Administration of medication via intradermal, subcutaneous and intramuscular injections

The aim of these guidelines is to facilitate the safe administration of injections (non-intra venous) for patients at Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH). 

The routes this guideline will cover are: 

  • Intramuscular injection (IM): Administering medication directly into muscle (Macqueen et al 2012). This route is commonly used for immunisations. 
  • Subcutaneous injection (SC): Administering medication below epidermis and dermis layers into the subcutaneous tissue (Ford et al 2010). This route is commonly used for insulin and heparin.
  • Intradermal injection (ID): Delivers medication to the dermis, just below the epidermis. This route is commonly used for local anaesthetics prior to an invasive procedure.  

Note: While this guideline refers to the ‘child’ throughout, all activities are, of course, applicable to young people.

This guideline includes:

Background

The use of alternative medication administration routes (such as epidural infusions and intravenous patient and nurse controlled analgesia) has reduced the number of injections administered by nurses to children. However certain medications may only be administered by injection to facilitate absorption of medication (Ford et al 2010). Proper injection technique using evidenced based practice will reduce discomfort and complications for the child and young person receiving an injection (Hunter 2008, Greenway 2014, Clancy and Furyk 2012). 

Necessary skills for good safe injection technique include knowledge of anatomy and physiology for suitable injection sites (rationale 6). It is vital that there is good communication between the nurse, parent and child before the procedure begins (rationale 7).

Preparation of child and family for injection

Choosing site for injection

The factors that must be considered when selecting a site for injection include, the size and age of the child (Rationale 12), the ability to position the child (Rationale 13), the size of the muscle to tolerate the volume to be injected (Rationale 14) and the frequency of the injections required (Rationale 15). 

An area that feels tender, hard or lumpy should be avoided. For a child having regular injections, the sites must be rotated (Rationale 16) (Macqueen et al 2012).

The injection route (IM, SC, ID) must be on the prescription (Rationale 17) and the route for administration must be suitable for the medication to be injected.

Intramuscular injection (IM):

There are two main sites used for the administration of IM injections in children:

  • The deltoid muscle is the preferred site for intramuscular and deep subcutaneous injections in larger children (Rationale 18). It is suitable for small volume injections such as immunizations but not for repeated use or large volumes. It should be used with caution in children under 3 years old (Hemsworth, 2000). 
  • The vastus lateralis is the preferred site for intramuscular and deep subcutaneous injections in infants under one year and children up to 3 years old (Rationale 19) (World Health Organization 2010, Cook and Murtagh 2005). 

Subcutaneous injection (SC): 

Deep subcutaneous injections should be administered as indicated for IM injection sites. Other sites that can be used include the upper thigh, the abdomen, upper arm and buttocks. Sites must be rotated to prevent fibrosis and ensure adequate absorption (Macqueen et al 2012).

Intradermal injection (ID):

The most common sites used are the inner surface of the forearm and the upper back, under the scapula. An injection site must be free from lesions, rashes, moles, hair or scars (Lynn, 2011).

Preparation of the injection for all routes

The injection for all routes should be prepared using aseptic non-touch technique. Preparation here is described once all equipment has been gathered for medications in a glass vial or freeze dried container to be drawn up into the injection syringe.

Medicated solution in a glass vial
  1. Wash hands and put on non-sterile gloves
  2. Tap the top of the glass vial gently to move any medication into the lower part of the vial. (Rationale 20)
  3. Cover the top of the vial with the inside of a sterile alcohol wipe package (e.g. Steret ®) and break open the vial on the pre-marked line.
  4. Inspect the medicated solution for any glass fragments or signs of contamination. Discard if any signs are observed and start the procedure again (Rationale 21).
  5. Insert either a filter needle or needle size 23 G attached to the syringe into the vial and withdraw the prescribed amount of medication with the vial held tilted upside down keeping the tip of the needle below the level of the medication (Rationale 22).
  6. After removal from the vial re-sheath the needle with one hand (Rationale 23).
  7. Hold the syringe in a vertical position and tap the syringe gently to expel the air bubbles (Rationale 24).
  8. Ensure accurate amount of medicine in syringe – as prescribed. Syringes are calibrated to give the correct volume of medication accounting for the medication that remains in the hub of the syringe and needle after administration.
  9. Remove the needle and discard in a sharps container.  Attach a new appropriate size needle, needle size determined by the route of administration (Rationale 25). 

