Procedures Used to Prepare and Administer Intramuscular Injections: A Study of Infertility Nurses
ABSTRACT Objective: To describe the procedures infertility nurses use to prepare and administer intramuscular injections of fertility medications.Design: Descriptive survey.Participants: Nurses listed as members of the Nurses Professional Group of the American Society for Reproductive Medicine (N= 645) were surveyed. Completed questionnaires were returned by 219 of the nurses.Main Outcome Measures: Volume of diluent, needle selection, site selection, internal rotation of the extremity distal to the injection site, and use of the z-track technique.Results: There was wide variation in the gauge and length of needles used to administer the medications, with most nurses using a 22 g, 1-1/2-in needle for all medications. Most nurses changed the needle between preparing and administering medications; however, filter needles were seldom used. There was wide variation in the volume of diluent used to reconstitute medications. Most of the nurses used the dorsogluteal site for injections. Although almost all of the nurses indicated that they routinely rotated injection sites, they infrequently used sites other that the dorsogluteal site. Most nurses did not rotate the extremity distal to the injection site when administering injections and even fewer used the z-track technique.Conclusions: This study demonstrated wide variation in the procedures used by infertility nurses to prepare and administer intramuscular injections of fertility medications. Many nurses did not use procedures that can reduce the pain and tissue trauma associated with intramuscular injections
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ABSTRACT: This paper is the report of a study to determine the effect on pain of internally rotating the foot, pointing the toes down and/or using the Z-track technique during intramuscular injection and to investigate differences in pain perception related to gender and body mass index. A randomized controlled trial was carried out from September to November 2010 on 75 patients receiving diclofenac sodium intramuscularly at a university hospital in Zonguldak, Turkey. The primary outcome measure collected was pain intensity, measured on a visual analogue scale. Each subject received three injections by the same investigator using three different techniques. The three techniques were randomly allocated, and the subjects were blinded to the injection technique being used. After each injection, another investigator, who had no prior knowledge of which injection technique was used, immediately assessed pain intensity using the visual analogue scale. Research findings demonstrated that the Z-track and internally rotated foot techniques significantly reduced pain intensity during intramuscular injection. Statistically significant differences in pain intensity were observed between the three injection techniques. The results supported the hypothesis that the internally rotated foot and Z-track techniques significantly reduce pain intensity.International Journal of Nursing Practice 08/2014; · 0.54 Impact Factor
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ABSTRACT: Background: Infertility treatment affects a person physiologically and psychosocially and becoming pregnant does not necessarily spell the end to the problems caused by infertility. Few studies in Taiwan have investigated the psychological aspects of pregnancy after infertility. Therefore, the purpose of this study was to explore the impact of past infertility on Taiwanese women's experience of their present pregnancies. Methods: A descriptive, qualitative study was conducted using semistructured in-depth interviews with 11 pregnant women. Colaizzi's phenomenology was selected for data analysis. Results: Three themes were generated from the interview data. These themes were: (A) a feeling of great relief; (B) uncertainty about the outcome of the pregnancy; and (C) adaptive behaviors; including (a) asking for reconfirmation, (b) informing their significant others, and (c) lifestyle changes. Conclusions: Although the pregnancy allowed the previously infertile women to cast off a heavy burden and reduced the pressure on them to continue the family line, after the initial period of happiness, ambivalence emerged. As the pregnancy progressed, particularly after the women felt fetal movement, they began to develop a mother-child relationship. However, all the women believed that until the baby was born, there was no way to be certain that the baby would be healthy. During the period before the birth, the women sought various channels for reassurance.01/2004;
Procedures Used to Prepare and
Administer Intramuscular Injections:
A Study of Infertility Nurses
Janet L. Engstrom, RN, PhD, CNM, Nina N. Giglio, RN, MS, CNM,
Susan M. Takacs, RN, MS, OGNP, Marla C. Ellis, RN, MS, CNM,
Doris I. Cherwenka, CNM, RN, MS
ity nurses use to prepare and administer intramus-
cular injections of fertility medications.
Design: Descriptive survey.
Participants: Nurses listed as members of the
Nurses Professional Group of the American Society
for Reproductive Medicine (N = 645) were sur-
veyed. Completed questionnaires were returned by
21 9 of the nurses.
Main Outcome Measures: Volume of diluent,
needle selection, site selection, internal rotation of
the extremity distal to the injection site, and use of
the z-track technique.
