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International Journal of Nursing Practice 2014; ••: ••–••
RESEARCH PAPER
The effect on pain of three different methods of intramuscular injection: A randomized controlled trial Dilek Kara MSc Instructor, Department of Nursing, School of Health, Uludag University, Bursa, Turkey
Ülkü Yapucu Günes¸ PhD Associate Professor, Department of Basic Nursing, Faculty of Nursing, Ege University, ˙I zmir, Turkey
Accepted for publication April 2014 Kara D, Yapucu Günes¸ Ü. International Journal of Nursing Practice 2014; ••: ••–•• The effect on pain of three different methods of intramuscular injection: A randomized controlled trial 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. Key words: internally rotated foot, intramuscular injection, pain intensity, randomized controlled study, Z-track technique.
INTRODUCTION Intramuscular (IM) injections are a common and painful part of routine health care. However, good injection techniques can make the experience relatively painless for the
Correspondence: Ülkü Yapucu Günes¸, Department of Basic Nursing, Faculty of Nursing, Ege University, 35040 Bornova, ˙I zmir, Turkey. Email: [email protected] doi:10.1111/ijn.12358
patient. Over the years, clinicians have tried to explore various methods to reduce pain, including the pain of injections.1,2 In order to reduce the complications and pain associated with IM injections, nurses should be familiar with recent literature and develop their skills accordingly.3,4 Nurses need to be knowledgeable about the assessment of pain, psychosocial and cultural factors affecting pain expression, genetic and ethnic determinants of pain © 2014 Wiley Publishing Asia Pty Ltd
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threshold and pain tolerance, and, most importantly, current evidence-based practices regarding pain, so that they can minimize injection pain.5,6 Although IM injection is a common nursing practice, there is a paucity of evidence-based practices with regard to IM injection pain.7
Literature review IM injections usually cause some degree of pain at the injection site,8 and a number of factors can affect a patient’s perception of pain associated with IM injection. The drug and the volume injected, the technique used, patient anxiety, patient position, the speed of delivery of the drug, the injection site, and the size and length of the needle bore are all factors that can have an effect on pain. Injury to nerve fibres from mechanical trauma caused by a needle puncture, by increasing pressure from an accumulation of fluid within the tissues, or by sudden distension of tissue from rapid introduction of fluid can lead to injection pain.5,8,9 In the literature, there are a number of studies that investigate the reduction of pain in IM injections. These studies have examined the effect of different factors and interventions, such as cold, manual pressure, acupressure, needle temperature, two-needle technique, injection speed, patient positioning and the Z-track technique.10–15 Barnhill et al.11 recommended that nurses use distraction techniques prior to administering the IM injection to the client in order to reduce pain. Keen14 found a significant decrease in both pain and injection site lesions with the Z-track technique, as did other studies.2,16 On the other hand, MacGabhann17 recorded more pain and bleeding with the Z-track technique than with the air bubble technique. Some studies have suggested that a two-needle process should be used to reduce consumer discomfort, with one needle for preparation and another for administration.18,19 In addition, the use of ice packs prior to the injection can help reduce pain.1 Barnhill et al.11 examined the effect of manual pressure on perceptions of pain from IM injections, and this study was repeated and refined by Chung and Wong.13 Bartell et al.12 found that needle temperature did not influence pain following IM injections. Positioning the patient to relax his or her muscles has been demonstrated to significantly decrease the pain levels experienced.15 Engstrom et al.20 recommended that internal rotation of the extremity distal to the injection site be performed to decrease tissue trauma and pain when injections are administered into the deltoid and dorsogluteal © 2014 Wiley Publishing Asia Pty Ltd
sites. One study reported that slow IM injections improved pain management,21 but another study conducted by Mitchell and Whitney9 found that injection durations of 10 and 30 s were not effective at reducing the perception of pain from IM injections. In the literature, there are conflicting results related to the effects of patient characteristics such as age, gender and body mass index (BMI) on injection pain.9,21–23 In a study by Lang et al.,23 it was reported that old patients felt less discomfort than younger ones during IM injection. Another study reported that age does not affect injection pain.24 Some studies reported that women experience more pain during IM injection,22,25 but another found that pain intensity for men was higher than for women.21 Nevertheless, the study results related to the effect of BMI on injection pain are not consistent.21,26,27 Because pain is unpleasant for all patients, it should be managed regardless of whether the pain is acute or chronic.28 Pain arising from IM injections should not be underestimated, because a painful injection might cause needle or injection phobia.8,29 There have been a number of studies to support many current practices and to reduce the risk of complications, but there are still areas where evidence to support practice needs to be obtained.
Aim of the study The aim of the study was to determine whether using the Z-track technique, internally rotating the foot and/or pointing the toes during an IM injection could reduce the pain. As gender and BMI can influence the perception of pain, we also investigated gender- and BMI-related differences in pain perception. The study’s hypothesis was that there would be significant differences in pain intensity depending upon whether patients received an IM injection with the Z-track technique, with the foot internally rotated and/or with the toes pointed down.
METHODS Study design An experimental design was used to assess the pain intensity associated with IM injections administered using three different methods.
