{"id":2875,"date":"2015-05-22T21:44:52","date_gmt":"2015-05-22T21:44:52","guid":{"rendered":"http:\/\/opentextbc.ca\/clinicalskills\/?post_type=chapter&p=2875"},"modified":"2021-06-09T15:51:06","modified_gmt":"2021-06-09T15:51:06","slug":"6-7-intradermal-subcutaneous-and-intramuscular-injections","status":"publish","type":"chapter","link":"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/6-7-intradermal-subcutaneous-and-intramuscular-injections\/","title":{"raw":"7.3 Intradermal and Subcutaneous Injections","rendered":"7.3 Intradermal and Subcutaneous Injections"},"content":{"raw":"Intradermal injections (ID)\u00a0<\/strong>are injections administered into the dermis, just below the epidermis. The ID injection route has the longest absorption time of all parenteral routes. These types of injections are used for sensitivity tests, such as TB (see Figure 7.13), allergy, and local anesthesia tests. The advantage of these tests is that the body reaction is easy to visualize, and the degree of reaction can be assessed. The most common sites used are the inner surface of the forearm and the upper back, under the scapula. Choose an injection site that is free from lesions, rashes, moles, or scars, which may alter the visual inspection of the test results (Lynn, 2011).\r\n\r\nEquipment used for ID injections is a tuberculin syringe calibrated in tenths and hundredths of a millilitre, and a 1\/4 to 1\/2 in., 26 or 27 gauge needle. The dosage of an ID injection is usually under 0.5 ml. The angle of administration for an ID injection is 5 to\u00a015 degrees. Once the ID injection is completed, a bleb (small blister) should appear under the skin.\u00a0Checklist 56 outlines the steps to administer an intradermal injection.\r\n\r\n[caption id=\"attachment_6011\" align=\"aligncenter\" width=\"300\"]\"TB<\/a> Figure 7.13 TB syringe[\/caption]\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
<\/a>Checklist 56: Administering an Intradermal (ID) Injection<\/caption>\r\n
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Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n
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Safety Considerations:\u00a0<\/span><\/h5>\r\n
    \r\n \t
  • Do not aspirate. It is not necessary to aspirate because the dermis is relatively without vessels.<\/li>\r\n \t
  • Always take steps to eliminate interruptions and distractions during medication preparation.<\/li>\r\n \t
  • If the patient expresses concerns about the medication or procedure, stop and explore the concerns. Re-verify order with physician if appropriate.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
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Steps<\/h4>\r\n<\/td>\r\n

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\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

1. Prepare medication or solution as per agency policy. Ensure all medication is properly identified. Check physician orders, Parenteral Drug Therapy Manual <\/em>(PDTM), and MAR to validate medication order and guidelines for administration.<\/td>\r\nProperly identifying medication decreases risk of inadvertently administering the wrong medication.\r\n\r\nPreparing medications ensures patient safety with medication administration.\r\n\r\n[caption id=\"attachment_6140\" align=\"aligncenter\" width=\"210\"]\"Comparing<\/a> Compare physician orders and MAR[\/caption]\r\n\r\n[caption id=\"attachment_6044\" align=\"aligncenter\" width=\"196\"]\"Preparing<\/a> Prepare medication from a vial[\/caption]<\/td>\r\n<\/tr>\r\n
2. Perform hand hygiene<\/a>.<\/td>\r\nGather all supplies: medication syringe, non-sterile gloves, alcohol swab and sterile gauze, Band-Aid (if required).\r\n\r\n[caption id=\"attachment_6038\" align=\"aligncenter\" width=\"184\"]\"Required<\/a> Required supplies[\/caption]<\/td>\r\n<\/tr>\r\n
3. Enter room and introduce yourself, explain procedure and the medication, and allow patient time to ask questions.<\/td>\r\nExplaining rationale increases the patient's knowledge and reduces their anxiety.<\/td>\r\n<\/tr>\r\n
4. Close the door or pull the bedside curtains.<\/td>\r\nThis provides patient privacy.<\/td>\r\n<\/tr>\r\n
