PROCEDURE FOR INTRAMUSCULAR INJECTION

	PROCEDURE	RATIONALE
1.	Check immunization record for name, date of birth, address and telephone number.	Verifies identity of client and allows for updating of information.
2.	Explain the risks and benefits of immunization, including minor and serious reactions that may occur.	Fulfills the requirement for informed consent. Provides an opportunity for discussion of appropriate treatment for any reactions.
3.	Obtain and record the immunization history, and screen for the present procedure.	Provides the opportunity for reviewing medical history, including previous immunization history.
4.	Verify or obtain dated consent.
5.	Arrange equipment on a barrier field, placed out of child's reach.
6.	Check anaphylaxis kit, noting appropriate doses for person to be immunized.	Noting the appropriate dose of adrenalin saves time if the dose is required.
7.	Wash hands. If in a group setting a hand wipe or sanitizer may be used.
8.	Check vaccine product for expiry date, label, amount and appearance.	Vaccine that is outdated or that looks unusual in terms of color, clarity or consistency may not be fully potent and should not be used. Vaccine without a clearly marked lot number should not be used.
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9.	Draw up vaccine as per specific product instructions.
10.	Select a site for injection. If this is not the first immunization, choose the limb opposite the site of the previous injection. In a child aged up to and including eighteen months, use the vastus lateralis muscle of the anterior thigh. In a child of eighteen months the deltoid is an alternate site. For older children, teens and adults, the deltoid muscle is a suitable site.	Rotating the injection site minimizes the trauma to muscle. This muscle is large and well developed. It is accessible, free of major nerves and blood vessels and can readily adsorb vaccine. Deltoid muscle injection in this age group may prevent pain that is associated with walking after a vastus lateralis injection. Deltoid is adequate and readily available.
11.	Assess the muscle mass for needle size and length. For an infant less than 4 months of age, a 25G 7/8" needle is suitable. For older infants, children and adults, choose a 22-25G 1" needle. Medsaver (hubless) syringe recommended size is 23-25G, 1".	Age, weight, and available muscle mass must be considered when choosing needle. If the amount and general condition of the muscle mass indicate changes in gauge and length may be made. A 5/8" needle is appropriate for use in a child under the age of four months. A 1" needle is required for adequate muscle penetration in those 4 months of age and older. Materials (type of steel) used in the needle construction reduces the chance of the needle bending or breaking as vaccine is delivered.
12.	Changing the needle is not mandatory but may be done if sharpness is compromised.	A needle used to pierce a rubber stopper or ampoule may be used for subsequent injection, but if it has become blunt or bent should be replaced with a needle of the same size.
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13.	13. Landmark the injection site as follows: Vastus lateralis: Palpate for the greater trochanter and the lateral border of the kneecap. Visualize a vertical line between these landmarks. The vastus lateralis muscle is located lateral to this line. Using the greater trochanter as the upper border and the lateral border of the kneecap as the lower, divide the thigh into thirds. The anterolateral aspect of the middle third is where the belly of the vastus lateralis muscle lies, and the injection site is in the middle of this area, as shown. 4.2-3 Deltoid: Have the person's elbow flexed and the forearm supported. Locate the lower edge of the acromium process. Estimate a point opposite the axilla. Visualize an inverted triangle with the base at the acromium process and the apex just below the axilla. This defines the deltoid muscle. Locate a rectangular area in the middle of the muscle as follows-: upper edge: two to three finger widths below the acromium process. Lower edge: a point just above the axilla. Side edges: parallel to arm, slightly posterior to midline of outer arm. The injection site is in the middle of this area, as shown. 4.2-4
14.	For infant immunizations, have the child held securely with the site accessible. An older child may consent to standing alone or sitting next to the caregiver.
15.	Firmly spread skin with the thumb and index finger, grasping the muscle deeply on each side. Cleanse the site with antiseptic solution.	Compresses fat, stabilizes and isolates muscle. Obese clients may need the skin to be stretched tautly to displace subcutaneous tissue, in combination with grasping of the muscle.
16.	Insert the needle at an angle that is more than 45 degrees but less than 90 degrees, with the needle pointed towards the knee, as shown in Fig. 1. For the deltoid site, insert the needle at an angle that is more than 45 degrees but less than 90 degrees, with the needle pointed toward the shoulder (see Fig. 2).	These angle specifications ensure that vaccine is delivered deep into the belly of the muscle, promoting maximum absorption of the vaccine. Minimizes the chance of vaccine encountering subcutaneous tissue.
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17.	Release the isolated tissue when the needle is safely inserted.	Bunched tissue will be more painful to inject into.
18.	Aspirate. If blood appears in the syringe, withdraw the needle, discard the needle/syringe set in a sharps container, and begin procedure again at step 9. Do not recap the needle.	Prevents inadvertent intravenous injection.
19.	Inject vaccine at a moderate rate, using a smooth continuous motion.	A slow and steady rate of injection allows for gradual distension of muscle fibers by vaccine, minimizing pain.
20.	Withdraw needle and immediately dispose of the needle/syringe set in the sharps container. Do not recap the needle.	Leaving needle out or recapping increases the risk of needle stick injuries.
21.	Cover site with clean gauze, massaging gently. Alternately, cover the site with a band aid if bleeding occurs.	Promotes absorption of vaccine. Application of pressure helps to seal the puncture site if bleeding occurs.
22.	Praise child for being cooperative, allowing him or her to be comforted.
23.	Record procedure, noting preparation name, date of immunization, lot number, site, route and dose, on the Immunization and Health Record.
24.	Date and sign the Personal Record of Immunization , noting the preparation given. Appointment time for the next immunization can be noted here as well.	Updates the personal record for future reference.
25.	Dispose of vaccine containers in the sharps container.
26.	Provide caregiver with appropriate literature, and advise caregiver that the Department of Health and Community Services policy recommends that immunized persons remain in the clinic area for a 15 minute waiting period following the procedure.	Waiting period allows for an immediate response if an allergic or anaphylactic reaction occurs.
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