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Approximately one-third of adults in the United States are considered obese (Centers for Disease Control and Prevention [CDC], 2012); therefore, it is imperative that medical-surgical nurses make correct decisions when selecting a needle with an appropriate length for giving intramuscular (IM) injections in the deltoid muscle. Concerns regarding vaccine injection technique and reactogenicity have been reported and are directly related to incorrect needle-length selection in obese individuals. The intramuscular (IM) injection is one of the most common nursing procedures performed with an estimated 16 billion injections administered worldwide each year (World Health Organization [WHO], 2009). Due to easy access, patient comfort, and decreased risk for injury, IM injections into the deltoid muscle are the most frequently recommended for administering vaccines (CDC, 2011; WHO, 2009). Though it is a commonplace and everyday activity fundamental to patient care, this skill is not a simple one. Administration of an IM injection is a complex skill requiring not only dexterity in manipulating the syringe and needle, but also cognitive knowledge in determining the appropriate syringe and needle type as well as location of the injection site (Cocoman & Murray, 2008). Deltoid IM injection complications have resulted in permanent disabilities and legal actions due to inappropriate IM injection technique (Cocoman & Murray, 2008; Nicoll & Hesby, 2002). These occurrences have been attributed to inaccurate identification of the injection site, incorrect technique, and incorrect needle-length and size selection (Cocoman & Murray, 2008). Injection depth is a consideration that is becoming more critical as a result of increasing obesity in our patient population. Subcutaneous tissue thickness (SCT) increases with obesity and necessitates the selection of a longer needle to ensure appropriate injection depth (Koster, Stellato, Kohn, & Rubin, 2009). While studies of IM injection technique exist, the correlation between obesity and appropriate needle-length has not been thoroughly investigated. This is a concern because medications designed for absorption through the muscle may instead be delivered into subcutaneous tissue if an inappropriate needle-length is used for the IM injection. Although the patient still receives the medication injected into subcutaneous tissue, the absorption is slower and the medication efficacy can be compromised or negated completely leading to vaccine and drug failure (Middleman, Anding, & Tung, 2010). Complications such as abscesses and granulomas have been reported when medication was injected into the subcutaneous tissue rather than the muscle (Waiters & Furyk, 2010; Wynaden et al., 2006). Impact of Obesity on IM Injection Technique With obesity on the rise in all developed countries, questions arise as to whether or not the standard needle-length of 25-38 mm (1-1.5 inches) used in IM administration will deposit the medication into the muscle of obese individuals (Zaybak, Gunes, Tamsel, Khorshid, & Eser, 2007).According to Zayback and colleagues (2007), intramuscular injections are defined as injections in which the needle pierces the muscle by at least 5 mm (1/5 inch). As SCT increases, there is concern that using a standard needle-length may not be adequate in this population (Koster et al., 2009). In the last six years, researchers... Get Full Access Gale offers a variety of resources for education, lifelong learning, and academic research. Log in through your library to get access to full content and features! Access through your library Copyright: COPYRIGHT 2014 Jannetti Publications, Inc. Source CitationGale Document Number: GALE|A360608998 Introduction Aim Definition of Terms Assessment Special Considerations Companion Documents Links Evidence Table IntroductionA medication administered into a muscle is known as an intramuscular (IM) injection. The IM route allows for rapid absorption of specific medications. Choosing a muscle is dependent on the medication volume and the age or size of the patient. Poor technique and incorrect landmarking of the injection site can lead to site reactions, sub-optimal medication absorption and adverse events. For IM immunisation information, please refer to The Australian Immunisation Handbook. AimThis guideline aims to facilitate the administration of intramuscular injections to maximise the therapeutic effect while minimising potential complications and patient discomfort. Definition of TermsAnterolateral: Anterior and lateral position situated in the front and to the side. Greater trochanter:A bony prominence at the top of the femur where the hip and thigh muscles are fixed. Trauma informed practice: ‘Trauma-informed care is a way of approaching interactions with children and families in which providers remain cognizant of the impacts of trauma while also taking actions to prevent potentially traumatic experiences’ (Boles, 2017). Z- tracking: A technique used to prevent medication leakage, particularly for oily injections. Displace the skin and subcutaneous tissue by pulling the skin laterally or downward from the injection site. Holding it taut, quickly and smoothly insert the needle into the muscle at a 90-degree angle. This technique is preferred in adult/ adolescent patients. AssessmentClinical judgement is required when selecting an injection site and needle length. Summary
When IM has been prescribed:
 Site selection and land marking:Vastus LateralisThe anterolateral aspect of the thigh, or vastus lateralis muscle, is the preferred IM site for neonates and infants. Up to 1ml can be injected into this site in neonates, up to 3mls in children and up to 5mls in adults. This is the preferred site for anaphylaxis management in all ages.