Results: There was wide variation in the gauge
and length of needles used to administer the med-
ications, with most nurses using a 22 g, 1 -’/rin
needle for all medications. Most nurses changed the
needle between preparing and administering med-
ications; however, filter needles were seldom used.
There was wide variation in the volume of diluent
used to reconstitute medications. Most of the nurses
used the dorsogluteal site for injections. Although
almost all of the nurses indicated that they routinely
rotated injection sites, they infrequently used sites
other that the dorsogluteal site. Most nurses did not
rotate the extremity distal to the injection site when
administering injections and even fewer used the z-
Conclusions: This study demonstrated wide
variation in the procedures used by infertility nurses
to prepare and administer intramuscular injections
of fertility medications. Many nurses did not use
procedures that can reduce the pain and tissue
Obiective: To describe the procedures infertil-
trauma associated with intramuscular injections.
J O G ”
29, 159-1 68; 2000.
Keywords: Ai r-loc k-Ferti I ity drugs-I ntra-
muscular in jections-Needles-Z-track
Accepted: September 1999
The intramuscular injection of medication is
a procedure commonly performed by nurses. In-
tramuscular injections are associated with discom-
fort, pain, and trauma to the injected tissue
(Chezem, 1973; Engel, 1967; Sutton, Evans, Ri-
naldi, & Norton, 1996; “Tissue Damage” 1970).
Intramuscular injections also can cause serious tis-
sue, musculoskeletal, and neurologic complica-
tions such as abscess, tissue necrosis, muscle dam-
age, nerve injury, paralysis, and death (Beecroft &
Redick, 1989; Clark, Williams, Willis, & Mc-
Gavran, 1970; Greenblatt & Allen, 1978; Obach,
Aragones, & Ruano, 1983). Thus, proper prepara-
tion and administration of intramuscular injections
are important aspects of nursing practice.
The proper preparation and administration
of intramuscular injections involve the use of
equipment and procedures that minimize tissue
trauma and discomfort, reduce the risk of compli-
cations, and ensure that the correct dose of the
medication is delivered to the muscle to achieve
the maximum therapeutic effect of the drug. Al-
though performed routinely by nurses, intramus-
cular injection is a complex procedure requiring
numerous decisions regarding equipment and
methods as well as technical proficiency. The pro-
cedural and equipment decisions are summarized in
Table 1. Preparation of an injection involves selecting
equipment such as needle gauge and length, determining
the need for a filter needle and whether the needle
should be changed between preparing and administer-
ing the medication. Preparation of the medication for
injection requires decisions about the volume of diluent
to use when reconstituting medications and whether to
use the air-lock technique. The administration of an in-
tramuscular injection requires decisions regarding the
injection site, volume of medication to be injected, posi-
tion of the patient for the injection, speed of the injec-
tion, and whether to use procedures such as the z-track
technique, pinching or spreading of the tissue, and mus-
Despite the frequency with which intramuscular
injections are administered and the associated risks of
pain, tissue trauma, and serious complications, many
aspects of injection procedures have not been studied
adequately and some have never been studied. For ex-
ample, many nurses massage the injection site after ad-
ministering medication intramuscularly. However, the
safety and efficacy of muscle massage after intramuscu-
lar injection have not been studied and expert opinion
on the practice is conflicting. Some experts suggest that
Procedural and Equipment Decisions
Involved in the Preparation and
Administration of Intramuscular Injections
Changing the needle between preparation and ad-
ministration of the medication
Preparation of the injection
Volume of diluent used to reconstitute medications
Use of the air-lock technique
Administration of the injection
Selection of the injection site
Maximum volume of medication that can be admin-
istered to a site
Rotation of injection sites
Aspiration of the injection site
Management of a bloody aspirate
Rotation of the extremity distal to the injection site
Speed of the injection
Whether the tissue at the injection site should be
pinched or spread
Use of the z-track technique
Use of muscle massage after injection
massaging the injection site may reduce the pain and
discomfort associated with the injection (Newton, New-
ton, & Fudin, 1992), whereas others suggest that mas-
sage may increase tissue trauma (Beyea & Nicoll, 1995;
Keen, 1990; Lilley, 1995).
In addition to the lack of research regarding the
actual injection procedures, the procedures used by
practicing nurses to prepare and administer intramuscu-
lar injections have not been described in published re-
search. Descriptions of nurses' current clinical practices
can be an important source of information in an area
where there is little or no research. Description of cur-
rent practices also can identify areas of needed research.
