Why is it important to change the needle after drawing up a medication and before injecting it into a patient?
Administering injections; Giving a needle; Giving insulin Follow these steps to fill the syringe with medicine. Hold the syringe in your hand
with the needle pointed up. With the cap still on, pull back the plunger to the line on your syringe for your dose. This fills the syringe with air. For example, if you need 1 cc of medicine, pull the plunger to the line marked 1 cc on the syringe. (Some bottles of medicine may say mL.) Next, remove the cap and insert the needle into the rubber top of the vial. Do not touch or bend the needle. Depress the plunger and push the air into the vial. This keeps a vacuum from forming so that the
medicine will flow easily into the syringe. Turn the vial upside down and hold it up in the air. Make sure that the medicine covers the tip of the needle the entire time. As before, pull back the plunger to the line on your syringe for your dose. Remove the needle from the vial. The medicine is ready to inject. To get prepared: Check Your MedicineCarefully check your medicine:
Get the Vial ReadyPrepare your medicine vial:
Filling the Syringe With MedicineFollow these steps to fill the syringe with medicine:
To remove air bubbles from the syringe:
ReferencesAuerbach PS. Procedures. In: Auerbach PS, ed. Medicine for the Outdoors. 6th ed. Philadelphia, PA: Elsevier; 2016:444-454. Smith SF, Duell DJ, Martin BC, Gonzalez L, Aebersold M. Medication administration. In: Smith SF, Duell DJ, Martin BC, Gonzalez L, Aebersold M, eds. Clinical Nursing Skills: Basic to Advanced Skills. 9th ed. New York, NY: Pearson; 2016:chap 18. Version InfoLast reviewed on: 1/29/2022 Reviewed by: Linda J. Vorvick, MD, Clinical Associate Professor, Department of Family Medicine, UW Medicine, School of Medicine, University of Washington, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team. Part 2 of this two-part series on injection techniques describes the evidence base and procedure for administering a subcutaneous injection AbstractThe subcutaneous route allows drugs such as insulin and heparin to be absorbed slowly over a period of time. Using the correct injection technique and selecting the correct site will minimise the risk of complications. This is the second article in a two-part series on injection techniques. Part 1 covers the intramuscular route. Citation: Shepherd E (2018) Injection technique 2: administering drugs via the subcutaneous route. Nursing Times [online]; 114: 9, 55-57. Author: Eileen Shepherd is clinical editor at Nursing Times.
This articles was updated 12th November 2021. IntroductionDrugs administered by the subcutaneous route are deposited into subcutaneous tissue (Fig 1); small volumes (up to 2ml) of non-irritant, water-soluble drugs can be administered by subcutaneous injection (Dougherty and Lister, 2015). Unlike muscle, subcutaneous tissue does not have a rich blood supply, and absorption of drugs delivered via that route is therefore slower than via the intramuscular route (see part 1) (Dougherty and Lister, 2015). This slower rate of absorption is beneficial when continuous absorption of a drug is required; for example, with insulin or heparin (Hunter, 2008). Factors affecting blood flow to the skin, including exercise and changes in environmental temperature, can affect drug absorption. The subcutaneous route may be unreliable in patient with conditions that result in impaired blood flow, such as circulatory shock (Dougherty and Lister, 2015). It is often suggested that the subcutaneous route is relatively pain free (Zijlstra et al, 2018; Srivastava and Robson, 2012) but the evidence supporting this assertion is poor and further research is required. A Cochrane review in 2017 looked at the duration of pain and bruising after subcutaneous heparin injection and reported that a slow injection – taking 30 seconds to administer – may reduce pain but there is no difference in bruising compared with a fast injection (Mohammady, 2017). The researchers noted that the evidence was of low quality. Complications associated with subcutaneous injections include abscesses and, in patients who require frequent injections, there is a risk of lipohypertrophy; this is characterised by an accumulation of fat under the skin. Lipohypertrophy occurs when multiple injections are repeatedly administered into the same area of skin. It can be painful and unsightly, and affect drug absorption, but can be prevented by rotating injection sites (Down and Kirkland, 2012). PreparationSite selectionRecommended sites for subcutaneous injection include the lateral aspects of the upper arm and thigh, and the umbilical region of the abdomen (Ogston-Tuck, 2014; Hunter, 2008). The back and lower loins can also be used (Fig 2). Injection sites should be:
