Skill Variation:Using an Insulin Injection Pen to Administer Insulin via the Subcutaneous Route

Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis. This tissue has few blood vessels, so drugs administered here have a slow, sustained rate of absorption into the capillaries. Various sites may be used for subcutaneous injections, including the outer aspect of the upper arm, the abdomen (from below the costal margin to the iliac crests), the anterior aspects of the thigh, the upper back, and the upper ventral- or dorsogluteal area. Figure 1 displays the sites on the body where subcutaneous injections can be given. Absorption rates differ among the various sites. Injections in the abdomen are absorbed most rapidly; ones in the arms are absorbed somewhat more slowly; those in the thighs, even more slowly; and those in the ventral or dorsogluteal areas have the slowest absorption (American Diabetes Association [ADA], 2020).

It is important to choose the right equipment to ensure depositing the medication into the intended subcutaneous tissue and not the underlying muscle. Equipment used for a subcutaneous injection includes a syringe of appropriate volume for the amount of drug being administered. A 25- to 30-gauge, ⅜;- to 1-inch needle can be used; the 25-gauge, ⅝;-inch needles are most commonly used for subcutaneous injections for adults (Taylor et al., 2023). Needle length ranges exist because patients present with different amounts of subcutaneous tissue that varies based on age, body mass index, and general build—choose the needle length based on the amount of subcutaneous tissue present (Shepherd, 2018b) and that ensures the needle terminates in the subcutaneous tissue (Taylor et al., 2023). Some medications are packaged in prefilled cartridges with a needle attached. One example is an insulin injection pen, which may be used for subcutaneous injection of insulin (see the accompanying Skill Variation for technique). Confirm that the provided needle is appropriate for the patient before use. If not, the medication will have to be transferred to another syringe and the appropriate needle attached.

Subcutaneous injections are administered at a 45- or 90-degree angle, with the 45-degree angle used only for patients with a limited amount of subcutaneous tissue. Choose the angle of needle insertion based on the amount of subcutaneous tissue present and the length of the needle. In general, insert the shorter, ⅜;-inch needle, at a 90-degree angle (common on prefilled and insulin syringes). The longer, ⅝;-inch needle, may be inserted at a 45-degree angle. Figure 5-1 in the chapter opener on page 200 shows the angles of insertion for subcutaneous injections.

Usually, no more than 1 mL of solution is given subcutaneously. Giving larger amounts adds to the patient's discomfort and may predispose to poor absorption. It is necessary to rotate sites or areas for injection if the patient is to receive frequent injections. This helps to prevent buildup of fibrous/adipose tissue and permits complete absorption of the medication. Further information regarding insulin administration and rotation of injection sites can be found in the General Considerations at the end of this skill.

Box 5-1 discusses techniques for reducing discomfort when injecting medications subcutaneously or intramuscularly.

Assessment

Assess the appropriateness of the drug for the patient. Review the medical history and allergy, assessment, and laboratory data that may influence drug administration. Check the expiration date before administering the medication. Assess the site on the patient where the injection is to be given. Avoid sites that are bruised, tender, hard, swollen, inflamed, or scarred. These conditions could affect the reliability of absorption (ADA, 2020; Gelder, 2014). Assess the patient's knowledge of the medication. If the patient has deficient knowledge about the medication, this may be the appropriate time to begin education about it. If the medication may affect the patient's vital signs, assess them before administration. If the medication is for pain relief, assess the patient's pain before and after administration. Verify patient name, dose, route, and time of administration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

• Knowledge deficiency
• Infection risk
• Injury risk

Outcome Identification and Planning

The expected outcomes to achieve are that the patient receives the medication via the subcutaneous route and experiences the intended effect of the medication. Other outcomes that may be appropriate include the following: the patient does not experience adverse effects, and the patient understands and engages with the medication regimen.