Although the research on intramuscular injections
is limited, some aspects of the procedure have been
studied and demonstrated to be effective in reducing tis-
sue trauma, pain, and complications associated with in-
tramuscular injections. For example, studies published
in the nursing literature demonstrate that internal rota-
tion of the extremity distal to the injection site reduces
tissue trauma and pain (Itty, Kurian, & Cherian, 1977;
Kruszewski, Lang, & Johnson, 1979; Lang, Zawacki,
&Johnson, 1976; Rettig & Southby, 1982). However,
nurses' awareness of the benefits of this procedure and
the extent to which this information has been incorpo-
rated into routine clinical practice are unknown.
The limited amount of nursing research on intra-
muscular injection procedures and the lack of informa-
tion regarding which injection procedures are used by
nurses in routine clinical practice were the impetus for
performing the current study. The purposes of this study
were to describe the procedures used by nurses to pre-
pare and administer intramuscular injections and to de-
termine whether nurses use research-based injection
procedures that have been demonstrated to be effective
in reducing the pain, tissue trauma, and complications
associated with intramuscular injections.
Infertility nurses were studied because they ad-
minister a large number of intramuscular injections and
commonly administer medications that require reconsti-
tution or must be withdrawn from ampules and vials. In
addition, because infertility nurses often prepare med-
ications in dosages that exceed the manufacturer's
guidelines, they must decide how best to reconstitute
and administer these medications.
The study sample consisted of the 645 individuals
listed as members of the Nurses Professional Group
(formerly the Nurses Special Interest Group) of the
American Society for Reproductive Medicine (formerly
the American Fertility Society) in June 1993. Two hun-
dred and twenty members (34.1%) completed and re-
160 J O G "
Volume 29, Number 2
turned the questionnaire. One questionnaire was not
included in the analysis because the respondent was not
a nurse, leaving a final sample size of 219 nurses. The
age of the nurses ranged from 25 to 62 years (M =
39.8; SD = 7.1). The nurses’ years in professional nurs-
ing ranged from 3 to 40 years (M = 15.9 years; SD =
7.1). The nurses’ years in infertility nursing ranged
from 1 to 30 (M = 6.4 years; SD = 4.9). The basic
nursing education levels of the respondents included li-
censed practical nurse (3.7%), associate degree
(22.8%), diploma (30.6%), and baccalaureate degree
(42.9%). Their highest levels of education were li-
censed practical nurse certificate (2.8 %), associate de-
gree (12.9%), diploma (18.3%), baccalaureate degree
(42.2%), masters degree (22.9%), and preparation as a
nurse practitioner (0.9%).
The instrument used was a 110-item questionnaire de-
veloped specifically for the purposes of this study. The
items on the questionnaire pertained to the techniques
used to prepare and administer intramuscular injec-
tions. Specific topics addressed in the questionnaire in-
cluded the following:
(a) the selection of equipment, such as needle
gauge, needle length, and need for a filter nee-
dle, and whether the needle should be changed
between preparing and administering the in-
(b) medication preparation issues such as the vol-
ume of diluent used to reconstitute medica-
tions and use of the “air-lock’’ technique;
(c) injection procedures such as selection of an in-
jection site, rotation of injection sites, maxi-
mum volume of medication injected into each
of the sites, whether the extremity distal to the
injection site was rotated internally for the in-
jection, tissue aspiration prior to injection,
management of a bloody aspirate, speed of the
injection, and whether procedures such as the
z-track technique, stretching or pinching the
tissue, and muscle massage were used.
The questionnaire addressed the preparation and
administration of three medications commonly used to
treat infertility: human menopausal gonadotropin
(hMG), a powdered medication packaged in ampules
that must be reconstituted with an aqueous solution;
human chorionic gonadotropin (hCG), a powdered
medication packaged in a vial that must be reconsti-
tuted with an aqueous solution; and progesterone in oil,
an oil-based medication packaged in a vial. The ques-
tionnaire also included items regarding the demo-
graphic, educational, and professional characteristics of
The items on the questionnaire were developed by
reviewing publications on intramuscular injections
identified using computerized and manual literature
searches, reviewing nursing textbooks for recommenda-
tions on the procedures used to prepare and administer
intramuscular injections, and discussing intramuscular
injection practices with infertility nurses and nurses in
other specialty areas. The content validity and readabil-
ity of the items were verified by having two faculty
members who taught the nursing fundamentals course
at a major university review the questionnaire. The
items on the questionnaire required forced choice an-
swers, but also allowed the choice of “other,” with ac-
companying space for respondents to explain their an-
swers. The items and responses were grouped and
arranged in a logical order to facilitate responses.