As the amount of subcutaneous fat varies between patients, individual patient assessment is vital before carrying out the procedure. It is important to avoid inadvertently injecting the drug into muscle, as intramuscular injection can affect drug absorption; for example, inadvertent administration of insulin into the muscle can lead to accelerated insulin absorption and lead to hypoglycaemia (Down and Kirkland, 2012). A lifted skinfold technique (pinching or bunching the skin) can be used to lift the subcutaneous layer away from the underlying muscle (Down and Kirkland, 2012) (Fig 3). This method reduces the risk of inadvertent intramuscular injection when undertaken correctly; however, releasing the skin too quickly before the injection is completed or lifting it incorrectly can increase that risk (Down and Kirkland, 2012). NeedlesSafety needles should be used for subcutaneous injections to reduce the risk of needle- stick injury (Health and Safety Executive, 2013). Some drugs such as heparin come in a pre-loaded syringe and patients prescribed insulin may use insulin delivery devices. Needle size is measured in gauges (diameter of the needle) – a 25G is commonly used for subcutaneous injections (Dougherty and Lister, 2015; Public Health England, 2013). Needle size depends on the viscosity of the liquid being injected (Dougherty and Lister, 2015). Needles need to be long enough to inject the drug into the subcutaneous tissue. They come in lengths of 4-8mm. Dougherty and Lister (2015) suggest the required needle length can be estimated by pinching the skin using the lifted skinfold technique (Fig 3) and selecting a needle that is 1.5 times the width of the skinfold. Skin preparationThere is debate around the use of alcohol-impregnated swabs to clean injection sites. The World Health Organization (2010) suggested that if a patient is physically clean and generally in good health, swabbing of the skin before injection is not required. This was supported by Hicks et al (2011) in the First UK Injection Technique Recommendations. In older patients and those who are immunocompromised, skin preparation using an alcohol-impregnated swab (70% isopropyl alcohol) may be recommended (Dougherty and Lister, 2015). The patient’s condition should be individually assessed and local policies should be followed. AspirationIt is common practice to draw back on a syringe after the needle has been inserted to check whether it is in a blood vessel. This is not recommended for subcutaneous injections as this is unlikely to occur (Lister et al, 2020). GlovesThe WHO (2010; 2009) stated that gloves need not be worn for this procedure if the skin of both health worker and patient is intact. It also notes that gloves do not protect against needlestick injury. Nurses need to assess risk in each individual patient (Royal College of Nursing, 2018) and be aware of local policies for glove use. Angle of injectionIt is recommended that subcutaneous injections, particularly of insulin, are administered at a 90-degree angle to ensure that the medication is delivered into the subcutaneous tissue (Down and Kirkland, 2012; Hunter, 2008). However, patient assessment is vital – patients who are cachectic and therefore have minimal amounts of subcutaneous tissue may require injections to be delivered at a 45-degree angle. PHE (2013) recommends that subcutaneous vaccinations are given with the needle at a 45-degree angle to the skin and the skin should be pinched together (PHE, 2013). Equipment
Procedure
Box 1. ‘Five rights’ of medicines administration
Ağaç E, Güneş UY (2011) Effect on pain of changing the needle prior to administering medicines intramuscularly: a randomized controlled trial. Journal of Advanced Nursing; 67: 3, 563-568. Dougherty L, Lister S (2015) The Royal Marsden Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell. Down S, Kirkland F (2012) Injection technique in insulin therapy. Nursing Times; 108: 10, 18-21. Health and Safety Executive (2013) Health and Safety (Sharp Instruments in Healthcare) Regulations 2013: Guidance for Employers and Employees. Hicks D et al (2011) Diabetes Care in the UK. The First UK Injection Technique Recommendations. Hunter J (2008) Subcutaneous injection technique. Nursing Standard; 22: 21, 41-44. Lister et al (2020) The Royal Marsden Manual of Clinical Nursing Procedures. WILEY Blackwell. Mohammady M et al (2017) Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity. Cochrane Database of Systematic Reviews; 10: CD008077. Ogston-Tuck S (2014) Subcutaneous injection technique: an evidence-based approach. Nursing Standard; 29: 3, 53-58. Public Health England (2013) Immunisation Procedures: The Green Book, Chapter 4. Royal College of Nursing (2018) Tools of the Trade: Guidance for Health Care Staff on Glove Use and the Prevention of Contact Dermatitis. Srivastava L, Robson P (2012) Pain from subcutaneous injections: myth or reality. BMJ Supportive and Palliative Care; 2: A62. World Health Organization (2010) WHO Best Practices for Injections and Related Procedures Toolkit. World Health Organization (2009) WHO Guidelines on Hand Hygiene in Health Care. Zijlstra E et al (2018) Impact of injection speed, volume, and site on pain sensation. Journal of Diabetes Science and Technology; 12: 1, 163-168. Why do we change needle before injection?Change the needle. Doing so will ensure that the needle used for the injection is sharp, thereby reducing pain (Agac and Günes, 2011). A safety-engineered needle should be used as this reduces the risk of sharps injury. Dispose of the used needle in a sharps container according to local policy.
Why do you change needle after drawing up medication?The safest practice is for a syringe and needle to be used only once to administer a medication to a single patient, after which the syringe and needle should be discarded. This practice prevents inadvertent reuse of the syringe and protects healthcare personnel from harms such as needlestick injuries.
What happens if you use the same needle over and over?Reuse of needles or syringes to access medication can result in contamination of the medicine with germs that can be spread to others when the medicine is used again.
What happens if you use the same needle twice?The fine tip of needles can become slightly distorted with re-use and this can increase the chance of experience pain whilst putting the needle in or taking the needle out.
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