5. Compare MAR to patient wristband and verify this is the correct patient using two identifiers.<\/td>\r\nThis ensures accuracy of the medication or solution and prevents errors.\r\n\r\nTwo patient identifiers are patient name and date of birth.\r\n\r\n[caption id=\"attachment_6460\" align=\"aligncenter\" width=\"147\"]\"Identify<\/a> Compare MAR with patient wristband[\/caption]<\/td>\r\n<\/tr>\r\n
6. Assess patient for any contraindications to the medications.<\/td>\r\nAssessment is a prerequisite for every medication given.<\/td>\r\n<\/tr>\r\n
7. Select appropriate site for administration. Assist the patient to the appropriate position as required.<\/td>\r\nSite should be free from lesions, rashes, and moles. Selecting the correct site allows for accurate reading of the test site at the appropriate time.\r\n\r\n[caption id=\"attachment_6659\" align=\"aligncenter\" width=\"230\"]\"Assess<\/a> Assess site for ID injection[\/caption]<\/td>\r\n<\/tr>\r\n
8. Perform hand hygiene<\/a> and apply non-sterile gloves.<\/td>\r\nGloves help prevent exposure to contaminants.\r\n\r\n[caption id=\"attachment_6141\" align=\"aligncenter\" width=\"197\"]\"Apply<\/a> Apply non-sterile gloves[\/caption]<\/td>\r\n<\/tr>\r\n
9. Clean the site with an alcohol swab or antiseptic swab. Use a firm, circular motion. Allow the site to dry.<\/td>\r\nPathogens from the skin can be forced into the tissues by the needle. Allowing the skin to dry prevents introducing alcohol into the tissue, which can be irritating and uncomfortable.\r\n\r\n[caption id=\"attachment_6040\" align=\"aligncenter\" width=\"194\"]\"Cleaning<\/a> Clean injection site[\/caption]<\/td>\r\n<\/tr>\r\n
10. Remove needle from cap by pulling it off in a straight motion.<\/td>\r\nThis decreases risk of accidental needle-stick injury.\r\n\r\n[caption id=\"attachment_6462\" align=\"aligncenter\" width=\"227\"]\"Remove<\/a> Remove needle from cap[\/caption]<\/td>\r\n<\/tr>\r\n
11. Using non-dominant hand, spread the skin taut over the injection site.<\/td>\r\nTaut skin provides easy entrance for the needle.\r\n\r\n[caption id=\"attachment_6046\" align=\"aligncenter\" width=\"183\"]\"Holding<\/a> Hold skin taut prior to injection[\/caption]<\/td>\r\n<\/tr>\r\n
12. Hold the syringe in the dominant hand between the thumb and forefinger, with the bevel of the needle up.<\/td>\r\nThis allows for easy handling of the syringe.\r\n\r\n[caption id=\"attachment_6047\" align=\"aligncenter\" width=\"194\"]\"Holding<\/a> Hold needle with bevel up[\/caption]<\/td>\r\n<\/tr>\r\n
13. Hold syringe at a 5- to 15-degree angle from the site. Place the needle almost flat against the patient's skin, bevel side up, and insert needle into the skin. Insert the needle only about 1\/4 in., with the entire bevel under the skin.<\/td>\r\nKeeping the bevel side up allows for smooth piercing of the skin and induction of the medication into the dermis.\r\n\r\n[caption id=\"attachment_6049\" align=\"aligncenter\" width=\"204\"]\"ID<\/a> ID injection[\/caption]<\/td>\r\n<\/tr>\r\n
14. Once syringe is in place, slowly inject the solution while watching for a small weal or bleb to appear.<\/td>\r\nThe presence of the weal or bleb indicates that the medication is in the dermis.\r\n\r\n[caption id=\"attachment_6051\" align=\"aligncenter\" width=\"208\"]\"Presence<\/a> Presence of a bleb (white raised circle)[\/caption]<\/td>\r\n<\/tr>\r\n
15. Withdraw the needle at the same angle as insertion, engage safety shield or needle guard, and discard in a sharps container.\r\n\r\nDo not massage area after injection.<\/td>\r\nWithdrawing at the same angle as insertion minimizes discomfort to the patient and damage to the tissue.\r\n\r\nProper needle disposal prevents needle-stick injuries.\r\n\r\n[caption id=\"attachment_6461\" align=\"aligncenter\" width=\"172\"]\"Discard<\/a> Discard syringe in sharps container[\/caption]\r\n\r\nMassaging the area may spread the solution to the underlying subcutaneous tissue.\r\n\r\nGently pat with sterile gauze if blood is present.<\/td>\r\n<\/tr>\r\n
16.\u00a0If injection is a TB skin test, circle the area around the injection site to allow for easy identification of site in three days.<\/td>\r\n\r\n\r\n[caption id=\"attachment_6052\" align=\"aligncenter\" width=\"181\"]\"Draw<\/a> Draw circle around injection site[\/caption]<\/td>\r\n<\/tr>\r\n