To landmark the vastus lateralis, position the patient lying down or being held by a parent. Palpate the muscle below the greater trochanter and above the lateral femoral condyle (knee joint). Divide the muscle into thirds and administer the injection into the middle third of the muscle, in the outer anterolateral aspect, lateral to the midpoint of the thigh.
DeltoidThe deltoid muscle is the preferred injection site in children aged 3-18 years when muscle mass is more developed. It is suitable for small volume injections. The recommended volume is 1ml; however, up to 2mls can be administered.
The deltoid muscle is a rounded triangle shape. To landmark this site, the patient should be sitting comfortably with their arm visible from the shoulder to the top of the elbow. Palpate the acromion (outer edge of the scapula) and trace an imaginary inverted triangle below the shoulder. The injection should be given 3-5cms below the acromion, in the middle of the triangle.
DorsoglutealThe dorsogluteal is not the preferred site due to its proximity to the sciatic nerve and major blood vessels. If landmarked correctly however, it is safe to use. Up to 4mls can be injected into this site.
The patient can be positioned lying on their stomach or standing up. The muscle is located in the upper outer quadrant of the buttock, approximately 5-8cm below the iliac crest. For confirmation, an imaginary line can be drawn between the posterior superior iliac spine and the greater trochanter of the femur.
The patient can be positioned lying on their stomach, side or standing up. To locate the muscle, place the palm of a hand over the greater trochanter of the femur, facing the index finger and thumb towards the umbilicus, along the anterior iliac spine. Place the middle finger toward the iliac crest creating a ‘V’ shape. The injection is given in the middle of the ‘V’. Needle size:A hypodermic needle is used to administer IM injections. These come in different sizes (gauge and length) and are selected based on the patient’s size and the muscle used. A higher gauge needle refers to a smaller outside diameter of the needle tubing. Needle sizes most commonly used at RCH include: 25g x 25mm ORANGE 23g x 25mm BLUE 21g x 38mm GREEN Equipment:- Appropriate size needle for administration - Drawing up needle and syringe (if medication not pre-filled) - Sharps container - Alcohol impregnated swab (if area visibly soiled) - Cotton ball - Band-Aid (check for allergies) - Personal Protective Equipment (PPE) for hazardous medications or infectious patients The Procedure- Prepare patient and obtain consent - Perform the five moments of hand hygiene - Prepare equipment as per Aseptic Technique - Complete the six rights of medication administration - Don PPE if required (particularly for hazardous medications) - Draw up or prime medication as per Paediatric Injectable Guidelines - Position patient in a safe and comfortable position Procedure Management Guideline - Consider the use of comfort techniques such as distraction, buzzy bee, ice or a countdown - Landmark injection site (see above) - Clean site with an alcohol swab (if required) - Stretch the skin flat (Z-tracking if applicable) - Inject the needle to the hub at a 90-degree angle - Do not aspirate or drawback as this can increase pain and discomfort in children - Inject the medication at a slow and steady pace - Remove the needle and apply a cotton ball - Place the needle in a sharps container - Apply Band-Aid - Remove PPE (if required) - Perform the five moments of hand hygiene
Special Considerations
Companion Documents
LinksThe Australian Immunisation Handbook (health.gov.au) Evidence TableThe evidence table for this guideline can be accessed here. AcknowledgementsAll images and videos were created by the Royal Children’s Hospital Creative Studios for the purpose of this guideline. Please remember to read the disclaimer. The development of this nursing guideline was coordinated by Mica Schneider, RN Specialist Clinics, and approved by the Nursing Clinical Effectiveness Committee. First published May 2022. When giving injections to obese client which of the following needle size should you use?Women weighing more than 200 lbs (90 kg) or men weighing more than 260 lbs (118 kg): Use of a 1½" needle is recommended.
When giving an intramuscular injection which site should the nurse avoid in obese adults?Zaybek et al., (2007) determined that dorsogluteal and ventrogluteal sites should not be used in women whose BMI is greater than 24.9. These authors further stated obese women have the highest risk of IM injection failure with both ventrogluteal and dorsogluteal sites because of subcutaneous tissue thickness.
What gauge needle is used for intramuscular injections?Intramuscular (IM) injections
Needle length is usually 1"–1½", 22–25 gauge, but a longer or shorter needle may be needed depending on the patient's weight. Note: An alternate site for IM injection in adults is the anterolateral thigh muscle.
What is a 27 gauge needle used for?Many dentists prefer using smaller gauge (27- or 30-gauge) needles for anesthesia injection, believing that needles with a smaller diameter result in less injection pain than wider diameter needles.
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What size needle does the nurse use for an obese patient who requires an im injection?
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