Questionnaires were mailed directly to each of the
645 members of the Nurses Professional Group of the
American Society for Reproductive Medicine. Each
questionnaire was accompanied by an addressed,
stamped, return envelope and a covering letter that de-
scribed the purposes of the study and explained that
participation was voluntary and that all responses were
The returned questionnaires were coded and en-
tered into a computerized database. The entered data
were printed and checked twice for accuracy by sepa-
rate members of the research team. Data were analyzed
using the Statistical Analysis System’s (Cary, NC) com-
puter programs. Frequencies and univariate statistics
were used to describe the respondents’ responses to the
items on the questionnaire.
This study was approved by the institutional re-
view board of the participating university, the Nurses
Professional Group, and the American Society for Re-
productive Medicine. The anonymity of the respondents
was protected by using unnumbered and unmarked
questionnaires and return envelopes.
The needle gauges that infertility nurses selected to
administer infertility medications varied widely (see
Table 2). For medications administered in aqueous so-
lutions (hMG and hCG), the needle gauge selected var-
ied from 21 g to 27 g, with a 22-g needle selected most
frequently (47%). For progesterone in oil, the needle
gauge (g) selected varied from 18 g to 25 g, with the 22-
g needle selected most frequently (55.2%).
The needle lengths selected to administer injec-
tions into each of the intramuscular injection sites are
described in Table 3. The needles selected ranged from
J O G ”
Needle Gauge Selected for Intramuscular
Injection of Infertility Medications
(n = 219)
(n = 219)
(n = 210)
Note. hMG = human menopausal gonadotropin.
hCG = human chorionic gonadotropin.
1-in to l-%
the deltoid site, for which needle length ranged from 5/8
in to 1 4 in. The most frequently selected needle length
for injections into the dorsogluteal, ventrogluteal, rectis
femoris, and vastus lateralis sites was 1 4 in. The most
frequently selected needle length for injections into the
deltoid site was 1 in. Needle length was adjusted for
obese patients by only 24.8% of the nurses.
The practice of changing the needle between the
preparation and administration of hMG, hCG, and
progesterone was performed by 63.3%, 84.5%, and
77.7% of the nurses, respectively. Filter needles were
used to prepare hMG, hCG, and progesterone by only
14.2%, 1.9%, and 1.5% of the nurses, respectively.
(n = 68) %
in for each of the injection sites, except for
Preparation of the Medication for Injection
The volume of diluent used to reconstitute hCG
varied from 0.5 ml to 5 ml for 5,000 I U and from 1 ml
to 5 ml for 10,000 IU (see Table 4). Although the volume
of diluent used varied, the nurses most frequently used 1
ml of diluent to reconstitute 5,000 IU of hCG and 2 ml
of diluent to reconstitute 10,000 IU. Similarly, the vol-
ume of diluent used to reconstitute hMG varied widely.
However, the nurses most frequently used 1 ml of diluent
when reconstituting 1 or 2 ampules of hMG, and 2 ml of
diluent when reconstituting 3 to 12 ampules of hMG.
The air-lock technique was used for the preparation and
administration of hMG, hCG, and progesterone by
21.8%, 21.3%, and 24% of the nurses, respectively.
Administration of the Injection
The nurses' estimates of the percentage of injec-
tions that they administered to each of the intramuscu-
lar injection sites indicated that the majority used the
dorsogluteal site for most of the injections. The mean
estimated percentage of injections administered to the
dorsogluteal site was 92% for hMG, 92.1% for hCG,
and 93.4% for progesterone. Most of the nurses indi-
cated that they always used the dorsogluteal site for all
of the injections of hMG (52.6%), hCG (64%), and
progesterone (75.4%) that they administered. The next
most commonly selected site was the ventrogluteal site.
The mean estimated percentage of injections adminis-
tered to the ventrogluteal site was 5.3% for hMG, 5.4%
for hCG, and 4.7% for progesterone. Each of the other
sites was selected less than 1.5% of the time. The ma-
jority (81.5%) of the nurses indicated that they were
most confident administering injections into the dorso-
gluteal site. The remainder indicated that they were
most confident administering injections into the ven-
trogluteal (4.5%) and deltoid (0.5%) sites. No nurses
indicated they were most confident using the rectis
femoris and vastus lateralis sites. None of the nurses in-
dicated that they were least confident administering in-
jections into the dorsogluteal site, whereas 39% ,
26.2%, 22.6%, and 11.8% indicated that they were
least confident using the deltoid, ventrogluteal, vastus
lateralis, and rectis femoris sites, respectively.
