pantoprazole 40 mg IV now
What do you need to know before you begin?
Reason for primary infusion & reason for IV med
Drug information (expected & unexpected)
Client’s history & allergies
Client’s knowledge of medication
IV compatibility!!!

7. Video Review IV therapy IV Medications
Monitoring an IV Site, checking Infusion Rate, and Changing an IV Solution Container
Replacing IV Solution Container and Administration Tubing
IV Medications
Administrating IV Medications by Piggyback Infusion

8. Review – Subcutaneous Medication/Insulin
Order: Lovenox 40 mg SC OD
Available: 300mg/3ml (100mg/ml)
Info: Lovenox is a sterile aqueous solution containing enoxaparin sodium, a low molecular weight heparin. Lovenox® is indicated for the prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE)
How much do you withdrawl?
0.4 ml
Identify the appropriate syringe:
1 ml
Where are you going to administer this medication?
Outer aspect of abdomen (never arms)

9. Video Review Mixing Two Insulin's in One Syringe
Important information you need to know?
If insulin’s are compatible
Is it safe to give (know clients blood sugar)
Insulin(s) information (onset, peak, duration)
Draw up rapid acting insulin first (unmodified)
Check dose with RN/instructor
Know S&S of hyper/hypoglycemia
Injections sites

10. Intramuscular Injections (IM’s)
Faster absorption
Less danger of causing tissue damage
Risk of injecting into blood vessels exists
Muscle is less sensitive to irritating and viscous drugs
Large well developed muscles (adults) can tolerate as much as 5 ml of medication (infants ml, toddler 1-2ml, preschool 2-3ml, adolescents 3-5ml)
Usual max dose: 3mL in adult

11. Vastus lateralis and ventraogluteal sites used in infants
Deltoid used in well developed children and adolescents
In estimating needle length in children, grasp muscle between thumb and index, needle length showed be half the distance between fingers.
Insert needle as close to 90 degrees as possible
Rotate sites to decrease risk of hypertrophy

12. Needle Gauge Gauge often determined by length
Most water soluble medications use:
22-27 gauge needle
More viscous medications use:
18-25 gauge needle
Older or cachectic clients may need shorter smaller gauge needle

13. Needle length Average length: Children: 5/8 – 1 inch
Adults: 1- 1 ½ inches

14. Assessment Assess integrity of a muscle prior to injection
Help client assume a position that reduces strain on the muscle.
Area must be free of infection or necrosis, bruising or abrasions, underlying bones, nerves & major blood vessels.

15. Assessment Review order (medication rights)
Obtain medication information
Review history and assess factors contraindicating injection (muscle atrophy, shock, impaired circulation)
What would you do if contraindicated?
Call prescriber for alternative route!
Medical history, allergies, medication history
Client’s knowledge/concerns

16. Prepare Medication 6 rights, 3 checks
Prepared correct dose from vial/ampule
Replace needle with needle for injection
Children: 5/8 – 1 inch
Adults: 1- 1 ½ inches (22-27 gauge)
: 1 ½ inch (18-25 gauge) viscous medications
Check arm band/compare with MAR
Explain procedure, locate site, BE CONFIDENT

17. Ventrogluteal Site: #1
A deep site, situated away from major nerves and blood vessels, less chance of contamination in incontinent clients or infants because it is away from rectum.
Easily identified by prominent bony landmark.
Safe for all clients

18. Ventrogluteal Land marking (p. 599):
Place heel of hand over the greater trochanter of the client's hip
right hand over left hip
left hand over right hip

19. Ventrogluteal con’t… Point thumb towards client's groin
Index finger over anterior superior iliac spine
Extend middle finger back along the iliac crest toward the buttock
Create a triangle between index finger, middle finger and the iliac crest (towards the buttocks)
Inject in the middle of this triangle
Flexing of the knee and hip helps person to relax

21. Vastus Lateralis site
Vastus Lateralis - lacks major nerves and blood vessels, rapid drug absorption, developed muscle
Site used for giving children IM medication (preferred for immunizations)
Client should lie with the knee slightly flexed or in a sitting position

22. Vastus Lateralis Cont’d
Land marking (p.600):
Located on the anterior lateral aspect of the thigh
Handbreadth above the knee to a handbreadth below the greater trochanter of the femur.
In width, from the midline of the thigh to the midline of the thighs outer side.
Inject into the middle third of the muscle.

24. Deltoid site
Not well developed in most adults & children (not recommended for use in infants or children)
Radial & ulnar nerves & brachial artery lie within the upper arm along the humerus
Used when other injection sites are inaccessible
Used for small amount of drugs (1 ml or less)

25. Deltoid site con’t… Landmarking (p. 600): Expose upper arm
Palpate lower edge of the acromion process (base of triangle)
Inject in the middle of the triangle (3-5 cm below the acromion process)

27. Dorsogluteal site No longer a recommended site
Runs risk of striking underlying sciatic nerve, greater trochanter, major blood vessel.
Often used by nurses in hospitals (4 quadrant landmarking), practice is slowly changing

28. Z track Method Minimizes tissue irritation by sealing the
drug within the muscle tissues and
decreasing pain.
Recommended technique for all IM’s
when possible

29. Z track Method

30. Implementation Privacy Wash hands Expose only required area
Select appropriate injection site & ensure client is comfortable
Landmark site
Cleanse site with antiseptic (center and rotate outward ~ 5 cm)
With nondominant hand, pull skin cm down or lateral (Z track), hold this position until medication is administered.
Gauze in nondominant hand

31. Remove cap (pull straight off)
Hold syringe like a dart
Inject quickly at 90 degrees
Hold lower part of syringe to stabilize syringe
Pull back on plunger 5-10 sec, if no blood inject medication slowly (1 ml/10 sec)
Wait 10 sec, slowly withdrawl needle, place gauze over site
Assess site
Observe response to medication
Record on MAR, record response (i.e prn/STAT)
Document and report undesirable effects

32. Video: Intramuscular Injection

33. Practice Examples Order: Demerol 50 mg IM q4h, prn
Order: Gravol 25 mg IM, q4h, prn
Supplied :
Demerol 50 mg / ml (ampule)
Gravol 50 mg / ml (vial)
How much do you need of each?
Demerol: 1 ml
Gravol: 0.5 ml
(Draw up medication from vial first, using filtered needle)

34. Practice Examples 2. Order: Diphenhydramine 25mg IM stat
Supplied: 50 mg/ml
3. Order: Dimenhydrinate 50mg IM/IV/PO q4-6 h prn Supplied 50 mg/ml

35. Example Order: Solumedrol 100 mg IM stat Directions for Reconstitution
Available 40 mg: Aseptically add 1 mL Bacteriostatic Water for Injection
Available 125 mg: Aseptically add 2 mL Bacteriostatic Water for Injection
How much do you draw up in the syringe?
1.6 ml
125 mg X mg = 1.6 ml
2 ml ? Or
Dose X Stock mg X 2ml = 1.6 ml
Have mg

36. Lets Practice Next Lab: Sterile Dressings
Perry & Potter: Chapter 38 & 39