SUBCUTANEOUS MEDICATION ADMINISTRATION

DOCUMENT TYPE: PROCEDURE

Site Applicability This procedure applies to all clinical areas at BC Children’s Hospital and Sunnyhill Health Center.

Practice Level/Competencies RNs, RPNs and LPNs may administer subcutaneous injections that are within their scope and competencies

Policy Statement(s) Administration of subcutaneous medications requires a prescriber’s order (exceptions: RN initiated protocols). The order must meet safe prescribing practices as described in Medication Order Requirements Policy. Health care providers administering any medication are responsible for knowing the classification of drug to be administered, its mode of action and side effects in order to provide safe care.  The “Rights of Medication Administration” are consistently used by all health care providers when administering medications.  This procedure is to guide clinicians in the safe and effective administration of medications via subcutaneous injection. For injection of subcutaneous insulin, refer to subcutaneous insulin injection policy and procedure.

Equipment & Supplies  Medication in pre-filled syringe  Appropriate-sized needle  Chlorhexidine/alcohol swab  Dry gauze pad  Band aid as needed

Procedure

STEPS RATIONALE 1. CHECK chart for patient allergies and prescriber's Medication orders that meet safe prescribing practices written order which specifies the drug name, promote patient safety. indication, dosage, route and frequency of The subcutaneous route is used when small volumes administration of medication need to be absorbed at a slow, steady rate and is commonly used for insulin, anticoagulation therapy, allergy desensitization, immunizations, colony growth factors. 2. CHECK “rights of medication administration" As per the Policy “Medication Administration- General Guideline” 3. IDENTIFY patient with 2 patient identifiers and Failure to correctly identify patients prior to ENSURE patient and family understand what procedures may result in errors. medication is being given and why and how, any Reduces child and family’s anxiety. Evaluates and possible side effects and that questions are reinforces understanding of previously taught answered. information and confirms consent for medication administration.

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DOCUMENT TYPE: PROCEDURE

4. SELECT appropriate injection site based on: Skin thickness and subcutaneous tissue thickness a. child's subcutaneous tissue mass varies by age and site. The older the child, the b. medication volume thicker the skin and subcutaneous tissue. Arms have c. previous subcutaneous injection sites the least thickness, followed by thighs, abdomen and d. absorption rate needed buttocks. NOTE: The most common sites for SQ injection Select the most appropriate site that can safely include the center third of lateral aspect of upper accommodate the fluid volume being arm, the abdomen and center third of anterior thigh. administered without causing injury to the child. Maximum fluid volume is 1 mL. Rotating sites will prevent tissue damage and may increase absorption. The abdomen has the most rapid absorption followed by the arms, thighs, buttocks. The abdomen is therefore the preferred site when faster absorption is required.

NOTE: subcutaneous injections should not be administered near a scar, bruise, burn, skin lesion/abrasion or within a 5 cm radius of the umbilicus as this may increase pain and also affect the absorption rate. 5. PERFORM hand hygiene. Routine Infection Control practices; reduces transmission of microorganisms. 6. APPLY local anesthetic cream to site Decreases pain at injection site. as appropriate. 7. GATHER needed equipment and supplies. Facilitates completion of procedure in a timely manner. 8. PERFORM hand hygiene and DON clean gloves. Routine Infection Control practices; reduces transmission of microorganisms. 9. ATTACH appropriate needle size to the syringe. The shortest length needle should be used to avoid intramuscular injection. 10. POSITION patient and perform distraction or Proper positioning ensures patient's safety other psychological intervention as needed. and comfort. Engage Child Life Specialist, as required. Psychological interventions can help to reduce the pain and distress associated with needle-related procedures. 11. OBTAIN help of second nurse as needed.

12. CLEAN site (circular area approximately 5-8 Decreases risk of infection. cm) with chlorhexidine/alcohol swab and allow skin to dry.

13. PINCH tissue with thumb and index finger. Lifts the adipose tissue from the underlying muscle to prevent the solution from being injected into the muscle

14. INSERT needle with a steady, smooth motion at Inserting the needle with a steady, smooth motion a 45 degree angle. causes less displacement and shearing of the tissue, which decreases pain.