Needle Length Selected for Intramuscular Injection of Infertility Medications
Into Each Injection Site
(n = 79) %
(n = 203) %
(n = 95) %
1 4 in
(n = 69) '%
162 J O G "
Volume 29, Number 2
Reported Volume of Diluent Used to Constitute Human Chorionic Gonadotropin
(hCG) and Human Menopausal Gonadotropin (hMG)
Mode (ml) Minimum (ml) Maximum (ml)
"Manufacturers' recommendations do not specify an exact volume to be used for reconstitution (Physicians' Desk Reference. [ 19981. Montvale,
NJ: Medical Economics.)
"Manufacturers' recommendation is 1 or 2 ml of diluent for one ampule or vial of hMC. No recommendations for higher dosages are provided
(Physici~rrs' Desk Reference. 119981. Montvale, NJ: Medical Economics.)
The maximum volume of medication that the
nurses would inject into each site is described in Table
5. The maximum volume injected into the dorsogluteal
and ventrogluteal sites ranged from 1-5 ml, with the
nurses most frequently injecting a maximum volume of
3 ml. For the deltoid, rectus femoris, and vastus lateralis
sites, the maximum volume injected ranged from 1-3
ml, with the nurses most frequently indicating that they
would inject a maximum volume of 2 ml.
Injection sites were rotated routinely by 98.2% of
the nurses, but only 19.8% had a written schedule for
site rotation. The injection site was recorded in the med-
ical record by 75.9% of the nurses.
Almost all of the nurses (96.3%) aspirated the tis-
sue at the injection site before injecting the medication.
However, the procedures used to manage a bloody aspi-
rate varied among the nurses: 49.8% withdrew the nee-
dle completely from the tissue, changed the needle but
not the syringe or medication, then reinjected; 27%
withdrew the needle completely from the tissue and dis-
carded the syringe and needle with the medication;
17.7% withdrew the needle slightly, reaspirated, and
Maximum Volume of Medication Injected Into Each Site
then injected the medication if the second aspirate was
clear; and 5.6% of the nurses indicated that they used
Most nurses in this study did not internally rotate
the extremity distal to the injection site when adminis-
tering injections into the deltoid and dorsogluteal sites.
Only 26.2% of the nurses who used the deltoid site in-
ternally rotated the arm before administering the injec-
tion, and only 44.9% internally rotated the femur when
administering injections into the dorsogluteal site.
The speed with which nurses injected the medica-
tion in the syringe once the needle was placed in the tis-
sue was described as follows: as fast as possible, 7.4%;
somewhat fast, 33.8%; neither fast nor slow, 42.6%;
somewhat slow, 13.9%; and very slow, 2.3%.
The tissue at the injection site was always pinched
for injection by 26.8% of the nurses and sometimes
pinched by 15.6%. In contrast, the tissue at the injec-
tion site was spread by 52.7%. The z-track technique
was always used by only 12.6% of the nurses and some-
times used by 11.1 %. Muscle massage after injection
was practiced by 70.5%.
The results of this study demonstrate a wide vari-
ation in the procedures used by infertility nurses to pre-
pare and administer intramuscular injections. The re-
sults also indicate that many infertility nurses do not use
procedures that have been demonstrated by research to
decrease discomfort, tissue trauma, and complications
and that increase the likelihood of administering med-
ication to the muscle rather than the subcutaneous tis-
sue to achieve the maximum therapeutic effect of the
drug. These findings suggest that many nurses may be
unaware of the research on intramuscular injections
which has demonstrated decreased tissue trauma and
pain when selected injection procedures are used.
Several characteristics of needles must be consid-
ered when selecting a needle for an intramuscular injec-
tion. The nurse must determine the appropriate gauge
and length of the needle, whether there is the need for a
filter needle, and whether to change the needle between
the preparation and administration of the injection.
The relationship between the needle gauge used
for intramuscular injections and tissue trauma, injection
pain, and complications has not been studied. Thus,
evidence-based guidelines for clinical practice are not
available. However, smaller lumen needles are thought
to cause less tissue trauma and reduce the amount of
pain associated with intramuscular injections. Larger
lumen needles are thought to make a larger track
through the subcutaneous tissue, thereby increasing the
risk of medication backflow from the muscle to the sub-
cutaneous tissue, which may increase tissue trauma and
decrease the bioavailability of the medication. In this
study the selection of needle gauge varied greatly among
the nurses. Medications in aqueous solutions were ad-
ministered with 21-g to 27-g needles, and medication in
an oil base was administered with 18-g to 25-g needles.