Sample and setting Patients at the university hospital in Zonguldak, Turkey, constituted the research population. Using pain scores as the primary outcome, a power calculation showed that 67 participants were needed to detect a 20% difference in
Effect on pain of three different methods in IM injection
pain scores using 80% power and a 5% significance level. Assuming that approximately 10% of the participants would have incomplete data or would not complete the survey, 75 patients who satisfied the study criteria and who attended the surgery clinics of the university hospital between September and December 2010 were selected for the sample. Patients who had a medical order for diclofenac sodium three times a day were included in the study, whereas those with a disease or disorder that influenced pain perception, such as sensory–motor deficiency, diabetes, peripheral vascular disease or peripheral neuropathy, were excluded from the study. The reason for the choice of diclofenac sodium in our study was that it is a routinely prescribed analgesic for surgical patients in the hospital where the study was performed. Because it is very difficult to secure voluntary participation in studies related to IM injection, it was necessary to select a routine practice in the hospital. The subjects chosen were 18 years of age or older; their medication was administered at least three times in a day; they had no pain in their buttocks before the procedure; and they were sufficiently conscious to answer questions about their pain.
Data collection instruments A structured, self-administered questionnaire was used for data collection. The questionnaire consisted of two parts: the first contained items on age, gender and BMI, and the second part contained a 100 mm visual analogue scale (VAS) that was used to measure perceived pain intensity during the IM injection. Zero represented no pain and 100 represented extreme pain. Immediately following each injection, the subjects were given a VAS and asked to rate the intensity of the pain experienced at the site at the time of injection. They rated the intensity of site pain by placing a mark at a point along the vertical line of the VAS. The VAS pain score was obtained by measuring in millimetres the distance from zero to the subject’s mark. VASs have been extensively researched and show good acceptability, responsivity and validity for children and adults.30,31
Data collection procedure All injections were administered to the dorsogluteal site. Each subject received three injections of diclofenac sodium at 8 h intervals (08.00, 16.00 and 24.00) from the same investigator using the three different techniques. Injection technique was selected randomly for each injection. The random selection was based on casting lots.
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Table 1 Intramuscular injection protocol for all participants and techniques Diclofenac sodium Syringe size Needle size Changing needle Air lock Site Wipe Insertion angle Aspiration Injection duration Needle withdrawal After the injection Data recorded
3 mL (a glass ampoule) 5 mL 21-gauge Two needle technique 0.2 mL air lock inserted Right and left dorsogluteal site Area cleansed with alcohol and allowed to air-dry before needle insertion 90° Aspirated 1 mL per 10 s At the same angle as insertion Light pressure applied at the injection site after the injection; site not massaged Another investigator assessed and recorded pain intensity
Injections were given to the subjects starting with the right dorsogluteal site, followed by the left, and the third injection was again given on the right. The subjects were blinded to the injection technique being administered. After each injection, another investigator, who had no prior knowledge of which injection technique was used, immediately assessed pain intensity using the VAS and recorded it on the data collection form. IM injection protocols were similar for all participants and techniques, and the researcher administered all the injections according to this protocol, which was designed as shown in Table 1.
Injection techniques In technique A, the injection was administered to the patient in prone position with his or her toes pointing down. In technique B, the injection was administered to the patient in prone position with one foot internally rotated. In technique C, the injection was administered to the patient in prone position with his or her toes pointing down, using the Z-track technique. After cleaning the site with an antiseptic swab, the overlying skin and subcutaneous tissues were pulled approximately 2.5 cm laterally. The investigator held the skin taut with the non-dominant hand, and the medication was injected if there was no blood return on aspiration. The needle remained inserted © 2014 Wiley Publishing Asia Pty Ltd
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for 10 s, and then the skin was released after withdrawing the needle.
Ethical approval The study was approved by the appropriate ethics committees (reference number 2010–135). All participants received an explanation of the study before participating and gave informed written consent before voluntary participation.
Data analysis Statistical analysis was performed with SPSS 18.0 software (SPSS, Inc., Chicago, IL, USA). Continuous variables were expressed as mean ± standard deviation, and categorical variables as frequency and percentage. The Friedman test was used to determine the difference between perceived pain intensities for techniques A, B and C. The effect of gender on pain was also explored
using the Mann–Whitney U-test. The Kruskal–Wallis test was used to evaluate the effect of age and BMI on pain intensity. A P value of less than 0.05 was considered statistically significant for all tests.
RESULTS The flowchart presented in Figure 1 shows the number of patients eligible for the study, the exclusions and reasons, and the number of patients lost to follow-up. Seventy-five subjects were recruited to the main study. Demographic data are shown in Table 2. The ages of the subjects ranged from 18 to 65 years, with a mean age of 46.4 ± 15.1. Twenty-nine subjects (38.7%) were women, and 46 subjects (61.3%) were men. The mean BMI was 27.1 ± 6.08. Sixty-four per cent of the patients were taken from the general surgery unit and 36% from the orthopaedics unit. All subjects were sufficiently alert and conscious to answer questions about their pain.