For intramuscular injections: use a 23G (blue) or 25G (orange) length 25mm (short 25G available for premature infants) (Rationale 26) (Royal College of Paediatricians and Child Health (RCPCH) 2002, Greenway 2014). Needle length and gauge will depend on the size of the child but for the majority of children a 25mm long, 23 to 25 gauge needle will be appropriate.  The needle needs to be long enough to ensure the medication reaches the muscle layer but not so long that it touches the bone. For some immunisations, using a longer needle length reduces the rate of a local reaction (Diggle and Deeks 2000).

For subcutaneous injections: use a 23G (blue) or 25G(orange) length 16mm or an insulin needle (Rationale 27).

For intradermal injections: 26G (brown) length 10mm (Rationale 28).

Freeze dried medication in a rubber topped vial
  1. Wash hands and put on non-sterile gloves
  2. Remove the metal/plastic cap and clean the rubber bung on the top of the vial using a 70% isopropyl alcohol wipe for at least 30 seconds and allow this to dry (Rationale 29). 
  3. Do not touch the rubber bung after cleaning it (Rationale 30).
  4. Refer to manufacturer’s and pharmacy guidelines for the type and volume of diluent suitable for dissolving the freeze-dried medication (Rationale 31).
  5. Draw up the appropriate volume of diluent with a filter needle or needle size 23 G and syringe.
  6. Insert the needle into the rubber top of the vial and inject the required volume of diluent slowly into the vial. 
  7. Allow the freeze-dried medication to disperse completely in the solution (Rationale 32).
  8. Check the dissolved medication for any signs of contamination, e.g. cloudiness. If any signs of contamination are observed discard and start the procedure again (Rationale 33).
  9. Using the same syringe and needle as used for diluting, withdraw all of the medication with the vial held tilted upside down keeping the tip of the needle below the level of the medication (Rationale 34).
  10. Remove the needle from the vial. After removal re-sheath the needle with one hand (Rationale 35).
  11. Hold the syringe in a vertical position and tap the syringe gently to expel the air bubbles (Rationale 36).
  12. Discard any additional medication from the syringe into a blue pharmaceutical waste container, leaving the prescribed amount of medication in the syringe. (Rationale 37
  13. Remove the needle and discard in a sharps container.  Attach a new appropriate sized needle, needle size determined by the route of administration (Rationale 25).

For intramuscular injections: use a 23G(blue) or 25G(orange) length 25mm (short 25G available for premature infants).

For subcutaneous injections: use a 23G(blue) or 25G(orange) length 16mm or insulin needle (Shin and Kim 2006).

For intradermal injections: use a 26G (brown) length 10mm.

Skin Preparation

There are many differences of opinion regarding skin cleansing prior to administering injections (Pratt et al 2005). The Department of Health (DH) (2013) does not recommend the use alcohol swabs if the skin is visibly clean. The RCPCH (2002) say that formal skin disinfection is not necessary prior to immunisation. For the immunocompromised child however it is recommended that a sterile 70% alcohol impregnated swab is used and then allowed to dry for 30 seconds before the injection is given (Dougherty and Lister 2015). 

Children that are not immunocompromised and have no skin infections the nurse administering the injection should ensure that the skin is visibly clean and is, if required, washed with soap and water prior to the administration of an injection.

Skin disinfection with an alcohol swab is not necessary prior to subcutaneous or intradermal injection, irrespective of the child’s immune status.

Prior to intramuscular injections, skin disinfection with a sterile 70% alcohol swab (e.g. Steret ®) is recommended. This must be allowed to dry before in injection (Rationale 38, 39).  

Administration of the injection

Intramuscular

  1. Identify an appropriate site for administration according to size and age of child. The maximum volume for a intramuscular injection is 2mls (Macqueen et al 2012) in the thigh and 1ml in the deltoid muscle.
  2. Prepare the injection site as above (see skin preparation).
  3. There is more than one technique for administering IM injections (Ogston-Tuck 2014). Whichever technique is used, the needle must not be deep enough to touch the bone but must penetrate deeply into the chosen muscle (Rationale 40). The needle in all sites is inserted at 90 degree angle (Rationale 41).

