NUR 113: SKILL 22-3: ADMINISTERING SUBCUTANEOUS INJECTIONS

1. NUR 113: SKILL 22-3: ADMINISTERING SUBCUTANEOUS INJECTIONS

2. SKILL 22-3: ADMINISTERING SUBCUTANEOUS INJECTIONS You give subcutaneous medications in small doses of less than 2 mL that are isotonic, nonirritating, nonviscous, and water soluble. Subcutaneous injections involve depositing medications into the loose connective tissue underlying the dermis. Because subcutaneous tissue does not contain as many blood vessels as muscles, medications are absorbed more slowly than with intramuscular injections (IM). Examples of subcutaneous medications include epinephrine, insulin, allergy medications, opioids, and heparin. Because subcutaneous tissue contains pain receptors, the patient often experiences some discomfort. The best subcutaneous injection sites include the outer aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs.

3. SKILL 22-3: ADMINISTERING SUBCUTANEOUS INJECTIONS Choose an injection site that is free of skin lesions, bony prominences and large underlying muscles or nerves. Site rotation prevents the formation of lipohypertrophy or lipoatrophy in the skin. Let’s talk about insulin! Health care providers plan insulin injection times based on blood glucose levels and when a patient will eat. Knowing the peak action and duration of the insulin is essential when developing an effective diabetes management plan.

4. COMPARISON OF INSULIN PREPARATIONS

5. COMPARISON OF INSULIN PREPARATIONS – CONT’D

6. GENERAL GUIDELINES FOR INSULIN ADMINISTRATION • Store vials of insulin in the refrigerator, not the freezer. Keep vials currently being used at room temperature. Do not inject cold insulin. • Inspect vials before each use for changes in appearance (e.g., clumping, frosting, precipitation, change in clarity or color) indicating lack of potency. • Do not interchange insulin types unless approved by the patient’s prescriber. • Preferred injection site includes the abdomen, avoiding a 5 cm • (2 inch) radius around the umbilicus and the outer aspect of the thighs. • Have patient self-administer insulin whenever possible. Generally children begin self-administration by adolescence. • Patients who take insulin need to self-monitor their blood glucose. • All patients who take insulin should carry at least 15 g carbohydrate (e.g., 4 ounces of fruit juice, 4 ounces of regular soft drink, 8 ounces of skim milk, 6 to 10 hard candies) in the event of a hypoglycemic reaction.

7. Let’s start the SKILL: SKILL 22-3 SKILL 22-3: LET’S BEGIN!

8. ASSESSMENT • Check accuracy & completeness of each MAR or computer printout with prescriber’s written medication order. Check patient’s name, medication name and dosage, route of administration, and time of administration. Recopy or reprint any portion of the MAR that is difficult to read. • Assess patient’s medical and medication history. • Assess patient’s history of allergies; known type of allergies & normal allergic reaction. • Remove medication reference information for medication action, purpose, normal dose, side effects, time and peak of onset and nursing implications.

9. ASSESSMENT – CONT’D • Observe patient’s previous verbal and nonverbal responses toward injection. • Assess for contraindication to subcutaneous injections such as circulatory shock or reduced local tissue perfusion. • Assess patient’s symptoms before initiating medication therapy. • Assess adequacy of patient’s adipose tissue. • Assess relevant laboratory results (e.g., blood glucose, partial thrombo-plastin). • Assess patient’s knowledge of medication.

10. PLANNING – EXPECTED OUTCOMES FOLLOWING THE PROCEDURE: • Patient experiences no pain or mild burning at the injection site. • Remember, this medication may cause minor tissue irritation. • Patient achieves desired effect of medication with no signs of allergies or undesired effects. • It is important that the medication is administered without patient injury. • Patient explains purpose, dosage and effect of the medications. • This demonstrates learning

11. IMPLEMENTATION • Perform hand hygiene and prepare medication using aseptic technique. • Check label of medication carefully with MAR or computer printout 2 times when preparing the medication. • Take medication (s) to patient at the correct time (see agency policy). Medications that require exact timing include stat, first-time or loading doses, and one time doses. Give time-critical scheduled medications (e.g., antibiotics, anticoagulants, insulin, anticonvulsants, immunosuppressive agents) at exact time ordered (no later than 30 minutes before or after scheduled dose). • Give non-critical scheduled medications within a range of 1 or 2 hours of scheduled dose. • During administration, apply six rights of medication administration. • Close room curtain or door • Identify patient using two identifiers (i.e., name & birthday or name and account number) according to agency policy. Compare identifiers in MAR / medical record information on patient’s identification bracelet and / or ask patient to state their name.