Enrollment
Assessed for eligibility (n = 98)
Excluded (n = 12) ♦ Not meeting inclusion criteria (n = 7) ♦ Declined to participate (n = 5)
Analysis
Follow-up
Allocation
Randomized (n = 86)
Allocated to technique A (n = 86)
Allocated to technique B (n = 86)
Allocated to technique C (n = 86)
Discontinued intervention (n = 11)
Discontinued intervention (n = 11)
Discontinued intervention (n = 11)
Analysed (n = 75)
Analysed (n = 75)
Analysed (n = 75)
Figure 1. Flowchart of study.
© 2014 Wiley Publishing Asia Pty Ltd
Effect on pain of three different methods in IM injection
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Table 2 Demographic characteristics of the patients (n = 75) Age (years), mean (SD) Gender, n (%) Female Male Body mass index (kg/m2), n (%) < 18.5 18.5–24.9 25–29.9 30–39.9 Diagnosis, n (%) Pleural effusion Gonarthrosis Otitis Fracture
46.4 (15.15) 29 (38.7) 46 (61.3) 5 (6.7) 27 (36) 23 (30.7) 20 (26.7) 14 (18.6) 21 (28) 25 (33.4) 15 (20)
The mean score for perceived pain intensity for technique A (with toes pointing down) was 1.49 ± 1.28; it was 0.95 ± 0.91 for technique B (with an internally rotated foot) and 1.25 ± 1.44 for technique C (the Z-track technique) (Fig. 2). There was a significant difference between the three techniques in terms of pain intensity (χ2(2) = 9.35, P = 0.009). Although the gender effect on pain intensity associated with technique B (internally rotated foot) was significant (U = 424.0, P = 0.008), there was no significant gender difference in pain intensity for technique A (toes pointing down) (U = 624, P = 0.639) or for technique C (the Z-track technique) (U = 616, P = 0.578) (Fig. 3). The influence of age on pain intensity was not statistically significant for technique A (with toes pointing down) (KW = 0.324, P = 0.988), for technique B (with an internally rotated foot) (KW = 4.823, P = 0.306) or for technique C (the Z-track technique) (KW = 5.233, P = 0.264). The influence of BMI on pain intensity was significant in both technique A (toes pointing down) (χ2(3) = 12.5, P = 0.006) and technique C (the Z-track technique) (χ2(3) = 12.0, P = 0.007). However, there was no significant association between BMI and pain intensity with technique B (internally rotated foot) (χ2(3) = 7.5, P = 0.057).
DISCUSSION The findings revealed that the pain intensity perceived by the subjects was 1.49 with technique A (toes pointing
Figure 2. A comparison of the mean perceived pain intensity between technique A (in prone position with toes pointing down), technique B (in prone position with an internally rotated foot) and technique C (in prone position with toes pointing down using the Z-track technique) (n = 75). VAS, visual analogue scale.
down), 0.95 with technique B (internally rotated foot) and 1.25 with technique C (the Z-track technique). Even though these results were not clinically critical, the patients felt less pain statistically during IM injections administered using technique B (internally rotated foot). These results are congruent with the literature.15,32 When medication is administered to the relaxed muscle, patients experience less discomfort due to the reduction of muscle resistance and pressure on neural crests.32 Our result is similar to the findings of other studies,15,33 which reported that placing the patient in the prone position with an internally rotated foot would cause the greater trochanter of the femur bone to move anteriorly, effectively relaxing the gluteal muscle so that patients experienced less pain. In the present study, patients reported less pain with the Z-track technique than with technique A. When compared with technique B, however, it is clear that the Z-track technique caused more pain. In the literature, it has been suggested that the Z-track technique should be used with the full range of IM medications,34 as it is believed to reduce pain as well as the incidence of leakage.14,35,36 However, there are inconsistent data in the © 2014 Wiley Publishing Asia Pty Ltd
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Figure 3. A comparison of the mean perceived pain intensity for males and females under technique A (in prone position with toes pointing down), technique B (in prone position with an internally rotated foot) and technique C (in prone position with toes pointing down using the Z-track technique) (n = 75). VAS, visual analogue scale.
literature regarding the Z-track technique. In one study undertaken by MacGabhann,17 more pain and bleeding were recorded with the Z-track technique. However, in contrast to our findings, Erdal et al.16 and Rodger and King2 found that a significant decrease in both pain and injection site lesions was associated with the Z-track sites. These conflicting results indicate that more research is needed on the Z-track technique. Although the effect of gender on pain intensity associated with technique B (internally rotated foot) was significant, there was no significant difference in pain intensity for technique A (toes pointing down) or for technique C (the Z-track technique). Nevertheless, women reported higher pain intensity than men for all three techniques. The present findings were in congruence with the literature.21,22 Compared with men, women have more subcutaneous tissue in the buttocks. Pain receptors are located within the subcutaneous layer, not in muscle tissue. Thus, women consistently report more pain from all IM injections.22 In addition, our results are supported by Mitchell and Whitney,9 who assert that women consistently have higher mean pain scores with regards to IM injection. © 2014 Wiley Publishing Asia Pty Ltd
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In the present study, age had no significant effect on pain intensity in the three techniques. Although there was no statistically significant difference between age groups in terms of pain intensity, the patients in the age group of 60–65 years reported less pain intensity in all three techniques. Similarly, in another study conducted by Lang et al.,23 older people experienced less pain in IM injections. In contrast, one study reported that higher injection pain was associated with increased age.21 In addition, some of the literature indicates that IM injections can exacerbate muscle pain due to the loss of muscle tone, strength and mass in older adults.8,32 The conflicting results could be due to the techniques used in IM injections or to individual differences. Although BMI had a significant effect on VAS pain intensity in both technique A (toes pointing down) and technique C (the Z-track technique), it had no effect on pain intensity with technique B (internally rotated foot). However, patients with low weight (BMI < 18.5 kg/m2) reported increased pain intensity compared with normal and obese patients in all three techniques. Ozdemir et al.21 also found that patients with low or normal weight experienced more pain in IM injections. Our results are in congruence with the study by Ozdemir et al.21 In contrast, earlier studies proposed that obese individuals have lower pain response thresholds and pain tolerance owing to a disturbance in endogenous morphine production.26,27 Moreover, Nisbet37 noted that injections into the dorsogluteal area were more likely to be into adipose tissue rather than muscle due to the fact that the subcutaneous tissue is thicker in obese people, and consequently, as pain receptors are located within the subcutaneous layer, not in muscle tissue, obese patients experience more pain. Our result, which is inconsistent with the literature, could be due to the low number of patients with lower weight in our study. It seems that this finding needs more investigation.
