Medication Administration: Subcutaneous

CLINICAL GUIDELINES

A healthcare prescriber orders medications.
Medications are administered by a registered nurse (RN), licensed practical nurse (LPN), physician, child, or family member who is knowledgeable about the medication and techniques of administering a subcutaneous (SC) injection to a child.
Principles of pharmacologic management (see Chapter 6) are followed.
Medications are given subcutaneously when a slower rate of absorption is desired because fatty tissue has fewer blood vessels than muscle. This site can be used only for medications that do not cause tissue irritation.
Medications are administered within 1 hour of prescribed time.

CHILD AND FAMILY ASSESSMENT AND PREPARATION

Assess the child’s previous experience with injections.
Prepare the child, as appropriate to cognitive level, and family for the injection before administration.

KidKare Enlist the child’s cooperation by having the child hold the bandage. Tell the child that it is okay to yell or cry and that his or her job is to stay as still as possible.
Provide therapeutic play as indicated, or involve a child life specialist, to allow the child to work through his or her fears and master control of the situation.
Assess for drug and latex allergies; if present, implement latex precautions and notify healthcare prescriber of drug allergy. Label child’s record and apply identification band indicating allergies.
Use a topical anesthetic (e.g., EMLA, LMX4, vapocoolant) if injection is painful and when time allows to reduce pain and trauma of injection (see Chapter 7).
Position the child upright, have family member hold infant upright to reduce pain perception.

TABLE 71-1 Needle Length and Size Recommendations for Subcutaneous Injection^a

	Length	Gauge	Amount of Infusion
Adolescent or adult	½ to 5/8 inch	25-30	0.5-1 mL
Obese person	7/8 inch	25-30	0.5-1 mL
Infant or child	3/8 inch	25-30	No more than 0.1 mL for intradermal No more than 0.5 mL for subcutaneous to small child or 1 mL to preschool-aged or school-aged child
^aaRecommended sizes for insulin needles are 4 mm, 5 mm, 6 mm lengths and 29-31 gauge.

PROCEDURE
Administering Subcutaneous Injections

Steps	Rationale/Points of Emphasis
1 Verify the order with the child’s medical record, and check for allergy to drug; if present, do not administer drug, and notify prescriber.	Verifies correct drug, dose, route, time, and patient. Allergic reactions to medications may be life threatening.
2 Perform hand hygiene.	Reduces transmission of microorganisms.
3 Obtain medication and read the label to verify with the order. Check for expiration date; if expired, do not administer.	To decrease chance of medication error, patient, route, dose, frequency, and time to be administered must be verified each time a medication is administered.
	caREminder
	Medication should be at room temperature before administration; cold medication increases discomfort of the injection.
4 Check the amount of medication to be administered to determine syringe size and appropriateness for the child (see Table 71-1 ). Limit volume according to the age of the child and the amount of adipose tissue.	Large volumes of medication injected into the subcutaneous tissue can result in tissue injury. The subcutaneous route is occasionally used to administer continuous infusions (e.g., chemotherapy, iron chelation).
5 Choose appropriate needle gauge and length for the medication, child size, and site (see Table 71-1 ). Do not use a needle longer than 5/8 inch.	Viscous medication requires a larger gauge needle. Use the needle with the smallest bore (large gauge = 25 or 27 gauge) possible. A longer needle may result in intramuscular instead of subcutaneous administration.
6 Draw up correct amount of medication into syringe. If there is a large volume of medication, more than one injection may be needed. KidKare Draw up the medication in the medication room. The sight of the needle can increase the child’s anxiety.	Medications must be measured accurately because a small error in the amount may cause serious dosage errors. Do not draw up additional air into the syringe. Clearing the needle of medication can affect dose administered.
7 Verify medication with electronic record or take medication record and syringe with medication to the child to administer. Verify the child’s identity by comparing name on medication (if verified electronically) or on medication record with child’s identification band and any other patient identifier required by the institution.	Ensures proper identification of the child.
8 Don gloves.	Standard precaution to reduce transmission of microorganisms.
9 Evaluate the child’s subcutaneous tissue; choose the most appropriate site considering the adequacy and condition of subcutaneous tissue and duration of therapy (Figure 71-1).	Subcutaneous injection sites include abdomen, lateral upper arms, and thighs. Wide variations in the amount of subcutaneous fat in children exist. This may necessitate choosing an alternative site in the child. When frequent subcutaneous injections are administered, rotate injection sites.
Figure 71-1 Sites for subcutaneous injections.	Do not give in operative site or an extremity that has a pathologic process. Complications associated with giving subcutaneous injections are often the result of inappropriate sites.
10 Evaluate the use of biobehavioral interventions: distraction (storytelling, blowing bubbles), cold therapy, and other methods (see Chapter 7 ).	May decrease perception of pain sensation.
	KidKare Give the child choices, as appropriate (e.g., which leg or side), which gives the child some control of the situation.
11 Hold the child securely. Assess the need for additional help holding the child, and obtain help as indicated. Family members should not be responsible for securing the child but may remain to give support, such as holding the child’s hand.	Decreases chance of injury from movement because even cooperative children have a tendency to move during injections.
12 Cleanse the site with antiseptic wipe and allow to dry. (Insulin injections do not require skin preparation.)	Allowing the antiseptic to dry allows antimicrobial action of antiseptic and minimizes pain at the site of injection. The small-gauge needle used for injection of insulin cannot carry sufficient number of bacteria to cause infection.
13a Grasp the site; in slim children, a skin fold may need to be lifted. Insert the needle quickly at a 45-90-degree angle. Insert at 45 degrees if there is little subcutaneous tissue or a longer needle is used or at 90 degrees if subcutaneous tissue is abundant.	Elevating the site separates the subcutaneous skin from the muscle. Use caution not to pinch, do not insert the needle toward the site where the fingers are holding the skin.
13b Inject the medication.	Slow injection may reduce pain.
14 Withdraw the needle quickly at the same angle at which it was inserted and apply pressure over the site with a dry cotton ball. Do not recap the needle, to reduce chance of needle-stick injury.	Alcohol over an injection site may sting and prolong bleeding. Do not massage the site unless recommended for the drug.
15 Place adhesive bandage over site.	Young children may believe that their insides will leak out the injection site if a bandage is not used. KidKare Use character or colorful bandages to comfort the child.
16 Dispose of needle, syringe, and waste in appropriate receptacle.	Prevents needle-stick injuries.
17 Remove gloves and perform hand hygiene.	Reduces transmission of microorganisms.
18 Comfort the child and have the family member comfort the child after the injection.	Promotes positive relationship and decreases longterm negative effects of painful procedures. KidKare Giving the child a sticker or other reward can help promote comfort and provide positive feelings.
19 Return to the room a short time later for positive interaction with the child.	Playing or other activities will help the child not associate the nurse with only painful procedures. Gives opportunity to further evaluate the child’s response to procedure.