For immunisations there is no need to aspirate (Rationale 42) (DH 2013). For other injections, aspiration to observe for the presence of blood has been advised if the gluteus maximus muscle is used (Rationale 43) (Crawford and Johnson 2012). If no blood is observed, administer the medication pushing the plunger slowly and smoothly. If blood is observed remove the needle and syringe repeat the procedure. 

Mitchell and Whitney (2001) recommend plunger depression at a rate of 10 seconds per ml of medication. Taddio et al (2009) recommend rapid injection in immunisation (Rationale 44). 

Skin stretch technique: Stretch the skin between the forefinger and thumb of one hand and using the other hand insert the needle in dart like motion at a 90°angle and then release the stretch on the skin (DH 2013).

Pinch up technique: Gently pinch up a small area of skin, subcutaneous tissue and muscle and insert the needle in a dart like motion at a 90° angle and then release the pinch-up.

Z-track technique: Push the skin down and then pull the skin taught in one direction. Then insert the needle in a dart like motion at a 90° angle and keep the pull on the skin until the needle is ready for removal from the site (Antipuesto 2010, Dougherty and Lister 2015). This technique requires the co-operation of the child and is not advised for immunisations. This technique has been shown to reduce pain (Barron and Hollywood 2010).

  1. Once the injection has been given, wait 10 seconds following the administration of medicine before removing the needle from the site of administration (Rationale 45). 
  2. Do not massage the site following administration of the medication (Rationale 46).
  3. Use gauze to apply gentle pressure if the injection site bleeds (Rationale 47).
  4. Dispose of sharps in a sharps container.  Remove gloves and wash hands. Record medication administered and the site used (Rationale 48).

Subcutaneous

  1. Identify an appropriate site for administration. For regular subcutaneous injections the site must be rotated (refer to patients records to identify appropriate site) (Rationale 49) (Macqueen et al 2012). 
  2. Check site is clean. The use of an alcohol skin swab is not recommended but the skin should be clean (Rationale 50).
  3. Utilise distraction techniques with the assistance of parent/carer or play specialist as appropriate (Rationale 51).
  4. Before injecting, the skin should be gently bunched up to avoid the muscle layer. Aspiration is not necessary (Rationale 52).
  5. The needle should be inserted at 90 degrees when using a short insulin needle, but at 45 degrees if the needle length is greater than 8mm or if the child does not have much subcutaneous tissue (Rationale 53) (Annersten and Willman 2005).
  6. The needle entry should be quick with the bevel facing towards the skin and the medication administered slowly. Needle withdrawal should also be quick (Rationale 54).
  7. Dispose of sharps in a sharps container. Record the administration including the site used (Rationale 55).

Intradermal

  1. Identify an appropriate site. The most common sites used are the inner surface of the forearm and the upper back, under the scapula. An injection site must be free from lesions, rashes, moles, hair or scars (Lynn, 2011) (Rationale 56). Do not use the same site if the child has already had ID injection in that site recently (refer to patients records to identify appropriate site) (Rationale 57).
  2. Check site is clean. The use of an alcohol skin swab is not recommended but the skin should be clean (Rationale 50).
  3. Remove the needle used for preparation (Rationale 58) of medication and dispose in a sharps container. Attach an appropriate size needle. For intradermal this will be a 26G 10mm needle. All intradermal medication will be drawn up in a 1ml syringe unless it is supplied in a pre-filled syringe. 
  4. Utilise distraction techniques with the assistance of parent/carer or play specialist as appropriate (Rationale 59).
  5. Stretch the skin taut between thumb and forefinger with the non-dominant hand (Rationale 60).
  6. With the other hand insert the needle into the skin with the bevel up, at a 10–15 degree angle (almost parallel with the surface) to the depth of 2–5 mm just under the epidermis (Rationale 61). When administering the medication a raised blanched bleb (blister or large vesicle) or small wheal may form around the injection site which is normal for an ID injection (Rationale 62).
  7. Remove needle and dispose sharps in a sharps container.  Document the administration and the site used (Rationale 63).

Nursing observations

  1. It is important to assess the child during and after the administration for any adverse events. If there are signs of anaphylaxis the emergency protocol should be instituted (Rationale 64)
  2. Complications following any injection, at any site, can arise and these may include tissue fibrosis, infection due to poor technique, pain and needle phobia. These should be documented and appropriately treated (Rationale 65) (Malkin 2008). 
  3. In addition, complications following intramuscular injections can also include nerve damage, haemorrhage and abscesses secondary to large volume injections (Rationale 66). These should be documented and treated (Rationale 67).
  4. Any child with a clotting disorder should be assessed for the need for intramuscular injection and the route changed to subcutaneous if appropriate. For these patients, pressure should be applied to the site for one minute after the injection (Rationale 68) (DH 2013) (Plotkin et al 2008).