Although some nurses used larger lumen needles, most
of the nurses used smaller lumen needles, with many
nurses using 25-g or 27-g needles to administer medica-
tions in aqueous solutions, and 23-g or 25-g needles to
administer an oil-based medication. These findings sug-
gest that smaller lumen needles may be used safely to
administer these medications. However, research is
needed to determine whether smaller lumen needles are
associated with decreased tissue trauma and pain, and
problems such as bending and breakage.
The optimal length needle for intramuscular in-
jection has received limited study. Research conducted
using computerized tomography and autopsy to mea-
sure the subcutaneous thickness at the dorsogluteal site
in women demonstrates that any needle less than 1 4
T h e finding that many of the nurses
used 25 g or 27 g needles to administer
medications in aqueous solutions and 23
g or 25 g needles to administer oil-based
medications suggests that smaller lumen
needles may be safely used to
administer these medications.
in in length is unlikely to reach the muscle, and that a
l-%-in needle may not be long enough to reach the
muscle in many women (Cockshott, Thompson,
Howlett, & Seeley, 1982; Haramati, Lorans, Lutwin,
& Kaleya, 1994; Michaels & Poole, 1970). The use of
a needle that is too short results in medication being de-
posited into the subcutaneous tissue rather than the
muscle. Administration of some medications to the
subcutaneous tissue rather than the muscle has been as-
sociated with increased local side effects such as red-
ness and swelling and, in some cases, significant subcu-
taneous tissue trauma (Engmann et al., 1998; Michaels
& Poole, 1970). Administration of medication to the
subcutaneous tissue instead of the muscle also alters the
absorption of the medication and the subsequent serum
levels of the medications (Dobbs, Dumesic, Dumesic,
& Shapiro, 1994; Saal, Glowania, Hengst, & Happ,
1991). Thus, an adequate-length needle should be used
Volume 29, Number 2
to administer the medication into the muscle. In this
study, the majority of injections into the dorsogluteal,
ventrogluteal, rectis femoris, and vastus lateralis were
administered with a 1-%-in needle. However, 5.9% of
nurses used shorter needles for injections into the dor-
Changing the needle between preparing and ad-
ministering intramuscular medications is hypothesized
to reduce the risk of administering medications with a
dull or damaged needle, irritating the tissue with the
medication that adheres to the outside of the needle,
and using a contaminated needle. The majority of
nurses in this study changed the needle between the
preparation and administration of the medications.
However, three previous studies demonstrated that
changing the needle did not reduce macroscopic local
reactions to intramuscular injections of vaccines in chil-
dren (Ipp, Goldbach, Greenberg, & Gold, 1990; Sa-
lomon, Halperin, & Yee, 1987; Wiesenthal & Lauer,
1987). Although these studies suggest that changing the
needle may not be beneficial, only vaccines withdrawn
from vials were studied. The benefits and costs of
changing the needle between preparing and administer-
ing intramuscular injections of medications prepared by
reconstitution and for those withdrawn from glass am-
pules have not been studied.
Filter needles have a self-contained screen that cap-
tures particulate matter that may be present in the med-
ication. Microscopic glass particles are often present in
solutions prepared from medications packaged in am-
pules, regardless of the skill with which the ampule is
opened (Cosentino, 1994). Similarly, cores of rubber
from the rubber closure of vials can enter the solution or
lodge in the needle and then be drawn into the syringe
and administered with the medication (Cosentino, 1994).
The risk of injecting microscopic glass particles, rubber
plugs, or other particulate matter that may be present in
reconstituted medication can be minimized by using a fil-
ter needle to prepare the medication for injection, and
then changing the needle before the medication is admin-
istered (Cosentino, 1994). Thus, the infrequent use of fil-
ter needles by the nurses in this study was surprising, par-
ticularly because the medications studied all were
prepared from ampules and vials. However, the benefits
of filter needles are hypothetical-no studies of filter nee-
dles were found in the literature.
Preparation of Medication for Injection
Preparation of medication for injection entails de-
cisions about the volume of diluent for reconstituting
medications and whether to use the air-lock technique.