Study limitations One limitation of our study is that although all the subjects were conscious, they might have been affected by postoperative pain, and this factor could have affected the results of the study. For this reason, the generalizability of our research findings is limited to similar groups. Secondly, the three techniques were administered by the same investigator, so there could be a risk of biasing the results. Also, the sample size was small, and therefore more studies on larger samples should be implemented.
Effect on pain of three different methods in IM injection
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CONCLUSIONS The findings demonstrated that technique B (internally rotated foot) resulted in lower injection pain compared with technique C (Z-track technique) and technique A (toes pointing down). Therefore, we can say that IM injections should be administered to the patient in prone position with an internally rotated foot, and this should be a part of routine practice, as it reduces patient discomfort. Our findings also highlight the need for further research with a larger sample stratified by BMI and gender and with healthy human subjects so as to establish the generalizability of the results. We also need more research to investigate the effect of the Z-track technique on pain.
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ACKNOWLEDGEMENT We thank all those who participated in this study.
REFERENCES 1 Murphy JI. Reducing the pain of intramuscular (IM) injections. Advancing Clinical Care 1991; 6: 35. 2 Rodger MA, King L. Drawing up and administering intramuscular injections: A review of the literature. Journal of Advanced Nursing 2000; 31: 574–582. 3 Hunter J. Intramuscular injection techniques. Nursing Standard 2008; 22: 35–40. 4 Nicoll LH, Hesby A. Intramuscular injection: An integrative research review and guideline for evidence-based practice. Applied Nursing Research 2002; 15: 149–162. 5 Miller C, Newton SE. Pain perception and expression: The influence of gender, personal self-efficacy, and life-span socialization. Pain Management Nursing 2006; 7: 148– 152. 6 Monsivais D, McNeill J. Multicultural influences on pain medication attitudes and beliefs in patients with nonmalignant chronic pain syndromes. Pain Management Nursing 2007; 8: 64–71. 7 Cocoman A, Murray J. Intramuscular injections: A review of best practice for mental health nurses. Journal of Psychiatric and Mental Health Nursing 2008; 15: 424–434. 8 Cupitt M, Kasipandian V. Pain and intramuscular injections. Anaesthesia 2004; 59: 88–99. 9 Mitchell JR, Whitney FW. The effect of injection speed on the perception of intramuscular injection pain. AAOHN Journal: Official Journal of the American Association of Occupational Health Nurses 2001; 49: 286–292. 10 Alavi NM. Effectiveness of acupressure to reduce pain in intramuscular injections. Acute Pain 2007; 9: 201–205. 11 Barnhill B, Holbert M, Jackson N, Erickson R. Using pressure to decrease the pain of intramuscular injection.