Implementation

Action	Rationale
1. Gather equipment. Check each medication prescribed against the original in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's health status and can also be used to educate the patient about the medication.
3. Perform hand hygiene.	Hand hygiene prevents the spread of microorganisms.
4. Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room.	Organization facilitates error-free administration and saves time.
5. Unlock the medication supply system or drawer. Enter the passcode and scan employee identification, if required.	Locking the medication supply system or drawer safeguards each patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use. Entering the passcode and scanning ID allows only authorized users into the computer system and identifies the user for documentation by the computer.
6. Prepare medications for one patient at a time.	This prevents errors in medication administration.
7. Read the eMAR/MAR and read the label when selecting the proper medication from the medication supply system or the patient's medication drawer.	This is the first check of the label.
8. Read the label and compare the medication label with the eMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required.	This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary.
9. If necessary, withdraw the medication from an ampule or vial as described in Skills 5-3 and 5-4.
10. Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, read the label and recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient.	This third check ensures accuracy and helps to prevent errors. Note: Many facilities require the third check to occur at the bedside, after identifying the patient and before administration.
11. Label the syringe with the medication's name, dose, and amount (The Joint Commission, 2021).	Unlabeled syringes are unidentifiable and may lead to a medication administration error (The Joint Commission, 2021).
12. Log out of and/or lock the medication supply system before leaving it.	Locking the medication supply system or drawer safeguards the patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use.
13. Transport medications to the patient's bedside carefully and keep the medications in sight at all times.	Careful handling and close observation prevent accidental or deliberate disarrangement of medications.
14. Ensure that the patient receives the medications at the correct time.	Check facility policy, which may allow for administration within a period of 30 minutes before or 30 minutes after the designated time.
15. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
16. Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods (The Joint Commission, 2021):	Identifying the patient ensures the right patient receives the medications and helps prevent errors. The patient's room number or physical location is not used as an identifier (The Joint Commission, 2021). Replace the identification band if it is missing or inaccurate in any way.
a. Check the name on the patient's identification band.
b. Check the identification number on the patient's identification band.
c. Check the birth date on the patient's identification band.
d. Ask the patient to state their name and birth date, based on facility policy.	This requires a response from the patient, but illness and strange surroundings often cause patients to be confused.
17. Close the door to the room or pull the bedside curtain.	This provides patient privacy.
18. Complete necessary assessments before administering medications. Check the patient's allergy bracelet, if present, or ask the patient about allergies. Explain the purpose and action of the medication to the patient.	Assessment is a prerequisite to administration of medications. Explanation provides rationale, increases knowledge, promotes patient engagement, and reduces anxiety.
19. Scan the patient's bar code on the identification band, if required (The Joint Commission, 2021) (Figure 2).	Scanning provides an additional check to ensure that the medication is given to the right patient.
20. Based on facility policy, the third check of the label may occur at this point. If so, read the label and recheck the labels with the eMAR/MAR before administering the medications to the patient.	Many facilities require the third check to occur at the bedside, after identifying the patient and before administration. If facility policy directs the third check at this time, this third check ensures accuracy and helps to prevent errors.
21. Put on gloves.	Gloves help prevent exposure to contaminants.
22. Select an appropriate administration site. Assist the patient to the appropriate position for the site chosen. Drape, as needed, to expose only site area to be used.	Using an appropriate site and positioning prevent injury. Draping helps maintain the patient's privacy.
23. Identify the appropriate landmarks for the site chosen.	Good visualization is necessary to establish the correct site location and to avoid complications (Taylor et al., 2023).
24. Cleanse the area around the injection site with an antimicrobial swab. Use a firm, circular motion while moving outward from the injection site (Figure 3). Allow the area to dry.	Pathogens on the skin can be forced into the tissues by the needle. Moving from the center outward prevents contamination of the site. Allowing the antimicrobial solution to dry completely (5 to 20 seconds) ensures complete antimicrobial effectiveness (Gorski et al., 2021; Slater et al., 2018), and prevents introducing alcohol into the tissue, which can be irritating and uncomfortable.
25. Remove the needle cap with the nondominant hand, pulling it straight off.	The cap protects the needle from contact with microorganisms. This technique lessens the risk of an accidental needlestick.
26. Hold the syringe in the dominant hand between the thumb and forefinger. Use the thumb, index finger and middle finger on the nondominant hand to pinch up the skin and underlying fatty tissue (Figure 4). Inject the needle quickly at a 45- or 90-degree angle, depending on the amount of underlying subcutaneous tissue. (Figure 5).	Pinching up the skin and underlying fatty tissue lifts the adipose tissue away from underlying muscle and tissue (Shepherd, 2018b; Wolicki & Miller, 2020). Inserting the needle quickly causes less pain to the patient. For a person with a limited amount of subcutaneous tissue, insert the needle at a 45-degree angle (Shepherd, 2018b).
27. Move your nondominant hand to the lower end of the syringe and slide your dominant hand to the end of the plunger, taking care to avoid moving the syringe. Alternatively, move your middle finger into place on the syringe, holding the syringe with your thumb and middle finger, and move your index finger to the end of the plunger; taking care to avoid moving the syringe.	This allows for stabilization of the syringe and avoids movement. Moving the syringe could cause damage to the tissues and inadvertent administration into an incorrect area.
28. Inject the medication. Withdraw the needle quickly at the same angle at which it was inserted, while supporting the surrounding tissue with your nondominant hand.	Slow withdrawal of the needle pulls the tissues and causes discomfort. Applying counter traction around the injection site helps to prevent pulling on the tissue as the needle is withdrawn. Removing the needle at the same angle at which it was inserted minimizes tissue damage and discomfort for the patient.
29. Do not recap the used needle. Engage the safety shield or needle guard.	Safety shield or needle guard prevents accidental needlestick.
30. If blood or clear fluid appears at the site after withdrawing the needle, use a gauze square to apply gentle pressure to the site. Do not massage the site.	Massaging the site can damage underlying tissue and increase the absorption of the medication (Taylor et al., 2023). Massaging after heparin administration can contribute to hematoma formation.
31. Remove gloves and perform hand hygiene. Assist the patient to a position of comfort.	Removing gloves and performing hand hygiene reduces the risk of contamination of other items and the spread of microorganisms. Assisting the patient to a position of comfort promotes patient comfort.
32. Discard the needle and syringe in an appropriate container, such as a sharps receptacle.	Proper disposal of the needle prevents injury.
33. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk of infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
34. Document the administration of the medication immediately after administration.	Timely documentation helps to ensure patient safety.
35. Evaluate the patient's response to the medication within the appropriate time frame for the particular medication.	The patient needs to be evaluated for therapeutic and adverse effects from the medication.

Evaluation

The expected outcomes have been met when the patient has received the medication via the subcutaneous route and has experienced the intended effect of the medication, the patient did not experience adverse effects, and the patient has verbalized an understanding of the medication regimen.