Previous research has demonstrated that both the
volume and concentration of the medication injected
are associated with tissue trauma, and both affect the
rate of absorption of the medication from the tissue (Di-
ness, 1985; Schriftman & Kondritzer, 1957; Sidell, Cul-
ver, & Kaminskis, 1974). The volume of diluent used to
reconstitute the medications in this study varied widely
among the nurses. This widespread variation in the vol-
ume of diluent may be explained by the observation
that infertility nurses often administer medications in
doses that exceed the manufacturer's guidelines or ad-
minister medications for which the manufacturer's
guidelines are not explicit. Thus, nurses must make their
own decisions about the volume of diluent to be used.
However, the effects of altering the volume and concen-
tration of injections of infertility medications are un-
The air-lock technique is a procedure in which a
small volume of air (usually 0.1-0.2 ml) is drawn into
the syringe after the medication is prepared. The air-
lock technique is hypothesized to decrease the tissue
trauma and pain associated with injections by decreas-
ing the back-flow of medication into the subcutaneous
tissue. However, studies on the benefits of the air-lock
technique have produced conflicting results. Although
one study demonstrated that the air-lock technique re-
duced seepage from the injection site (Quartermaine &
Taylor, 1995), two studies demonstrated no beneficial
effect of the technique (Ipp et al., 1990; MacGabhann,
1998). Thus, the technique merits further study.
Although it may or may not reduce tissue trauma,
the air-lock technique is problematic because it alters
the dose delivered in medications packaged at a speci-
fied dose per volume (Chaplin, Shull, & Welk, 1985).
When the air-lock technique is used, the medication that
would normally remain in the needle and hub of the sy-
ringe is injected. Because syringes are calibrated to ac-
count for the dead space in the needle and the hub of the
syringe, use of the air-lock technique will result in the
injection of a larger than prescribed dose of medication.
This may be problematic for patients on small doses.
Previous research has demonstrated that when the vol-
ume of medication to be delivered is small and the med-
ication that remains in the dead space is administered,
the dose of the medication delivered is increased signif-
icantly (Berman et al., 1978).
Conversely, the air-lock procedure may be neces-
sary for medications such as hMG and hCG, which
must be reconstituted and delivered by dose (Wong,
1982). If the air lock technique is not used to adminis-
ter these medications, the patient will receive a smaller
than recommended dose (Wong, 1982). The percentage
of medication that remains in the dead space depends
on the dead space volume of the particular syringe, nee-
dle hub, needle, and total volume of the medication in-
jected. Most nurses in this study did not use the air-lock
technique when administering hCG or hMG, suggesting
that some infertility patients may be receiving a smaller
than prescribed dose of these medications.
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Administration of the Injection
Procedures involved in the administration of the
injection include the following: selecting an injection
site, aspirating tissue to verify that the needle has not
been placed in a blood vessel, managing a bloody aspi-
rate, positioning of the extremity distal to the injection
site, determining the speed with which the injection is
administered, using the z-track technique, pinching or
spreading the tissue over the injection site, and massag-
ing the site after injection.
The dorsogluteal site is commonly used for intra-
muscular injections. However, the ventrogluteal site is
better for intramuscular injections; anatomic dissections
of cadavers have demonstrated that there are no major
blood vessels or nerves in the ventrogluteal site (Zel-
man, 1961). In contrast, the dorsogluteal site is in close
proximity to major nerves and blood vessels and the lit-
erature is replete with reports of serious tissue and nerve
injury associated with injections into that site. In addi-
tion, autopsies have demonstrated that the skin-to-mus-
cle distance at the ventrogluteal site is less than the skin-
to-muscle distance at the dorsogluteal site (Michaels &
Poole, 1970), which increases the probability that the
medication will be administered to the muscle. Despite
the advantages of the ventrogluteal site, almost all of
the nurses in this study selected the dorsogluteal site for
most intramuscular injections they administered; other
injection sites were used infrequently. These findings
suggest that nurses are unaware of the advantages of the
ventrogluteal site or are not confident in using it.
Aspiration of the tissue before the intramuscular
injection of medication is considered an essential com-
ponent of the procedure and is performed to ensure that
the needle has not been placed into a blood vessel
(Kozier, Erb, Blais, & Wilkinson, 1995; Taylor, Lillis, &
LeMone, 1997). Thus, it was surprising that a few of
the nurses did not aspirate the tissue prior to injecting
medication. The management of a bloody aspirate var-
ied among the nurses in this study. Nursing textbooks
recommend that all of the equipment and medication
should be discarded when a bloody aspirate is obtained
(Kozier et al., 1995; Taylor et al., 1997). However, only
27% of the nurses in this study adhered to this recom-
mendation; most used a procedure that involved inject-
ing the medication contaminated by the bloody aspi-
rate. Although the nurses may have injected the bloody
medication because of the high cost of the fertility med-
ications, the effects of this practice are unknown.
