Subcutaneous Injection Techniques

• Subcutaneous (SC) injections are administered into the adipose tissue layer just below the epidermis and dermis.
• Adipose tissue has few blood vessels, leading to slow, sustained absorption of drugs administered this way.

Sites for SC injections:

• Abdomen: At or under the level of the belly button, about two inches away from the navel
• Arm: back or side of the upper arm
• Thigh: front of the thigh
• Upper back and upper ventral gluteal area

Equipment

• Syringe appropriate for the medication being given
• Antiseptic or alcohol swabs
• Medication ampule or vial
• Medication administration record (MAR)
• Disposable gloves
• Puncture-resistant container

Nursing Actions:

• Wash hands and put on clean gloves to reduce the number of microorganisms
• Prepare equipment to save time and effort

Withdrawing Medications

• Withdraw medications from an ampoule or a vial:

  • Hold the syringe like a pencil in the hand you write with
  • Take the cover off the needle
  • Tap the syringe with your finger to move air bubbles to the top

• Identify the client and explain the procedure to ensure correct medication safety before using

• Close the door or curtains around bed and keep gown or sheet draped over the client to provide privacy

• Select injection site; the injection site should be free of lesions:

  • Inspect skin for bruises, inflammation, edema, masses, tenderness, and sites of previous injections, and avoid these areas

• Assist client into a comfortable position:

  • Relax the arm, leg, or abdomen
  • Distract client by talking about an interesting subject or explaining what you are doing step by step; relaxation minimizes discomfort and distraction reduces anxiety

• Use an antiseptic swab to clean the skin at the site: Circular motion and mechanical action of swab remove microorganisms

• While holding the swab between fingers of the non-dominant hand, pull the cap from the needle; the swab remains accessible during the procedure

• Hold the syringe upright (with the needle on top) between thumb and forefinger of the dominant hand like a pencil; quick, smooth injection is easier with the proper position of syringe

• Pinch the skin with the non-dominant hand; the needle penetrates tight skin easier than loose skin; pinching the skin elevates subcutaneous tissue

• Inject the needle quickly and firmly at a 45 to 90-degree angle

• Release the skin

• Grasp the lower end of the syringe with non-dominant hand, and position the dominant hand to the end of the plunger; quick, firm injection minimizes discomfort; the angle depends on the amount of subcutaneous tissue present and the site used; movement of the syringe may cause discomfort

• Remove hand from the injection site and quickly withdraw the needle; supporting tissue around the injection site minimizes discomfort; removing hand before withdrawing the needle reduces the chance of a needle stick

• Apply pressure with the antiseptic swab, but do not push down on the needle with the swab while withdrawing it, as this will cause more pain, and some medications should not be massaged

• Assist the client to a comfortable position to promote comfort

• Discard the uncapped needle and syringe in a disposable needle receptacle; this decreases the risk of a needle stick

• Remove gloves and wash hands/hand hygiene to reduce the transmission of microorganisms

• Documentation is required

Mixing Two Types of Insulin

• Administer to patients who have diabetes, because these types of patients depend on insulin in their body to use glucose
• Combining two types of insulin in one syringe avoids the discomfort of two injections to control blood glucose level without cross-contamination of medication
• Regular insulin (unmodified insulin) is a rapid-acting, clear solution, while other types of insulin are cloudy (modified) because of the addition of proteins, which slow the absorption of the drug giving them an intermediate-to-long duration of action

Mixing Guidelines

• Regular insulin can be mixed with any other type of insulin and should always be drawn up in the syringe first
• NPH (Neutral Protamine Hagedorn) insulin can only be mixed with regular insulin
• Different types of Lente insulin can be mixed together, and with regular insulin, but not with any other type of insulin
• Insulin syringes are calibrated in 50 or 100 units per milliliter; Care must be taken not to confuse the two, as each marking represents one unit on a 50-unit syringe and 2 units on a 100-unit syringe; that could lead to medication error
• Insulin can be kept at room temperature for approximately 1 month; refrigeration is required for longer periods of time
• Insulin should not be given cold, but should be allowed to warm to room temperature

Special Considerations:

• Have D50W, sugar, orange juice, and glucagon available on unit
• Check the patient's blood sugar and for signs and symptoms of hypoglycemia, and if the patient is hypoglycemic, hold the dose and notify the physician for further orders
• If lispro (rapid acting) insulin is used, make sure meals are on unit; the onset of action is within 15 minutes
• Do not use insulin that has changed color or has become clumped or granular in appearance
• Regular and short-acting insulin should be clear, and other types should be uniformly cloudy
• Store unused insulin in a cool area, and use room temperature insulin for injection to limit irritation at the injection site
• Mix insulin by gently rotating between palms; Do not shake, this creates air bubbles in the mixture and syringe, thereby altering the dose delivered to the patient
• Commercial insulin concentrations of 100 or 500 U/mL are available
• 500 U/mL preparations are useful for the patient with insulin resistance who requires large doses, but should be stored separately to avoid an accidental overdose