17 18
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Journal of Pain and Symptom Management 1996; 12: 52– 57. Bartell JC, Roberts KA, Schutte NJ, Sherman KC, Muller D, Hayney MS. Needle temperature effect on pain ratings after injection. The Clinical Journal of Pain 2008; 24: 260– 264. Chung JW, Wong TK. An experimental study on the use of manual pressure to reduce pain in intramuscular injections. Journal of Clinical Nursing 2002; 11: 457–461. Keen MF. Intramuscular injection techniques to reduce site discomfort and lesions. Nursing Research 1986; 35: 207– 210. Retting FM, Southby JR. Using different body positions to reduce discomfort from dorsogluteal injection. Nursing Research 1982; 31: 219–221. Erdal E, Ulufer F, Es¸er ˙I . ˙I ntramüsküler enjeksiyon yerinde ag˘rı ve lezyonları azaltmak için ‘Z’ enjeksiyon ve standart enjeksiyon tekniklerinin kars¸ılas¸tırılması. Ege Üniversitesi Hems¸irelik Yüksekokulu Dergisi 1989; 5: 22–32. In Turkish. MacGabhann L. A comparison of two depot injection techniques. Nursing Standard 1996; 11: 33–37. Agac E, Gunes UY. Effect on pain of changing the needle prior to administering medicine intramuscularly: A randomized controlled trial. Journal of Advanced Nursing 2011; 67: 563–568. Rock D. Does drawing up technique influence patients’ perception of pain at the injection site? The Australian and New Zealand Journal of Mental Health Nursing 2000; 9: 147– 151. Engstrom JL, Giglio NN, Takacs SM, Ellis MC, Cherwenka DI. Procedures used to prepare and administer intramuscular injections: A study of infertility nurses. Journal of Obstetric, Gynecologic, and Neonatal Nursing 2000; 29: 159–168. Ozdemir L, Pınarcı E, Akay BN, Akyol A. Effect of methylprednisolone injection speed on the perception of intramuscular injection pain. Pain Management Nursing 2010; 12: 1–8. Chan VO, Colville J, Persaud T, Buckley O, Hamilton S, Torreggiani WC. Intramuscular injections into the buttocks: Are they truly intramuscular? European Journal of Radiology 2006; 53: 480–484. Lang SH, Zawacki AM, Johnson JE. Reducing discomfort. The American Journal of Nursing 1976; 76: 800–801. Komiyama O, Kawara M, DeLaat A. Ethnic differences regarding tactile and pain thresholds in the trigeminal region. The Journal of Pain 2007; 8: 363–369. Malkin B. Are techniques used for intramuscular injection based on research evidence? Nursing Times 2008; 12: 48–51. Keller J. Obesity and pain perception. IDEA Fitness Journal 2006; 3: 17. Pradalier A, Willer JC, Boureau F, Dry AJ. Relationship between pain and obesity: An electrophysiological study. Physiology & Behavior 1981; 27: 961–964.
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28 Erdine S. Pain. Istanbul: Nobel Medical Bookstore, 2000. 29 Campbell J. Injections. Professional Nurse (London) 1995; 10: 455–458. 30 Champion GD, Goodenough B, von Baeyer CL, Thomas W. Measurement of pain by self-report. In: Finley GA, McGrath PJ (eds). Measurement of Pain in Infants and Children. Progress in Pain Research and Management, Vol. 10. Seattle,WA, USA: IASP Press, 1998; 123–160. 31 Cline ME, Herman J, Show F, Marton RD. Standardization of the visual analogue scale. Nursing Research 1992; 41: 378– 379. 32 Potter PA, Perry AG. Fundamentals of Nursing Concepts, Process and Practice, 6th edn. St. Louis, MO, USA: Mosby, 2005.
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33 Kruszewski AZ, Lang SH, Johnson JE. Effects of positioning on discomfort from intramuscular injections in the dorsogluteal site. Nursing Research 1979; 28: 103–105. 34 Beyea SC, Nicoll LH. Administration of medications via the intramuscular route: An integrative review of the literature and research-based protocol for the procedure. Applied Nursing Research 1995; 5: 23–33. 35 Keen MF. Get on the right track with Z-track injections. Nursing 1990; 20: 59. 36 Newton M, Newton DW, Fudin J. Reviewing the ‘big three’ injection routes. Nursing 1992; 22: 3441. 37 Nisbet AC. Intramuscular gluteal injections in the increasingly obese population: Retrospective study. British Medical Journal 2006; 332: 637–638.
International Journal of Nursing Practice 2014; ••: ••–••
RESEARCH PAPER
The effect on pain of three different methods of intramuscular injection: A randomized controlled trial Dilek Kara MSc Instructor, Department of Nursing, School of Health, Uludag University, Bursa, Turkey
Ülkü Yapucu Günes¸ PhD Associate Professor, Department of Basic Nursing, Faculty of Nursing, Ege University, ˙I zmir, Turkey
Accepted for publication April 2014 Kara D, Yapucu Günes¸ Ü. International Journal of Nursing Practice 2014; ••: ••–•• The effect on pain of three different methods of intramuscular injection: A randomized controlled trial 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. Key words: internally rotated foot, intramuscular injection, pain intensity, randomized controlled study, Z-track technique.