Internal rotation of the extremity distal to the in-
jection site has been demonstrated in previously pub-
lished research to decrease tissue trauma and pain when
injections are administered into the deltoid and dorso-
gluteal sites (Itty et al., 1977; Kruszewski et al., 1979;
Lang et al., 1976; Rettig & Southby, 1982). Although
internal rotation of the extremity distal to the injection
site has been consistently demonstrated to reduce pain
and tissue trauma, most of the nurses in this study did
not perform this procedure.
The speed of intramuscular injections has not been
studied extensively. Although one study demonstrated
that speed of the injection does not influence the per-
ception of pain associated with the injection (Svendsen,
1984), another study demonstrated that speed of injec-
Research has demonstrated that
internal rotation of the extremity distal
to the injection site reduces pain and tissue
trauma when injections are administered
to the deltoid and dorsogluteal sites.
tion may be associated with tissue trauma and that
slower injections cause slightly less trauma (Svendsen,
1983). Thus, injections should be administered slowly.
In this study, the speed with which medication was in-
jected varied from “as fast as possible” to “very slow”
and was most commonly injected neither fast nor slow.
The z-track technique is a procedure wherein the
skin and subcutaneous tissue over the injection site are
displaced laterally before the injection, held in that po-
sition throughout the injection, and then returned to its
normal position immediately after the needle is removed
from the tissue. The z-track technique has been demon-
strated to reduce tissue trauma and pain (Keen, 1986;
Taylor, 1992). However, most of the nurses in this study
did not use the z-track technique routinely.
The issue of whether the tissue over the muscle at
the injection site should be pinched or spread for the in-
jection has not been studied. Approximately 27% of the
nurses in this study pinched the tissue. Pinching the tis-
sue may pull the subcutaneous tissue away from the
muscle, making the distance between the skin and the
Pevious studies of the z-track technique
have demonstrated that it is associated with
reduced pain and decreased tissue trauma.
muscle greater and increasing the chance that the needle
may not be long enough to reach the muscle. Con-
versely, spreading the skin prior to the intramuscular in-
jection of a drug may increase the probability of ad-
Volume 29, Number 2
ministering the medication into the muscle tissue be-
cause spreading the tissue may flatten the subcutaneous
tissue. Stretching the skin is also thought to facilitate
needle penetration, thereby decreasing tissue trauma.
However, only about half of the nurses in this study
spread the tissue before injection.
Many nurses in this study massaged the muscle
after an injection at that site. However, the efficacy of
muscle massage has not been studied and recommenda-
tions from experts are conflicting. Some experts suggest
that muscle massage decreases pain associated with in-
jection and facilitates absorption of the drug by spread-
ing the medication over a larger area (Newton et al.,
1992). Others suggest that massage may cause tissue ir-
ritation and force the medication back through the nee-
dle tract into the subcutaneous tissue (Beyea & Nicoll,
1995; Keen, 1990; Lilley, 1995).
The findings of this study emphasize the need for
widespread dissemination of the results of research that
has studied intramuscular injection procedures. Injec-
tion procedures that have been demonstrated to be ef-
fective in reducing pain and tissue trauma, such as the
z-track technique and internal rotation of the extremity
distal to the injection site, must be included in nursing
textbooks, continuing education programs, and profes-
sional guidelines. The need for increased research re-
garding intramuscular injection procedures is apparent
from the results of this study. Procedures that may re-
duce trauma and pain, such as the use of smaller-lumen
needles and filter needles, merit systematic investiga-
tion, and the results of these studies must be widely dis-
seminated to practicing nurses.
posia, USA, Norwell, MA.
This study was partially funded by Serono Sym-
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American Journal of Medical Science, 241, 563-574.
Janet L. Engstrom is an associate professor of maternal child
nursing at the University of Illinois at Chicago.
Nina N. Giglio is a certified nurse-midwife and is currently
on maternity leave.
Susan M. Takacs is an OGNP in private practice in Chicago,
Marla C. Ellis is a certified nurse-midwife in private practice
in Elgin, IL.
Doris I. Cherwenka is a certified nurse-midwife in private
practice in Hinsdale, IL.
Address for correspondence: Janet Engstrom, CNM, PhD,
University of Illinois at Chicago, Maternal-Child Nursing
(WC 802), 845 S. Damen, Chicago IL 60612. E-mail:
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