ROUTE AND SITE

1. The intradermal route injection provides a local, rather than systemic, effect and is used
primarily for diagnostic purposes such as allergy or tuberculin testing, or for local anesthetics.
The sites suitable for ID injection are similar to those for subcutaneous injections (Fig 2) but also
include the inner forearm and shoulder blades (Springhouse Corporation 1993).

2. The subcutaneous route is used for slow, sustained absorption of medication, up to 1-2 ml
being injected into the subcutaneous tissue. It is used for insulin injections which require a slow
and steady release, it is a relatively pain free and suitable for frequent injections.

3. The intramuscular (IM) route injection delivers medication into well perfused muscle,
providing rapid systemic action and absorbing relatively large doses. The choice of the site
should take into account the patient’s general physical condition and age; and the amount of
medication to be given. The five sites that are used for IM injections are:

• The Deltoid muscle of the upper arm which is the preferred site for vaccinations in adults.

• The Dorsogluteal (DG) performed by entering through the gluteus maximus muscle. Care
should be given to avoid damage to the sciatic nerve and vessels surrounding this area.

• The Ventrogluteal site is a safer option which accesses the gluteus medius muscle. Research
of IM injections has shown this site to be the primary location for IM use as it avoids all major
nerves and blood vessels; and there have been no reported complications (Beyea and Nicholl
1995).

• The Vastus Lateralis is a quadriceps muscle situated on the outer side of the femur and is
used as a primary site for children. It does have risks associated to it due to overuse but has been
suggested safe for children up to seven months old.

• The Rectus femoris is the anterior quadriceps muscle which is rarely used by nurses but is
easily accessed for self- administration, or for infants.
There is interesting research which shows that several aspects of the IM injection process varied
among texts. In an article titled “Are We On the Same Page? : A comparison of intramuscular
injection explanations in nursing fundamental texts” by Heather Carter-Templeton, and Tammie
McCoy, researchers compare instructions for IM techniques from five fundamental nursing
textbooks. Issues related to needle size selection and common procedures associated with IM
injections (z-track, bubble technique, filter needle, site selection) are explored and reported.

For example, in the use of the Deltoid muscle, the literature reviewed for the use of this muscle
was largely in agreement. Discrepancies were related to the method for determining the exact
injection site with the area for this muscle. Some authors recommended using an imaginary
triangle to isolate the injection site (Rodger & King, 2000); while others suggested a site two
finger breadths below the acromion process (Potter & Perry, 2005).

Regarding the Dosogluteal muscle, a query of 36 nurses at local clinical institutions yielded 27
responses to the EBP Information Sheet, a tool designed in an undergraduate baccalaureate
nursing course to collect data from practicing nurses on IM injection techniques. Seventy-five
percent stated that they utilized the DG muscle as the site of choice for administering large-
volume IM injections; 4% of the respondents did not identify a specific site (Avery et al. 2006).
However, Beyea and Nicoll (1995), Nicoll and Hesby (2002), Potter and Perry (2005), and
Rodger and King (2000) did not advocate the utilization of this site for IM injections!

4. Intravenous route injection uses a hypodermic injection into a vein for the purpose of instilling
a single dose of medication, injecting a contrast medium, or beginning an IV infusion of blood,
medication, or a fluid solution, such as saline or dextrose in water.