12. IMPLEMENTATION – CONT’D • At patient’s bedside again compare MAR or computer printout with names of medications on medication labels and patient name. Ask the patient if they have any allergies. • Discuss purpose of each medication, action, and possible adverse effects. Allow patient to ask any questions. Tell the patient that the injection will cause a slight burning or sting. • Perform hand hygiene and apply clean gloves. Keep sheet or gown draped over body parts not requiring exposure. • Select appropriate injection site. Inspect skin surface over sites for bruises, inflammation or edema. Do not use an area that is bruised or has signs associated with infection.

13. IMPLEMENTATION – CONT’D • Palpate sites and avoid those with masses or tenderness. Be sure that the needle is the correct size by grasping skinfold at the site with thumb and forefinger. Measure fold from top to bottom. Make sure that the needle is one-half length of the fold. • You can mistakenly give subcutaneous injections in the muscle, especially in the abdomen and thigh sites. Appropriate size of needle ensures that you inject medication into subcutaneous tissue. • When administering insulin or heparin, use abdominal injection site first, followed by thigh injection site. • Rotate insulin sites within an anatomic area (e.g., abdomen and systematically rotate sites within that area. • Rotating injection sites within the same anatomic site maintains consistency in day-to-day insulin absorption.

14. IMPLEMENTATION – CONT’D • Help patient into a comfortable position. Have them relax arm, leg, or abdomen, depending on the site selection. • Relocate site using anatomic landmarks • Clean site with antiseptic swab. Apply swab at center of the site and rotate outward in a circular direction for about 5 cm (2 inches). • Hold swab or gauze between third and fourth fingers of non-dominant hand. • Remove needle cap or protective sheath by pulling it straight off. • Hold syringe between thumb and forefinger of dominant hand; hold as a dart.

15. IMPLEMENTATION – CONT’D • ADMINISTERING THE INJECTION: • For the average-sized patient, hold skin across injection site or pinch the skin with non-dominant hand. • Inject needle quickly and firmly at a 45 to 90 degree angle. Release skin if pinched. • For an obese patient, pinch the skin at the site and inject needle at a 90 degree angle below tissue fold. • After the needle enters the site, grasp lower end of the syringe barrel with non-dominant hand to stabilize it. • Move the dominant hand to end of plunger and slowly inject the medication over several seconds.

16. ADMINISTERING THE INJECTION – CONT’D • Avoid moving the syringe. • Withdrew needle quickly while placing antiseptic swab or gauze gently over the site. • Applied pressure to the site, did not massage the site. • Help patient to a comfortable position. • Discarded uncapped needle or needle enclosed in safety shield and attached syringe into puncture and leak proof receptacle. • Removed gloves and performed hand hygiene • Stayed with patient for several minutes and observed for any type of allergic reactions.

17. EVALUATION • Returned to room in 15 to 30 minutes and ask if the patient feels any acute pain, burning, numbness or tingling at the injection site. • Inspect the site, noting any type of bruising or induration. Provide warm compress to the site. • Observe patient’s response to the medication at times that correlate with onset, peak and duration of medication. Review laboratory results as appropriate (e.g., blood glucose, partial thrombo-plastin). • Ask patient to explain purpose and effects of medication.

18. IDENTIFIED UNEXPECTED OUTCOMES • Patient complains of localized pain, numbness, tingling or burning at the injection site. • Patient displays adverse reaction with signs of urticarial, eczema, pruritus, wheezing and dyspnea. • Hypertrophy of skin develops from repeated subcutaneous injections. • Do not use site for future injections. • Instruct patient not to use site for 6 months.

19. RECORDING AND REPORTING • Recorded medication, dose, route, site, and time on MAR immediately after administration; signed MAR properly. • Recorded patient teaching, validation of understanding, and patient’s response to medication in nurses’ notes. • Reported any undesirable effects to health care provider, documented adverse effects in record.

20. END OF THE SKILL • This is the end of the skill. • Your book has provided a video for this skill & here is the link: • http://booksite.Elsevier.com/Perry-Potter/ClinicalSkills/video28.php • Elsevier: Perry-Potter – Clinical Nursing Skills and Techniques 8e-22.3 Administering Subcutaneous injections • While I have provided a summary for this skill, you will need to go and practice how to administer a subcutaneous injection in the nursing skills lab in order to pass the skill!