17. Discard remaining supplies, remove gloves, and perform hand hygiene<\/a><\/td>\r\nThis prevents the spread of microorganisms.\r\n\r\n[caption id=\"attachment_5972\" align=\"aligncenter\" width=\"150\"]\"Hand<\/a> Hand hygiene with ABHR[\/caption]<\/td>\r\n<\/tr>\r\n
18. Document the procedure and findings according to agency policy.<\/td>\r\nProper documentation helps ensure patient safety. Document time, date, location, and type of medication injected.<\/td>\r\n<\/tr>\r\n
19. Evaluate the patient response to injection within appropriate time frame.<\/td>\r\nThe patient will need to be evaluated for therapeutic and adverse effects of the medication or solution.<\/td>\r\n<\/tr>\r\n
Data source: ATI, 2015a; Berman & Snyder, 2016; Brookside Associates, 2015a; Clayton, Stock, & Cooper, 2010; Perry et al., 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n

Subcutaneous Injections<\/h2>\r\nSubcutaneous (SC) injections are administered into the adipose tissue layer just below the epidermis and dermis. This tissue has few blood vessels, so drugs administered by this route have a slow, sustained rate of absorption. Sites for SC injections include the outer aspect of the upper arm, the abdomen (from below the costal margin to the iliac crest) within one inch of the belly button, anterior aspects of the thighs, upper back, and upper ventral gluteal area (Lynn, 2011) (see Figure 7.14).\r\n\r\n[caption id=\"attachment_6529\" align=\"aligncenter\" width=\"274\"]\"SC<\/a> Figure 7.14 SC injection sites[\/caption]\r\n\r\nChoose a site that is free of skin lesions and bony prominences. Site rotation prevents the formation of lipohypertrophy or lipoatrophy in the skin. Physical exercise or application of hot or cold compresses influences the rate of drug absorption by altering local blood flow to the tissues. Any condition that impairs that blood flow to the subcutaneous tissue contradicts the use of subcutaneous injections. Examples of subcutaneous medications include insulin, opioids, heparin, epinephrine, and allergy medication (Perry et al., 2014).\r\n\r\nTo administer an SC injection, a 25 to\u00a030 gauge, 3\/8 in. to\u00a05\/8 in. needle is used. Some subcutaneous injections come prefilled with the syringe attached. Always confirm that the right-size needle is appropriate for the patient before use. Subcutaneous injections are usually given at a 45- to 90-degree angle. The angle is based on the amount of subcutaneous tissue present. Generally, give shorter needles at a 90-degree angle and longer needles at a 45-degree angle (Lynn, 2011).\u00a0SC injections do not need to be aspirated as the likelihood of injecting into a blood vessel is small. Usually, no more than 1 ml of medication is given subcutaneously, as larger amounts may cause discomfort to the patient and may not be absorbed appropriately (Lynn, 2011).\r\n\r\nThere are varying opinions on\u00a0whether to pinch the skin during administration. Pinching is advised for thinner patients in order to lift the adipose tissue up and away from the underlying muscle and tissue. If pinching is used, release the pinch when the needle is inserted to avoid injecting into compressed tissue. Note, too, that elevating or pinching the skin has been found to increase the risk of injury, as the needle may pierce the opposite side of the skin fold and enter the skin of the health care worker (Black, 2013). The abdomen is the best location for an SC injection if a patient has little peripheral SC tissue. If patient is obese, use a needle that is long enough to insert through the tissue at the base of the skin fold (Perry et al., 2014).\r\n

Insulin SC Injections<\/h2>\r\nInsulin is considered a high-risk medication, and special care must be taken to ensure the correct amount of medication and type of insulin is administered at the correct time. As well, safety checks related to a patient receiving SC insulin should be carried out\u00a0(Ellis & Parush, 2012). Table 7.5 lists specific guidelines for administering insulin (and see Figure 7.15).\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
Table 7.5 Guidelines for Administering SC Insulin<\/caption>\r\n
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Insulin<\/b><\/p>\r\n<\/td>\r\n

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\u00a0Additional Information<\/strong><\/p>\r\n<\/td>\r\n<\/tr>\r\n

