Administering Subcutaneous Injections

• To deposit medication into the subcutaneous tissue layers safely, avoiding injury to the patient, while ensuring proper drug absorption after injection.
• Reasons medications are given parenterally are
• To prevent irritation to the gastrointestinal tract.
• To prevent destruction of the medication by first-pass hepatic effect or gastric juices.
• To anesthetize specific areas of the body.
• To achieve a rapid effect.
• When the physical or mental state of the patient prohibits the use of other routes.

• Review the medication order for patient's name, drug name, dosage, and time and route of administration.
• Know information specific to drug that is ordered: action, purpose, time of onset and peak action, dosage, side effects, and nursing implications.
• Review patient's allergy, medical, and medication history.
• Know reasons for giving medication by this route and if subcutaneous injection is contraindicated (circulatory shock or reduced local tissue perfusion).

Special Considerations

• Subcutaneous injection is an effective method of drug delivery that is used quite frequently in nursing.
• However, some “rules of thumb” must be kept in mind for the nurse using this method.
• First, a well-lighted area should be used to assess the site of injection.
• Second, when giving repeated doses on a regular basis, the use of a site rotation chart should be instituted and kept on the Medication Administration Record (MAR).
• Third, avoiding exposing the needle in the patient's line of vision decreases level of anxiety.
• Additionally, keep in mind the anatomy of the patients receiving the medication: obesity requires the use of a longer needle, and elderly people have less subcutaneous tissue stores and less skin elasticity.
• Insulin is routinely delivered by the subcutaneous injection route.
• Reference should be made to the section on insulin for added information.
• Efficient teaching to diabetic patients is beneficial because most of these patients will be self-administering these medications at home.
• Heparin is another medication that is commonly administered by subcutaneous injection.
• Some special considerations for heparin, owing to its anticoagulant effects, are
• Site of choice is the abdomen, because the layer of subcutaneous tissue here does not lie over any major muscles, leading to decreased chance of hematoma formation and movement.
• Use of a ½-inch, 25- to 27-gauge needle is a common choice.
• Changing the needle once the medication is drawn up to prevent heparin from remaining in needle, which could lead to inadvertent delivering of the medication into the intradermal tissue.
• Controversial views on aspirating prior to injection (review agency policy on this issue).
• Massaging the site after injection can increase incidence of bruising.
• Rotation of sites around abdomen to decrease irritation to tissue.

Relevant Nursing Diagnoses

• Risk for impaired skin integrity

• Mild burning/stinging sensation at site of injection
• Patient explains purpose and effects of medication
• No allergies or unwanted effects from medication

• MAR
• Alcohol swabs
• Gloves (nonsterile)
• Adhesive bandage
• 1- to 2-mL syringe (insulin syringe may be appropriate)
• Needle (½- to 1-inch, 25- to 27-gauge; dependent on patient's size)
• Medication to be administered

• Wash hands.
• Decreases transfer of microorganisms.
• Preparation of medication following the five rights of drug administration.
• Decreases the chance of making a drug error.
• Properly identify the patient from the identification bracelet and by asking his name.
• Ensures that medication not given to wrong patient.
• Give explanation of procedure and reason for giving drug in a calm, confident manner.
• Decreases patient anxiety level.
• Explanation helps patient to anticipate nurse's actions.
• Verify allergies on MAR with patient.
• Reduces chance of adverse reactions.
• Provide privacy.
• Lessens embarrassment.
• Don gloves.
• Prevents direct contact with body fluids.
• Perform or teach patient on the following steps of procedure.
• If patient is to self-administration at home.
• Selection of injection site.

  See Fig. 6.1A Subcutaneous Injection Sites

• Common sites are abdomen and upper arm.
• Easy for self-administration.
• Heparin should be injected into abdomen.
• Recommended site.
• Use alternative site if scarring, tissue irritation, or bulky dressings present.
• Rotation of sites, note on chart.
• Prevents repeated and permanent damage to tissue.
• Position patient; cleanse site with alcohol swabs.
• Provides access to site.
• Decreases microorganism transmission.
• With needle exposed, hold approximately 1 inch of fatty tissue between thumb and forefinger of nondominant hand.

  See Fig. 6.1B Pinch Tissue Between Thumb and Forefinger

• Elevates subcutaneous tissue.
• (NOTE: Grab skin gently with minimal manipulation if giving heparin injection.)
• Prevents tissue trauma.
• With dominant hand, insert needle at a 45-degree angle in one quick, smooth motion while holding syringe between thumb and forefinger. Use a 90-degree angle on a larger person.

  See Fig. 6.1C Insert Needle at a 45-Degree or 90-Degree Angle

• Quick, smooth insertion decreases discomfort.
• Angle prevents insertion into muscle layer.
• Obese people have larger layer of subcutaneous tissue.
• On release of skinfold, aspirate plunger, looking for blood return in the syringe.
• Presence of blood return indicates intravenous placement.
• If no blood return is noted, give drug slowly.
• Slow administration of drug reduces discomfort and trauma.
• If blood return is present:
• Withdraw needle.
• Apply pressure until bleeding stops.
• Assess for presence of hematoma/bruising.
• Apply bandage, if needed.
• Begin again from step 1.
• Prevents injection of drug intravenously.
• Subcutaneous medications are usually not indicated for intravenous absorption.
• Withdraw needle at the same angle as insertion,
• Prevents additional trauma to tissue.
• Wipe site with another alcohol swab while lightly massaging site.
• DO NOT massage after heparin injection.
• Massage stimulates circulation, improving distribution and absorption of drug.
• Massage after heparin injection may cause bruising.
• Place bandage, if needed.
• Decreases amount of bleeding from site.
• Discard all equipment in proper manner.
• Prevents accidental needle sticks, and keeps work environment clean.
• Wash hands.
• Reduces transmission of infection.
• Document administration on MAR.
• Required for legal purposes, and makes others aware that drug has been administered.

Evaluation and Follow-Up Activities

• After a short period of time, ask patient if there is acute pain, burning sensation, tingling, and/or numbness at site of injection
• Check for a response to the medication approximately 30 minutes after injection
• Assess that patient has an understanding for the purpose of the drug administered

Key Points for Reporting and Recording

• Name, dose, injection site, and administration route of drug, as well as date and signature in MAR.
• Any teaching that was done with patient during task.
• Any adverse reactions from drug administration.
• Any as-needed (PRN) or one-time orders for medications should be charted in nurse's notes—once at time of administration and another entry within 1 hour of patient's response to medication.
• Report any unwanted side effects of medication to physician and charge nurse.