Injections (intradermal, subcutaneous and intramuscular)

Written by Anam Malik

This page will cover intramuscular, subcutaneous and intradermal injections. The preparatory phase is similar, with the key differences being in the administration itself.

Introduction

Introduce yourself, and confirm the patient’s name and date of birth. Double check that the prescription for their medication matches with their identity. Explain the procedure, check the patient’s understanding and gain consent. Wash or gel hands.

Ask the patient if they are in any pain and are comfortable. Check for any allergies to medications and to latex. Ask the patient if they have a preferred site for the injection

As a medical student, you should always cross-check the medication and any diluents with an appropriately qualified colleague.

An injection can occasionally be painful, and so it is important to inform the patient beforehand, whilst also reassuring them. For example, you might say:

“I will be giving you some medication using a small needle. You will feel a sharp scratch and there may be a little pain, but I will do my best to keep you as comfortable as possible”.

Equipment

Collect a plastic tray, and clean both the inside and outside of the box thoroughly with an alcohol surface disinfectant wipe. You will then need to collect:

The needle you use for the injection itself will depend on the route of administration:

Drawing up needles on the other hand are blunter, and some in fact have a filter to ensure there are no unwanted residues.

Drug preparation

Wash hands again and wear non-sterile gloves. Use an 18 gauge needle to draw up medication into a syringe using aseptic non-touch technique.

Cover the drawing up needle with a cap and proceed to remove and dispose of it directly into a sharps bin. Remove any air in the syringe.

Put the prepared medication in to a tray. Remove your gloves and wash hands.

A smaller, 22 gauge needle may be used for medication in glass ampoules or when drawing up through rubber bungs.

Some drugs may need mixing/diluting. Check with the manufacturer guidelines.

Final checks

In the presence of an appropriately qualified colleague, check the following details of the procedure using their prescription drug chart:

Site preparation

Select an appropriate injection site based on the type of injection. If a patient receives regular injections, be sure to rotate the injection site to avoid lumps or fatty deposits forming under the skin. Avoid sites that are inflamed, bruised or scarred.

Expose the injection site appropriately and clean the area using an alcohol swab, then allow the site to dry.

Intradermal (examples include allergy sensitivity testing and the Mantoux test)

Subcutaneous (examples include insulin injections for those with diabetes mellitus) Intramuscular (e.g. vaccinations and administration of adrenaline)
Im-ventrogluteal-300x244

Injection

Intradermal

Hold the syringe in your dominant hand. With your free hand stretch the skin taut using your index finger and thumb. Warn the patient of a sharp scratch and insert the needle at a 10-15o angle to a depth of 2-5 mm under the epidermis. Inject up to 0.5ml until a wheal appears under the surface of the skin.

Withdraw the needle and dispose of it directly into sharps bin. Place some gauze on the injection site and apply gentle pressure.

Some people feel more comfortable looking away whilst receiving an injection, so you may wish to suggest this to them.

Subcutaneous

Hold the syringe in your dominant hand. With your free hand pinch a fold of skin between the thumb and index finger to allow better access to subcutaneous tissue. Warn the patient of a sharp scratch and quickly and firmly insert the needle at a 45o degree. Drawback to check for any blood. If no blood is aspirated, inject up to 2ml of medication.

Withdraw the needle and dispose directly into sharps bin. Place gauze on the injection site and apply gentle pressure. Replace gauze with clean plaster if required.

Some short needles (e.g. insulin needles) need to be inserted at a 90o angle instead.

If there is blood on the drawback, remove the needle and start again, explaining the reason to the patient. This also applies for the intramuscular injection.

Intramuscular

Hold the syringe in your dominant hand between your thumb and index finger, as if you were holding a dart. With your free hand stretch the skin using your index finger and thumb. If a patient is elderly or has reduced muscle bulk however, pinch the skin instead to allow muscle to bunch up. Insert 2/3 of the needle into the muscle firmly at a 90o angle.

Drawback to check for blood. If no blood is aspirated, inject the contents of the syringe slowly at a rate no greater than 1ml per 10 seconds.

Withdraw the needle and dispose of it directly into sharps bin. Place some gauze on the injection site and apply gentle pressure. Observe the site for any inflammation and inform the patient that the site may be sore for a few days.

The z-track method is a common technique used for intramuscular injections to prevent leakage of medication into the subcutaneous tissue underneath the skin. It involves retracting the skin while injecting, and then releasing the retracted skin when withdrawing the needle.

The maximum volume that can be given in an intramuscular injection is dependent on the site. For example, in the relatively thin deltoid muscle, a maximum of 1ml can be given. In the vastus lateralis and at the ventrogluteal site however, a maximum volume of 5ml is permitted.

Completion

Wash hands and dispose of the equipment appropriately. Check the comfort of the patient is comfortable and tell them to go to their general practice if they notice any signs of inflammation including redness, swelling or pain.

Thank the patient and record the name of the medication, the dose and the time the medication was given as well as signing your name in the patient’s drug chart.

List form

Instructions
When assessing each other, please click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end.
We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
:

  1. Introduction “Hello my name is SimpleOSCE and I am a medical student. I have been asked today to give you some medication via an injection. Can I confirm your name and DOB? Thank you.”
  2. Explain the procedure and gain consent.
  3. Ask about allergies (drug/latex) and if the patient had a preferred site of injection.
  4. Gather the correct equipment.
  5. Collect the appropriate needle for procedure.
  6. Check the expiry dates of equipment and medication.
  7. Wash hands and wear non-sterile gloves.
  8. Using an 18 gauge needle, draw up medication into a syringe.
  9. Dispose of the drawing up needle in to a sharps bin.
  10. Remove gloves.
  11. Expose the injection site and make the patient comfortable.
  12. Perform the 6 final checks in the presence of colleague (right patient, right drug, right dose, right route of administration, right time and date).
  13. Again, wash hands and wear a new set of non-sterile gloves.
  14. Clean the injection site using an alcohol wipe.
  15. Stretch the skin between your thumb and index finger (intradermal and intramuscular) or pinch the skin (subcutaneous) to prepare the site for injection.
  16. Warn the patient of a sharp scratch
  17. Insert the needle at the correct angle (leaving top third visible in intramuscular).
  18. Aspirate for blood.
  19. Inject the medication, withdraw the needle and apply gauze with gentle pressure.
  20. Dispose of the needle directly in to a sharps bin.
  21. Remove gloves and dispose of all equipment.
  22. Document injection in patient drug chart.
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