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DOCUMENT TYPE: PROCEDURE

Inserting needle into a skin lift at a 45 degree angle helps avoid possible IM injections.

15. INJECT the solution by pushing slowly on the Slow injection is recommended to reduce pain and plunger at a rate of 1 mL per 10 seconds. WAIT briefly bruising. Slow injection reduces pain during injection, before withdrawing the needle to help prevent however, rapid administration of small volumes (0.5 backtracking and RELEASE pinched tissue. mL or less) may be advised for children who are likely to move during the injection. Aspiration is not recommended as there is no data to document its necessity prior to the SC injection, there are no large blood vessels at the recommended subcutaneous injection sites and aspiration may increase the time it takes to administer the medication and is more painful for the patient. 16. APPLY pressure at the injection site using a Prevents leakage of the medication into the dry gauze pad. Do not massage site. surrounding tissue. Massaging the site can affect absorption, damage underlying tissue and cause bruising. 17. ASSESS injection site for complications and Allows clinician to provide interventions for any apply band aid as needed. minor complications. 18. DISPOSE used supplies and equipment Routine Infection Control practices; in appropriate container. reduces transmission of microorganisms. 19. REMOVE gloves and PERFORM hand hygiene.

Documentation DOCUMENT on appropriate record: o date and time o drug, dose, route o individual administering medication o patient's response to procedure o unexpected outcomes and related treatment o patient/family education o any other pertinent actions or observations

References Stacy J. Breedlove Shaffer. Medication Administration: Subcutaneous administration (Pediatric). Elsevier. Published February 2018. Subcutaneous insulin administration. CM 04.20. BC Children’s Hospital Child & Youth Health Policy and Procedure Manual. Annersten, M. and Willman, A. (2005). Performing Subcutaneous Injections: A Literature Review. Worldviews on Evidence-Based Nursing. 2(3):122-130.

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DOCUMENT TYPE: PROCEDURE

BC Centre for Disease Control (2012). Communicable Disease Control Immunization Program, Section IV – Administration of Biological Products. Vancouver: Author Cocoman, A. and Barron, C. (2008). Administering subcutaneous injections to children: what does the evidence say? Journal of Children's and Young People's Nursing. 2(2):84-89. Finkbeiner, K.S.: Subcutaneous Injection. In Trivits Verger, J. and Lebet, R.M., editors: AACN Procedure Manual for Pediatric Acute and Critical Care. St Louis, Missouri, 2008, Saunders Elsevier. Forum for Injection Technique (FIT) Canada. Recommendations for Best Practice in Injection Technique, March 2012. Retrieved on January 30, 2013 from http://www.bd.com/resource.aspx?IDX=25063. Harder, N. (2013). Medication Administration, Intravenous Therapy, and Nutritional Support. In Ateah, C.A., Scott, S.D. and Kyle, T. (Ed.), Canadian Essentials of Pediatric Nursing (pp.337-365), Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Hockenberry, M.J. and Wilson, D. Wong's Nursing Care of Infants and Children, eighth edition. St Louis, Missouri, 2007, Mosby Elsevier. Hunter, J. (2008). Subcutaneous injection technique. Nursing Standard. 22(21):41-44. Lo Presti, D., Ingegnosi, C. and Strauss, K. (2012). Skin and subcutaneous thickness at injecting sites in children with diabetes: ultrasound findings and recommendations for giving injection. Pediatric Diabetes, 13: 525–533 Pergallo-Dittko, V. (1997). Rethinking Subcutaneous Injection Technique. American Journal of Nursing, 97(5):71-72. Shin, H. and Kim, M.J. (2006). Subcutaneous tissue thickness in children with type 1 diabetes. Journal of Advanced Nursing, 54(1):29-34. Tubiana-Rufi, N. et al. (1999). Short Needles (8 mm) Reduce the Risk of Intramuscular Injections in Children with Type 1 Diabetes. Diabetes Care, 22(10):1621-1625.

Version History DATE DOCUMENT NUMBER and TITLE ACTION TAKEN 11-June-2019 C-05-12-60627 Subcutaneous Medication Administration Approved at: Pharmacy, Therapeutics & Nutrition Committee

Disclaimer This document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.

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