INTRODUCTION Intramuscular (IM) injections are a common and painful part of routine health care. However, good injection techniques can make the experience relatively painless for the
Correspondence: Ülkü Yapucu Günes¸, Department of Basic Nursing, Faculty of Nursing, Ege University, 35040 Bornova, ˙I zmir, Turkey. Email: [email protected] doi:10.1111/ijn.12358
patient. Over the years, clinicians have tried to explore various methods to reduce pain, including the pain of injections.1,2 In order to reduce the complications and pain associated with IM injections, nurses should be familiar with recent literature and develop their skills accordingly.3,4 Nurses need to be knowledgeable about the assessment of pain, psychosocial and cultural factors affecting pain expression, genetic and ethnic determinants of pain © 2014 Wiley Publishing Asia Pty Ltd
2
D Kara and Ü Yapucu Günes¸
threshold and pain tolerance, and, most importantly, current evidence-based practices regarding pain, so that they can minimize injection pain.5,6 Although IM injection is a common nursing practice, there is a paucity of evidence-based practices with regard to IM injection pain.7
Literature review IM injections usually cause some degree of pain at the injection site,8 and a number of factors can affect a patient’s perception of pain associated with IM injection. The drug and the volume injected, the technique used, patient anxiety, patient position, the speed of delivery of the drug, the injection site, and the size and length of the needle bore are all factors that can have an effect on pain. Injury to nerve fibres from mechanical trauma caused by a needle puncture, by increasing pressure from an accumulation of fluid within the tissues, or by sudden distension of tissue from rapid introduction of fluid can lead to injection pain.5,8,9 In the literature, there are a number of studies that investigate the reduction of pain in IM injections. These studies have examined the effect of different factors and interventions, such as cold, manual pressure, acupressure, needle temperature, two-needle technique, injection speed, patient positioning and the Z-track technique.10–15 Barnhill et al.11 recommended that nurses use distraction techniques prior to administering the IM injection to the client in order to reduce pain. Keen14 found a significant decrease in both pain and injection site lesions with the Z-track technique, as did other studies.2,16 On the other hand, MacGabhann17 recorded more pain and bleeding with the Z-track technique than with the air bubble technique. Some studies have suggested that a two-needle process should be used to reduce consumer discomfort, with one needle for preparation and another for administration.18,19 In addition, the use of ice packs prior to the injection can help reduce pain.1 Barnhill et al.11 examined the effect of manual pressure on perceptions of pain from IM injections, and this study was repeated and refined by Chung and Wong.13 Bartell et al.12 found that needle temperature did not influence pain following IM injections. Positioning the patient to relax his or her muscles has been demonstrated to significantly decrease the pain levels experienced.15 Engstrom et al.20 recommended that internal rotation of the extremity distal to the injection site be performed to decrease tissue trauma and pain when injections are administered into the deltoid and dorsogluteal © 2014 Wiley Publishing Asia Pty Ltd
sites. One study reported that slow IM injections improved pain management,21 but another study conducted by Mitchell and Whitney9 found that injection durations of 10 and 30 s were not effective at reducing the perception of pain from IM injections. In the literature, there are conflicting results related to the effects of patient characteristics such as age, gender and body mass index (BMI) on injection pain.9,21–23 In a study by Lang et al.,23 it was reported that old patients felt less discomfort than younger ones during IM injection. Another study reported that age does not affect injection pain.24 Some studies reported that women experience more pain during IM injection,22,25 but another found that pain intensity for men was higher than for women.21 Nevertheless, the study results related to the effect of BMI on injection pain are not consistent.21,26,27 Because pain is unpleasant for all patients, it should be managed regardless of whether the pain is acute or chronic.28 Pain arising from IM injections should not be underestimated, because a painful injection might cause needle or injection phobia.8,29 There have been a number of studies to support many current practices and to reduce the risk of complications, but there are still areas where evidence to support practice needs to be obtained.
Aim of the study The aim of the study was to determine whether using the Z-track technique, internally rotating the foot and/or pointing the toes during an IM injection could reduce the pain. As gender and BMI can influence the perception of pain, we also investigated gender- and BMI-related differences in pain perception. The study’s hypothesis was that there would be significant differences in pain intensity depending upon whether patients received an IM injection with the Z-track technique, with the foot internally rotated and/or with the toes pointed down.
METHODS Study design An experimental design was used to assess the pain intensity associated with IM injections administered using three different methods.
Sample and setting Patients at the university hospital in Zonguldak, Turkey, constituted the research population. Using pain scores as the primary outcome, a power calculation showed that 67 participants were needed to detect a 20% difference in
Effect on pain of three different methods in IM injection
pain scores using 80% power and a 5% significance level. Assuming that approximately 10% of the participants would have incomplete data or would not complete the survey, 75 patients who satisfied the study criteria and who attended the surgery clinics of the university hospital between September and December 2010 were selected for the sample. Patients who had a medical order for diclofenac sodium three times a day were included in the study, whereas those with a disease or disorder that influenced pain perception, such as sensory–motor deficiency, diabetes, peripheral vascular disease or peripheral neuropathy, were excluded from the study. The reason for the choice of diclofenac sodium in our study was that it is a routinely prescribed analgesic for surgical patients in the hospital where the study was performed. Because it is very difficult to secure voluntary participation in studies related to IM injection, it was necessary to select a routine practice in the hospital. The subjects chosen were 18 years of age or older; their medication was administered at least three times in a day; they had no pain in their buttocks before the procedure; and they were sufficiently conscious to answer questions about their pain.
Data collection instruments A structured, self-administered questionnaire was used for data collection. The questionnaire consisted of two parts: the first contained items on age, gender and BMI, and the second part contained a 100 mm visual analogue scale (VAS) that was used to measure perceived pain intensity during the IM injection. Zero represented no pain and 100 represented extreme pain. Immediately following each injection, the subjects were given a VAS and asked to rate the intensity of the pain experienced at the site at the time of injection. They rated the intensity of site pain by placing a mark at a point along the vertical line of the VAS. The VAS pain score was obtained by measuring in millimetres the distance from zero to the subject’s mark. VASs have been extensively researched and show good acceptability, responsivity and validity for children and adults.30,31
Data collection procedure All injections were administered to the dorsogluteal site. Each subject received three injections of diclofenac sodium at 8 h intervals (08.00, 16.00 and 24.00) from the same investigator using the three different techniques. Injection technique was selected randomly for each injection. The random selection was based on casting lots.