Insulin is considered a high-risk medication.<\/td>\r\nSpecial care must be taken to ensure the correct amount of medication and type of insulin is administered, at\u00a0the correct time. It is highly recommended to always get your insulin dosages double-checked by another health care provider. Always follow the standard for medication preparation at your agency.<\/td>\r\n<\/tr>\r\n
Insulin is only administered using an insulin syringe.<\/td>\r\nInsulin is the only drug with its own type of syringe with a needle attached. Insulin is always ordered and administered in units, based on a blood sugar reading and a diabetic insulin protocol (or sliding scale). Some hospitals have preprinted physician orders, and some hospitals have handwritten orders. Insulin syringes can come in 30-, 50-, or 100-unit measurements. Always read the increments (calibration) carefully.<\/td>\r\n<\/tr>\r\n
There are different types of insulin.<\/td>\r\nThere are rapid-, short-, intermediate-, and long-acting insulins. For each type of insulin, it is important to know how the insulin works and the onset, peak, and duration of the insulin.<\/td>\r\n<\/tr>\r\n
Administering two different types of Insulin.<\/td>\r\nIf a patient is ordered two types of insulin, some insulins may be mixed together in one syringe. Many insulins MAY NOT be mixed together. Do not mix Lantus (Glargine) or Levemir (Determir).If administering cloudy insulin preparations (Humulin \u2013 N), gently roll the vial between the palms of your hands to re-suspend the medication.\r\nAlways draw up the short acting insulin first, to prevent it from being contaminated with the long acting. If too much insulin is drawn up from the second vial, discard syringe and start again. Always check with the PDTM for the most current guidelines regarding insulin administration.Insulin orders may change from day to day. Always ensure the most current physician orders are being followed.<\/td>\r\n<\/tr>\r\n
Know about rotating injection sites.<\/td>\r\nInjection site rotation is no longer necessary as newer insulins have a lower risk for hypertrophy of the skin. Typically, a patient will pick one anatomic area (e.g., upper arm) and rotate the injection sites within that region to maintain consistent insulin absorption from day to day. Insulin absorption rates vary from site to site. The abdomen absorbs the fastest, followed by the arms, thighs, and buttocks.<\/td>\r\n<\/tr>\r\n
Know when to administer insulin.<\/td>\r\nThe timing of insulin injections is critical to correct insulin administration based on blood sugar levels and when the patient will eat. Knowing the peak action and duration of insulin is critical to proper insulin medication management. If giving insulin, always ensure the patient is not nauseated, is able to eat, and that food is arriving before the insulin starts working. Typically, short- or rapid-acting insulin is given 15 minutes before meals. Intermediate- or long-acting insulin may be given twice daily, at breakfast and dinner.<\/td>\r\n<\/tr>\r\n
Measure blood sugar levels and food intake.<\/td>\r\nInsulin injections are based on blood sugar values and on when the patient will eat. The timing of an insulin injection is critical to ensure the patient receives insulin correctly.<\/td>\r\n<\/tr>\r\n
Use insulin injection pens.<\/td>\r\nInjection pens\u00a0<\/strong>are a new technology used by patients to self-inject insulin using a syringe, needle, and prefilled cartridge of insulin. It is essential that patients be taught how to use injection pens so they understand the technology.\r\n\r\nA mini-infusion\u00a0pump<\/strong> is a battery-operated machine that delivers medications in very small amounts to patients with controlled infusion times. The most common types of mini-infusion sets are insulin pumps or subcutaneous infusion devices. For more information on mini-infusion sets and volume-controlled sets, see Suggested Online Resources<\/a> in section 7.8.<\/td>\r\n<\/tr>\r\n
Data source: Canadian Diabetes Association, 2013; Perry et al., 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n[caption id=\"attachment_6530\" align=\"aligncenter\" width=\"151\"]\"SC<\/a> Figure 7.15 Insulin syringe with needle attached[\/caption]\r\n
Special considerations:<\/h5>\r\n