Rationale

Rationale 1: To ensure they understand the reason for the injection and the process
Rationale 2: to ensure there is no risk of nerve damage
Rationale 3: to ensure it is prepared to eliminate all risk of infection 
Rationale 4: to ensure the injection is administered correctly
Rationale 5: to ensure that the care is safe and appropriate for the procedure  
Rationale 6: to ensure no major nerve or blood vessel is injected
Rationale 7: to ensure that the injection is given in a safe and timely manner
Rationale 8: Research has shown that knowledge of the procedure reduces anxiety
Rationale 9: Particularly with an older child to ensure they comply with skin cleanliness
Rationale 10: Relaxing the muscle reduces pain. 
Rationale 11: This will be the most comfortable and safe position
Rationale 12: Site will change according to size and age
Rationale 13: To ensure a good view and access to the site
Rationale 14: Some muscles will not tolerate large volumes
Rationale 15: Injections should not always be given in the same site
Rationale 16: To avoid complications and fibrosis of sites
Rationale 17: To comply with legal requirements 
Rationale 18: There is easy access and sufficient muscle mass in larger children
Rationale 19: There is easy access and sufficient muscle mass in small children where the deltoid is inappropriate
Rationale 20: To ensure all the medication is in the lower part of the vial
Rationale 21: To ensure only uncontaminated medication is administered
Rationale 22: To ensure no air gets into the syringe when aspirating the medication
Rationale 23: For safety and to prevent contamination
Rationale 24: To ensure no air will be administered
Rationale 25: So that the injection goes to the required depth. 
Rationale 26: So that the injection reaches the muscle layer and no further.
Rationale 27: They need to be short enough not to reach the muscle
Rationale 28: They need to be short enough to inject beneath the skin
Rationale 29: The cap does not guarantee sterility; it is just a dust cover.
Rationale 30: So that it does not become contaminated
Rationale 31: To ensure correct reconstitution
Rationale 32: To ensure fully reconstituted 
Rationale 33: To prevent patient contamination
Rationale 34: To prevent air getting into the syringe  
Rationale 35: For safety and to prevent contamination
Rationale 36: To prevent injection of air
Rationale 37: To ensure correct dose is given
Rationale 38: Site will not be fully clean if injected whilst alcohol is drying
Rationale 39: To prevent infection from skin flora
Rationale 40: To ensure the injection penetrates the muscle 
Rationale 41: To ensure the muscle is reached
Rationale 42: Research has shown this is not necessary
Rationale 43: This is a large vascular muscle used in adults only
Rationale 44: For safety in children who are otherwise well
Rationale 45: To ensure all the medication has been administered into the muscle and none into the subcutaneous layer in error. 
Rationale 46: This may affect the absorption
Rationale 47: Pressure will stop the bleeding
Rationale 48: To comply with policy and legal requirements. 
Rationale 49: To prevent lumps in the subcutaneous layer
Rationale 50: Alcohol can toughen the skin is unnecessary  
Rationale 51: To ensure the injection is given safely with minimal anxiety
Rationale 52: To ensure the injection is administered into the subcutaneous layer
Rationale 53: To ensure the injection does not enter the muscle
Rationale 54: To minimize pain and ensure optimal skin piercing 
Rationale 55: For governance and safety
Rationale 56: For optimal absorption and minimizing complications
Rationale 57: Sites should not be used more than once. 
Rationale 58: This needle will not be the correct size
Rationale 59: For safe and quick administration
Rationale 60: To allow for easy access for correct technique and to reduce pain
Rationale 61: To ensure the medication goes under the epidermis and no further
Rationale 62: This will indicate that the injection has been successfully administered
Rationale 63: For governance and safety. 
Rationale 64: As resuscitation guidelines
Rationale 65: For governance and to prevent future complications
Rationale 66: This is usually if incorrect technique has been used
Rationale 67: For governance and safety
Rationale 68: To prevent excessive bleeding. 

References

Antipuesto, D (2010) Z Track Method. Nursing Crib. [Last accessed 28.07.2017]

Annersten, M., & Wilmann, A. (2005). Performing subcutaneous injections: A literature review. Worldviews on Evidence-Based Nursing. 2(3): 122-130.