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Table 1 Intramuscular injection protocol for all participants and techniques Diclofenac sodium Syringe size Needle size Changing needle Air lock Site Wipe Insertion angle Aspiration Injection duration Needle withdrawal After the injection Data recorded
3 mL (a glass ampoule) 5 mL 21-gauge Two needle technique 0.2 mL air lock inserted Right and left dorsogluteal site Area cleansed with alcohol and allowed to air-dry before needle insertion 90° Aspirated 1 mL per 10 s At the same angle as insertion Light pressure applied at the injection site after the injection; site not massaged Another investigator assessed and recorded pain intensity
Injections were given to the subjects starting with the right dorsogluteal site, followed by the left, and the third injection was again given on the right. The subjects were blinded to the injection technique being administered. After each injection, another investigator, who had no prior knowledge of which injection technique was used, immediately assessed pain intensity using the VAS and recorded it on the data collection form. IM injection protocols were similar for all participants and techniques, and the researcher administered all the injections according to this protocol, which was designed as shown in Table 1.
Injection techniques In technique A, the injection was administered to the patient in prone position with his or her toes pointing down. In technique B, the injection was administered to the patient in prone position with one foot internally rotated. In technique C, the injection was administered to the patient in prone position with his or her toes pointing down, using the Z-track technique. After cleaning the site with an antiseptic swab, the overlying skin and subcutaneous tissues were pulled approximately 2.5 cm laterally. The investigator held the skin taut with the non-dominant hand, and the medication was injected if there was no blood return on aspiration. The needle remained inserted © 2014 Wiley Publishing Asia Pty Ltd
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for 10 s, and then the skin was released after withdrawing the needle.
Ethical approval The study was approved by the appropriate ethics committees (reference number 2010–135). All participants received an explanation of the study before participating and gave informed written consent before voluntary participation.
Data analysis Statistical analysis was performed with SPSS 18.0 software (SPSS, Inc., Chicago, IL, USA). Continuous variables were expressed as mean ± standard deviation, and categorical variables as frequency and percentage. The Friedman test was used to determine the difference between perceived pain intensities for techniques A, B and C. The effect of gender on pain was also explored
using the Mann–Whitney U-test. The Kruskal–Wallis test was used to evaluate the effect of age and BMI on pain intensity. A P value of less than 0.05 was considered statistically significant for all tests.
RESULTS The flowchart presented in Figure 1 shows the number of patients eligible for the study, the exclusions and reasons, and the number of patients lost to follow-up. Seventy-five subjects were recruited to the main study. Demographic data are shown in Table 2. The ages of the subjects ranged from 18 to 65 years, with a mean age of 46.4 ± 15.1. Twenty-nine subjects (38.7%) were women, and 46 subjects (61.3%) were men. The mean BMI was 27.1 ± 6.08. Sixty-four per cent of the patients were taken from the general surgery unit and 36% from the orthopaedics unit. All subjects were sufficiently alert and conscious to answer questions about their pain.
Enrollment
Assessed for eligibility (n = 98)
Excluded (n = 12) ♦ Not meeting inclusion criteria (n = 7) ♦ Declined to participate (n = 5)
Analysis
Follow-up
Allocation
Randomized (n = 86)
Allocated to technique A (n = 86)
Allocated to technique B (n = 86)
Allocated to technique C (n = 86)
Discontinued intervention (n = 11)
Discontinued intervention (n = 11)
Discontinued intervention (n = 11)
Analysed (n = 75)
Analysed (n = 75)
Analysed (n = 75)
Figure 1. Flowchart of study.
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Table 2 Demographic characteristics of the patients (n = 75) Age (years), mean (SD) Gender, n (%) Female Male Body mass index (kg/m2), n (%) < 18.5 18.5–24.9 25–29.9 30–39.9 Diagnosis, n (%) Pleural effusion Gonarthrosis Otitis Fracture
46.4 (15.15) 29 (38.7) 46 (61.3) 5 (6.7) 27 (36) 23 (30.7) 20 (26.7) 14 (18.6) 21 (28) 25 (33.4) 15 (20)
The mean score for perceived pain intensity for technique A (with toes pointing down) was 1.49 ± 1.28; it was 0.95 ± 0.91 for technique B (with an internally rotated foot) and 1.25 ± 1.44 for technique C (the Z-track technique) (Fig. 2). There was a significant difference between the three techniques in terms of pain intensity (χ2(2) = 9.35, P = 0.009). Although the gender effect on pain intensity associated with technique B (internally rotated foot) was significant (U = 424.0, P = 0.008), there was no significant gender difference in pain intensity for technique A (toes pointing down) (U = 624, P = 0.639) or for technique C (the Z-track technique) (U = 616, P = 0.578) (Fig. 3). The influence of age on pain intensity was not statistically significant for technique A (with toes pointing down) (KW = 0.324, P = 0.988), for technique B (with an internally rotated foot) (KW = 4.823, P = 0.306) or for technique C (the Z-track technique) (KW = 5.233, P = 0.264). The influence of BMI on pain intensity was significant in both technique A (toes pointing down) (χ2(3) = 12.5, P = 0.006) and technique C (the Z-track technique) (χ2(3) = 12.0, P = 0.007). However, there was no significant association between BMI and pain intensity with technique B (internally rotated foot) (χ2(3) = 7.5, P = 0.057).
