Current Approaches to Subcutaneous Injection

Yıl 2019, Cilt: 6 Sayı: 2, 406 - 411, 01.06.2019

Nuray Turan Gülsün Özdemir Aydın Nurten Kaya

https://doi.org/10.17681/hsp.449018

Öz

DOI:
10.17681/hsp.449018

Subcutaneous injection (SC) is one of the most common
parenteral drug administration methods performed by nurses. For this reason,
the change in the manner of preparation of some medicines nowadays requires
learning new information about the application. Thus, it is aimed to
reduce/eliminate the problems related to implementation. However, common
problems in this method are drug leaking out of the skin, hematoma and pain.
Insulin, heparin, some narcotics and allergy drugs are frequently administered
by SC injection method. In the literature, it is seen that as the volume of the
drug increases, the amount of leakage increases, the application of the drug to
the abdominal region less leakage, the rate of drug administration does not
affect the amount of leakage, and the volume of the drug increases. While the
thickness of the tip of the needle used in the injection does not affect the
backlash, the inlet angle of 450 causes more backlash than the inlet
angle of 900. Insulin, heparin, some narcotics and allergy drugs are
frequently administered by subcutaneous injection. After the subcutaneous
injection, usually 10 seconds waiting period was suggested, but the current
information indicates that at least 3 seconds should be waited. One of the
drugs is heparin which is commonly applied as subcutaneous injection.  Heparin injections are now available for
application. Studies in
the literature of heparin injections are made with low molecular weight
heparins (LMWH), and studies show that the duration of the drug administration
is related to prevention of pain and ecchymosis after injection. LMWH is
usually applied to the abdominal region, and rotation is recommended between
other subcutaneous SC injection sites for prolonged use. When the injection
duration is more than 10 seconds, it is seen that the pain is less and the
hematoma size does not changed after 48 hours and beyond.  Although it is shown that ice application is
effective before injecting, there is no advanced evidence. Especially
aspiration is not recommended during insulin and heparin administration. As a
result, scientific researches about SC injection applications are emerging day
by day. Updating existing literature data in this context will contribute to
increase the quality of nursing care.
From this point, the literature and research findings related to SC
injection application were discussed, and the prominence of the subject was
discussed and proposals for application were presented.

Anahtar Kelimeler

Nursing care, subcutaneous injection, current approaches

Subkütan Enjeksiyon Uygulamasında Güncel Yaklaşımlar

Öz

DOI:
10.17681/hsp.449018

Subkütan enjeksiyon
(SC), hemşirelerin en sık uyguladığı parenteral ilaç uygulama yöntemlerinden biridir.
Günümüzde bazı ilaçların hazırlanma şekillerinin değişmesi uygulamaya ilişkin
yeni bilgileri öğrenmeyi gerektirmektedir. Böylece uygulamaya ilişkin
sorunların azaltılması/ortadan kaldırılması hedeflenmektedir. SC enjeksiyon
yöntemi ile sıklıkla insülin, heparin, bazı narkotik ve allerji ilaçları
uygulanmaktadır. Ancak bu yöntemde sık karşılaşılan sorunlar; ilacın deri
dışına geri sızması, hematom ve ağrıdır. Literatürde, insülin uygulaması için
ilacın volümü arttıkça sızıntı miktarının arttığı, karın bölgesine uygulamada
daha az sızıntı olduğu, ilacın verilme hızının sızıntı miktarını etkilemediği,
verilen ilacın hacmi arttıkça sızıntı miktarının da arttığı görülmektedir.
Enjeksiyonda kullanılan iğne ucunun kalınlığı geri sızmayı etkilemezken, 45⁰’lik
giriş açısı 90^0’lik giriş açısına göre daha fazla geri sızmaya neden
olmaktadır. Subkütan enjeksiyondan sonra, genellikle 10 sn. beklenmesi
önerilmekte iken güncel bilgiler en az 3 sn. beklenmesi gerektiğini ifade
etmektedir. Sıklıkla SC uygulanan ilaçlardan biri de heparindir. Heparin
enjeksiyonları günümüzde uygulamaya hazır bulunmaktadır. Literatürde heparin
enjeksiyonuna ilişkin çalışmaların düşük molekül ağırlıklı (DMAH) heparinlerle
yapıldığı, araştırmaların daha çok ilacın verilme süresi, sonrasında ağrı ve
ekimozun önlenmesine ilişkin olduğu görülmektedir. DMAH heparin, genellikle
abdominal bölgesine uygulanmakta, uzun süreli kullanımda diğer SC enjeksiyon
bölgeleri arasında rotasyon önerilmektedir. Enjeksiyon uygulama hızının 10
sn.’den fazla olduğu çalışmalarda 48 st. ve sonrasında ağrının daha az, hematom
büyüklüğünün ise değişiklik göstermediği görülmektedir. Enjeksiyon uygulaması
öncesi buz uygulamasının etkili olduğu gösterilmekle birlikte ileri düzey
kanıtlar mevcut değildir. Özellikle insülin ve heparin uygulamaları sırasında
ise aspirasyon önerilmemektedir. Sonuç olarak SC enjeksiyon uygulamalarına
ilişkin her geçen gün bilimsel araştırmalar ortaya çıkmaktadır. Bu kapsamda var
olan literatür bilgilerinin güncellenerek uygulamaya aktarılması hemşirelik
bakımının kalitesinin artmasına katkı sağlayacaktır. Bu noktadan hareketle,
makalede, SC enjeksiyon uygulamasına ilişkin literatür ve araştırma bulguları
incelenerek konunun önemi tartışıldı ve uygulamaya yönelik öneriler sunuldu.

