Consent and Assessment

Consent

Consent must be sought prioir to any procedure

Below are steps to take when undertaking this for a Intramuscular injection but can be applied to all injections

• Administering an IM injection is a complex and invasive procedure, presenting inherent risks to the patient including infection, pain, injury or distress.

• Before deciding to administer a medicine via the IM route it is important that all non-pharmacological treatments are considered and alternative administration routes are explored fully by the nurse, in collaboration with the multidisciplinary team.

• Failure to advise patients of alternative treatment options is considered a breach of the professional duty of care

• Due to the associated risks, it is important that nurses gain informed consent from the patient by providing accurate, accessible and balanced information in language that the patient can understand and/or an easy-read format (McAleer and Marsh 2021).

• Explain the procedure, to gain consent and cooperation, and check the patient’s understanding of the reason for the injection. Also explain the desired effect and any common side-effects.

• To give consent, the patient needs to understand and retain the necessary information and may require support from family members or carers to communicate their decision (Mental Capacity Act 2005).

• Having delivered this information, it is important for the nurse to check the person’s understanding. The nurse can do this by asking them to explain the procedure in their own words – a response that goes beyond a verbatim recall would indicate that the patient has understood and retained the information (McAleer and Marsh 2021).

The resource below details the principles of consent which will add assessment for all interventions and interactions

Assessment

Patient assessment, medical history and allergy status

• A comprehensive patient assessment should be undertaken before administering an injection or infusion.

• This should include a full physical examination, since the patient’s musculoskeletal presentation will influence the injection site that is used. For example,for intramuscular injections = reduced or limited mobility can lead to muscle atrophy, which may complicate medicines administration into the gluteal muscle. Furthermore, impaired mobility may mean that some injection sites are challenging to access, for example it may be challenging to access the gluteal muscle if the person is a wheelchair user.

• The patient assessment should identify any reasonable adjustments required when undertaking the procedure, in accordance with local moving and handling policies. It should also consider the environment in which the procedure is being undertaken, for example in the patient’s home.

• It is also important to review the patient’s current and previous medicines to identify their previous responses to the medicine (injection or infusion) prescribed, including any side effects, indications or contraindications.

• The assessment also needs to include the individual’s allergy status. Failure to identify known allergies can cause harm to the individual and in some cases may be fatal. Allergic reactions or anaphylaxis can occur in response to various medicines, including vaccinations or antibiotics.