Equipment/Supplies

• Medication vial
• Two alcohol pads
• Insulin syringe
• Two needles (if applicable)

Steps for Preparing a Mixed Dose of Insulin:

• Wash hands. Roll the insulin bottles (vials) gently between your hands: Roll the cloudy insulin bottle until all the white powder has dissolved, and rolling the bottle warms the insulin if you have been keeping the bottle in the refrigerator
• The order in which you mix the clear (short or rapid-acting) and cloudy (long-acting) insulin is important; do not shake an insulin bottle because shaking creates air bubbles that can alter the dose
• Wipe the rubber lid of both insulin bottles with an alcohol wipe or a cotton ball dipped in alcohol, and let the alcohol dry; if you are using a bottle for the first time, remove the protective cover from the rubber lid without cleaning
• Remove the plastic cap that covers the needle on your insulin syringe, and do not touch the needle
• Pull the plunger back on your insulin syringe and draw air into the syringe equal to the number of units of cloudy insulin to be given
• Push the needle of the syringe into the rubber lid of the cloudy insulin bottle
• Push the plunger of the syringe to force the air into the bottle. This equalizes the pressure in the bottle when you later remove the dose of insulin
• Remove the needle from the bottle. Drawing air into the syringe for the clear insulin dose
• Pull the plunger of the syringe back and draw air into the syringe equal to the number of units of clear insulin to be given
• Push the needle of the syringe into the rubber lid of the clear insulin bottle
• Push the plunger to force the air into the bottle, and leave the needle in place; you will draw the clear insulin into the syringe first; it is important to follow this order
• Turn the bottle and syringe upside down, and position the tip of the needle so that it is below the surface of insulin in the bottle to prevent the aspiration of air
• Pull back the plunger to fill the syringe with slightly more than the correct number of units of clear insulin to be given
• Tap the barrel of the syringe so that trapped air bubbles move into the needle area and push the air bubbles back into the bottle; make sure that you have the correct number of units of insulin in your syringe
• Remove the needle from the clear insulin bottle
• Insert the needle into the rubber lid of the cloudy insulin bottle. Do not push the plunger because this would force clear insulin into your cloudy insulin bottle
• If clear insulin is mixed in the bottle of cloudy, it will alter the action of your other doses from that bottle
• Turn the bottle and syringe upside down, and position the tip of the needle so that it is below the surface of insulin in the bottle
• Slowly pull back the plunger of the syringe to fill the syringe with the correct number of units of cloudy insulin to be given, which will prevent air bubbles entering the syringe
• Remove the needle from the bottle; expel excess air or fluid from the syringe because air or insulin excess will incorrectly dose the patient
• You should now have the total number of units for the clear and cloudy insulin in your syringe, such as, if you need 10 units of clear and 15 units of cloudy, you should have 25 units in your syringe

Evaluation and Follow-up Activities:

• It is important to administer insulin mixture within 5 minutes of preparation because the action of regular insulin is reduced by its binding with NPH insulin
• After administration, discard the needle in the sharps container and wash hands to reduce the transfer of microorganisms.

Prevention of Needle-Stick Injuries

• Home healthcare workers can be at risk for needle stick or sharps injuries when they:
  • Handle needles that must be taken apart or manipulated after use.
  • Dispose of needles attached to tubing
  • Manipulate the needle in the client
  • Recap a needle
  • Use needles or glass equipment to transfer body fluid between containers
  • Fail to dispose of used needles in puncture-resistant sharps containers
  • Lack proper workstations for procedures using sharps
  • Work quickly
  • Bump into a needle, a sharp, or another worker while either person is holding a sharp

One-Handed Needle Recapping Technique

• A method that place the cap to needle on a clean and safe place
• To prevent your own finger or another person from being stuck accidentally

Recapping - One-Hand Technique

• Place the cap on a flat surface, then remove your hand from the cap
• With one hand, hold the syringe and use the needle to "scoop up" the cap
• When the cap covers the needle completely, use the other
• If you experience a needlestick or sharps injury or are exposed to the blood or other body fluid of a client during the course of your work, immediately follow these steps:
  • Wash needlesticks and cuts with soap and water
  • Flush splashes to the nose, mouth, or skin with water
  • Irrigate eyes with clean water, saline, or sterile irrigants
  • Report the incident to your supervisor
  • Immediately seek medical treatment