Anahtar Kelimeler

Hemşirelik bakımı, subkütan enjeksiyon, güncel yaklaşımlar

Kaynakça

• 1. Kaya N, Palloş A. Hemşirelik Bilim ve Sanatı, In. Atabek Aştı T, Karadağ A. eds. Parenteral İlaç Uygulamaları, İstanbul: Akademi Basın ve Yayıncılık, 2012, p. 762-809.
• 2. Yılmaz DU, Korhan EA, Hakverdioğlu G, Dikmen Y, Düzgün G, Erem A. İki farklı bölgeye uygulanan subkutan enjeksiyonun ağrı ve ekimoz oluşumuna etkisi. İzmir Katip Çelebi Üniversitesi Sağlık Bilimleri Fakültesi Dergisi 2016; 1(3): 15-20
• 3. Kaya A, Sargın M, Kulaksızoğlu M, Olgun N, Deyneli O, Dağdelen S, Hatun Ş, Siva ZO. Türkiye İnsülin Enjeksiyon Teknikleri ve Tedavileri Kılavuzu, 2018.
• 4. Præstmark KA, Stallknecht B, Jensen ML, Sparre T, Madsen NB, Kildegaard J. Injection technique and pen needle design affect leakage from skin after subcutaneous injections. Journal of Diabetes Science and Technology 2016; 10 (4): 914-22.
• 5. Lim STJ, Hui YCA, Lim PK, Lim CCE, Chia YY, Vasanwala R F. Ultrasound-guided measurement of skin and subcutaneous tissue thickness in children with diabetes and recommendations for giving insulin injections. Journal of Clinical & Translational Endocrinology 2018; 12: 26-35.
• 6. Potter PA, Perry AG, Stockert PA, Hall AM Fundamentals of Nursing. In. Medication Administration, 9th Ed. St Louis: Elsevier Inc, 647-49.
• 7. Diggle D. Are you FIT for purpose? The importance of getting injection technique right. J Diabetes Nurs. 2014; 18: 50.
• 8. Gibney MA, Arce CA, Byron KJ, Hirsch L. Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insülin injections: implications for needle length recommendations. Current Medical. Research & Opinion 2010; 26(6): 1519-30.
• 9. Hirsch L, Byron K, Gibney, M. Intramuscular risk at insulin ınjection sites—measurement of the distance from skin to muscle and rationale for shorter-length needles for subcutaneous ınsulin therapy. Diabetes Technology & Therapeutıcs 2014; 6(12): 1-7.
• 10. Zabaleta-Del-Olmo, E, Vlacho B, Jodar-Fernández L, Urpí-Fernández AM, Lumillo-Gutiérrez I, Agudo-Ugena J, et al. Safety of the reuse of needles for subcutaneous insulin injection: A systematic review and meta-analysis. International Journal of Nursing Studies 2016; 60: 121-32.
• 11. Dagdelen S, Deyneli O, Olgun N, Siva ZO, Sargin M, Hatun S, et al. Turkish insulin injection technique study: population characteristics of Turkish patients with diabetes who inject insulin and details of their injection practices as assessed by survey questionnaire. Diabetes Therapy 2018; 1-17.
• 12. Healthline. What is a subcutaneous injection? Erişim Adresi. https://www.healthline.com/health/subcutaneous-injection#types-of-medications, Erişim tarihi: 10.07.2018.
• 13. Berman AT, Snyder C, Frandsen G. Kozier & Erb's Fundamentals of Nursing, UK: Global Edition. Pearson Education, 2016, p.791-796.
• 14. Hockenberry MJ, Wilson D. Wong’s nursing care of infants and children 10th ed St. Louis: Mosby Company, 2015, p.919
• 15. World Health Organization. (2010). WHO best practices for injections and related procedures toolkit. Access Address : 09.07.2018.
• 16. Khawaja RA, Sikandar R, Qureshi R, Jareno RJM. Routine skin preparation with 70% isopropyl alcohol swab: Is it necessary before an injection? Quasi study. JLUMHS 2013; 12(2): 109.
• 17. Hutin Y, Hauri A, Chiarello L, Catlin M, Stilwell B, Ghebrehiwet T, Garner J. Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. Bulletin of the World Health Organization 2003; 81: 491-500.