Barron C. and Hollywood E. (2010) Drug administration. In Clinical Skills in Children’s Nursing, (Coyne I, Neill F. and Timmins F. Eds.), Oxford University Press. Oxford. 147- 181.

Clancy, M. and Furyk, J. (2012). Paediatric intramuscular injections for developing world settings: a review of the literature for best practices. Journal of Transcultural Nursing, 23(4):406-409.

Cook, I.F. and Murtagh, J., (2005). Optimal technique for intramuscular injection of infants and toddlers: a randomised trial. Medical Journal of Australia, 183(2): p.60.

Crawford, C.L. and Johnson, J.A., 2012. To aspirate or not: an integrative review of the evidence. Nursing, 42(3): 20-25.

Department of Health, UK. (2013). Immunisation against Infectious Diseases (The Green Book) [Last accessed 28.07.2017].

Diggle, L. and Deeks, J. 2000. Effect of needle length on incidence of local reactions to routine immunisation in infants aged 4 months: randomised controlled trial. BmJ, 321(7266): 931-933.

Dougherty L and Lister S. (2015). The Royal Marsden Hospital Manual of Clinical Nursing Procedures: Student Edition. 9th Ed. Chichester: Wiley-Blackwell

Ford L., Maddox C., Moore E. and Sales R. (2010). The safe management of medicines for children. In Practices in Children’s Nursing: Guidelines for Community and Hospital. 3rd ed. (Trigg E and Mohammed TA., Eds), Churchill Livingstone, Edinburgh, 417-445.

Greenway K. (2014) Rituals in nursing: intramuscular injection, Journal of Clinical Nursing, 23 (23-24): 3583–3588.  DOI: 10.1111/jocn.12627 

Hemsworth S. (2000). Intramuscular (IM) injection technique. Pediatric Nursing, 12(9): 17-20.

Hunter J. (2008) Intramuscular injection techniques, Nursing Standard 22(24): 35-40.

Lynn P. (2011) Fundamentals of nursing: The art and science of nursing care. Philadelphia: Lippincott Williams & Wilkins.
Macqueen S., Bruce E.A. and Gibson F. (2012) The Great Ormond Street Hospital Manual of Children’s Nursing Practices, Wiley-Blackwell, Oxford.

Malkin B. (2008) Are techniques used for intramuscular injection based on research evidence? Nursing Times 104(50-51): 48-51.

Mitchell, J.R. and Whitney, F.W.  (2001). The Effect of Injection Speed on the Perception of Intramuscular Injection Pain: A Clinical Update. Aaohn Journal. 49(6): 286-292.

Ogston-Tuck, S. (2014). Intramuscular injection technique: an evidence-based approach. Nursing Standard, 29(4): 52-59.

Plotkin, S., Orenstein, W.A., Offit, P.A. (2008) Vaccines (5th ed). Atlanta, GA: Saunders Elsevier.

Pratt, R.J., Hoffman, P.N. and Robb, F.F. (2005). The need for skin preparation prior to injection: point—counterpoint. British Journal of Infection Control, 6(4): 18-20.

Royal College of Paediatricians and Child Health (2002). Position Statement on Injection Technique. London

Schechter, N.L., Zempsky, W.T., Cohen, L.L., McGrath, P.J., McMurtry, C.M. and Bright, N.S. (2007). Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics, 119(5): .e1184-e1198.

Shin, H. and Kim, M.J. (2006). Subcutaneous tissue thickness in children with type 1 diabetes. Journal of advanced nursing, 54(1): 29-34.

Taddio A., Ilersich A. L., Ipp M.,Kikuta A. and Shah V. (2009) Physical interventions and injection techniques for reducing injection pain during routine childhood immunisations: systematic review of randomised controlled trials and quasi-randomised controlled trials, Clinical Therapeutics, 31, Supplement B, 48-76.

World Health Organization (2010) Best practices for injections and related procedures toolkit. Geneva: WHO

Document control information

Lead Author(s)

Elizabeth Leonard, Lead Practice Educator

Document owner(s)

Elizabeth Leonard, Lead Practice Educator

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
19 July 2017
Date approved: 
19 July 2017
Review schedule: 
Three years
Next review: 
19 July 2020
Document version: 
1.0