DISCUSSION The findings revealed that the pain intensity perceived by the subjects was 1.49 with technique A (toes pointing
Figure 2. A comparison of the mean perceived pain intensity between technique A (in prone position with toes pointing down), technique B (in prone position with an internally rotated foot) and technique C (in prone position with toes pointing down using the Z-track technique) (n = 75). VAS, visual analogue scale.
down), 0.95 with technique B (internally rotated foot) and 1.25 with technique C (the Z-track technique). Even though these results were not clinically critical, the patients felt less pain statistically during IM injections administered using technique B (internally rotated foot). These results are congruent with the literature.15,32 When medication is administered to the relaxed muscle, patients experience less discomfort due to the reduction of muscle resistance and pressure on neural crests.32 Our result is similar to the findings of other studies,15,33 which reported that placing the patient in the prone position with an internally rotated foot would cause the greater trochanter of the femur bone to move anteriorly, effectively relaxing the gluteal muscle so that patients experienced less pain. In the present study, patients reported less pain with the Z-track technique than with technique A. When compared with technique B, however, it is clear that the Z-track technique caused more pain. In the literature, it has been suggested that the Z-track technique should be used with the full range of IM medications,34 as it is believed to reduce pain as well as the incidence of leakage.14,35,36 However, there are inconsistent data in the © 2014 Wiley Publishing Asia Pty Ltd
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Figure 3. A comparison of the mean perceived pain intensity for males and females under technique A (in prone position with toes pointing down), technique B (in prone position with an internally rotated foot) and technique C (in prone position with toes pointing down using the Z-track technique) (n = 75). VAS, visual analogue scale.
literature regarding the Z-track technique. In one study undertaken by MacGabhann,17 more pain and bleeding were recorded with the Z-track technique. However, in contrast to our findings, Erdal et al.16 and Rodger and King2 found that a significant decrease in both pain and injection site lesions was associated with the Z-track sites. These conflicting results indicate that more research is needed on the Z-track technique. Although the effect of gender on pain intensity associated with technique B (internally rotated foot) was significant, there was no significant difference in pain intensity for technique A (toes pointing down) or for technique C (the Z-track technique). Nevertheless, women reported higher pain intensity than men for all three techniques. The present findings were in congruence with the literature.21,22 Compared with men, women have more subcutaneous tissue in the buttocks. Pain receptors are located within the subcutaneous layer, not in muscle tissue. Thus, women consistently report more pain from all IM injections.22 In addition, our results are supported by Mitchell and Whitney,9 who assert that women consistently have higher mean pain scores with regards to IM injection. © 2014 Wiley Publishing Asia Pty Ltd
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In the present study, age had no significant effect on pain intensity in the three techniques. Although there was no statistically significant difference between age groups in terms of pain intensity, the patients in the age group of 60–65 years reported less pain intensity in all three techniques. Similarly, in another study conducted by Lang et al.,23 older people experienced less pain in IM injections. In contrast, one study reported that higher injection pain was associated with increased age.21 In addition, some of the literature indicates that IM injections can exacerbate muscle pain due to the loss of muscle tone, strength and mass in older adults.8,32 The conflicting results could be due to the techniques used in IM injections or to individual differences. Although BMI had a significant effect on VAS pain intensity in both technique A (toes pointing down) and technique C (the Z-track technique), it had no effect on pain intensity with technique B (internally rotated foot). However, patients with low weight (BMI < 18.5 kg/m2) reported increased pain intensity compared with normal and obese patients in all three techniques. Ozdemir et al.21 also found that patients with low or normal weight experienced more pain in IM injections. Our results are in congruence with the study by Ozdemir et al.21 In contrast, earlier studies proposed that obese individuals have lower pain response thresholds and pain tolerance owing to a disturbance in endogenous morphine production.26,27 Moreover, Nisbet37 noted that injections into the dorsogluteal area were more likely to be into adipose tissue rather than muscle due to the fact that the subcutaneous tissue is thicker in obese people, and consequently, as pain receptors are located within the subcutaneous layer, not in muscle tissue, obese patients experience more pain. Our result, which is inconsistent with the literature, could be due to the low number of patients with lower weight in our study. It seems that this finding needs more investigation.
Study limitations One limitation of our study is that although all the subjects were conscious, they might have been affected by postoperative pain, and this factor could have affected the results of the study. For this reason, the generalizability of our research findings is limited to similar groups. Secondly, the three techniques were administered by the same investigator, so there could be a risk of biasing the results. Also, the sample size was small, and therefore more studies on larger samples should be implemented.
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CONCLUSIONS The findings demonstrated that technique B (internally rotated foot) resulted in lower injection pain compared with technique C (Z-track technique) and technique A (toes pointing down). Therefore, we can say that IM injections should be administered to the patient in prone position with an internally rotated foot, and this should be a part of routine practice, as it reduces patient discomfort. Our findings also highlight the need for further research with a larger sample stratified by BMI and gender and with healthy human subjects so as to establish the generalizability of the results. We also need more research to investigate the effect of the Z-track technique on pain.
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ACKNOWLEDGEMENT We thank all those who participated in this study.
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