• 18. Bartz L, Klein C, Seifert A, Herget I, Ostgathe C, Stiel S. Subcutaneous administration of drugs in palliative care: results of a systematic observational study. Journal of Pain and Symptom Management 2014; 48(4): 540-47.
• 19. Jin J F, Zhu LL, Chen M, Xu HM, Wang HF, Feng XQ, ...and Zhou Q. The optimal choice of medication administration route regarding intravenous, intramuscular, and subcutaneous injection. Patient Preference and Adherence 2015; 9: 923.
• 20. Crawford CL, Johnson JA. To aspirate or not: an integrative review of the evidence. Nursing, 2012; 42(3): 20-5.
• 21. Sepah Y, Samad L, Altaf A, Halim MS, Rajagopalan N, Khan AJ. Aspiration in injections: Should we continue or abandon the practice?. F1000 Research 2014; 3: 157.
• 22. Avşar G, Kaşikçi M. Assessment of four different methods in subcutaneous heparin applications with regard to causing bruise and pain. Int J NursPract. 2013; 19(4): 402-8.
• 23. Visvanathan V. Slow vs. fast subcutaneous heparin ınjections for prevention of pain and bruising. The American Journal of Nursing, 2015; 115(12):27.
• 24. Ahmadi M, Ahmadi R, Saadati Z, Mehrpour O. The effect of extended ınjection of subcutaneous heparin on pain ıntensity and bruising ıncidence. Electronic Physician 2016; 8(7): 2650.
• 25. Mohammady M, Janani L, Akbari SA, Nedjat S. Slow versus fast subcutaneous heparin injections for prevention of bruising and site-pain intensity (Protocol). Cochrane Database Syst Rev. 2016; 2: 1-6.
• 26. Heise T, Nosek L, Dellweg S, Zijlstra E, Præstmark KA, Kildegaard J, et al. Impact of injection speed and volume on perceived pain during subcutaneous injections into the abdomen and thigh: a single‐centre, randomized controlled trial. Diabetes, Obesity and Metabolism 2014; 16(10): 971-76.
• 27. Hanas R. Side Effects of Insulin Treatment. Type 1 Diabetes in Children, Adolescents, and Young Adults: How to Become an Expert on Your Own Diabetes. London: Class Publishing; 2007.
• 28. Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J, et al. New injection recommendations for patients with diabetes. Diabetes Metab. 2010; 36(suppl 2): S3-S18.
• 29. Wittmann A, Kover J, Kralj N, et al. Insulin leakage value in relation to pen needle length and administered dose after subcutaneous injection. Diabetes Technol Ther. 2010; 12: 587-90.
• 30. De Coninck C, Frid A, Gaspar R, Hicks D, Hirsch L, Kreugel G, et al. Results and analysis of the 2008-2009 insulin injection technique questionnaire survey. J Diabetes 2010; 2: 168-79.
• 31. Hansen B, Matytsina I. Insulin administration: selecting the appropriate needle and individualizing the injection technique. Expert Opin Drug Deliv. 2011; 8: 1395-406.
• 32. Kalra S, Balhara YP, Baruah MP, Chadha M, Chandalia HB, Chowdhury S, et al. Forum for injection techniques, India: the first Indian recommendations for best practice in insulin injection technique. Indian Journal of Endocrinol Metabolism 2012; 16: 876-85.
• 33. Saltiel-Berzin R, Cypress M, Gibney M. Translating the research in insulin injection technique: implications for practice. Diabetes Educ. 2012; 38: 635-43.
• 34. Clinical Procedures For safer Patient care. In. Parenteral Medication Administration, Access Access Address: https://opentextbc.ca/clinicalskills/chapter/6-7-intradermal-subcutaneous-and-intramuscular-injections/. Erişim Tarihi: 08.07.2018.