Subcutaneous (SC) injection – OSCE guide

Subcutaneous (SC) injections pierce the epidermis and dermis of the skin to deliver medication to the subcutaneous layer. It is a common route of delivery for medications such as insulin and low molecular weight heparin (LMWH). This guide discusses how to perform subcutaneous injection in an artificial OSCE setting and should not be used as a guide to administering injections to actual patients without first consulting your local medical school or hospital guidelines and undertaking the necessary training. Check out the subcutaneous (SC) injection OSCE mark scheme here.

Introduction

Introduce yourself

Wash hands

Confirm the patient’s details

Explain the procedure

Check the patient’s understanding of the medication being given and explain the indication for the medication.

Gain consent to proceed

Check for allergies

Check if the patient has a preferred injection site and if the patient is receiving regular subcutaneous injections, ensure that the injection sites are rotated.

Gather equipment

• Equipment tray
• The medication to be administered
• Patient’s prescription
• Syringe – the smallest syringe that will accommodate the medication volume
• Injecting needle – (26–30 gauge) – 13-16mm ¹
• Drawing up needle / Blunt filter needle (these filter out sub-visible particles of glass, rubber and other residues when drawing up from glass ampoules)
• Gauze or cotton swab
• Sharps container (for disposal of the needles)
• Non-sterile gloves

The 7 Rights

Return to the patient. Before proceeding, check the 7 rights of medication administration

1. Right person – check the patient’s arm band against the name on the prescription. Where possible aim to use two identifiers (e.g. from the patient and the arm band)

2. Right drug – check the labelled drug against the prescription – ensure expiry date is appropriate

3. Right dose – check the dose against the prescription

4. Right time – confirm when the last dose was given

5. Right route – see below

6. Right to refuse – has the patient consented?

7. Right documentation of the prescription and allergies – does the patient have any allergies?

Once these have been confirmed prepare the medication. Always use a separate drawing up needle and injection needle.

 Injection steps

1. Wash hands

2. Don gloves 

3. Draw up the appropriate medication into the syringe using a drawing up needle.

4. Remove the drawing up needle and immediately dispose of it in the sharps bin, then attach the needle to be used for injection.

5. Choose an appropriate site, common sites include: ¹

• Abdomen (avoid injecting within a 2 inch radius around the umbilicus) – this is the preferred site if giving a low molecular weight heparin injection
• Upper outer aspect of arm
• Outer aspect of the upper thigh
• Upper buttock
• See examples of site locations here

Do NOT use a site that is inflamed, irritated, bruised or contains scar tissue

If multiple injections are given, use different sites for each subsequent injection.

If frequent injections are given, rotate sites.

6. Position the patient to provide optimal access to your chosen site.

7. Cleaning the site:

• WHO does not recommend the use of alcohol based cleansing wipes prior to administration of subcutaneous medication as this can predispose an individual to developing hardened skin at the injection site ²^,³
• If the skin is visibly soiled it should be cleaned with soap and water
• Routine cleaning is not required prior to subcutaneous injection

8. Pinch a 5cm fold of skin between the thumb and index finger (using your non dominant hand) – pinching the skin increases the depth of the subcutaneous tissue available.

9. Warn the patient of a sharp scratch.

10. Pierce the skin at a 45 – 90 degree angle, aiming to remain in the subcutaneous tissue layer. Insert the needle quickly and firmly, with the bevel facing up.

11. Aspirate to check the location of the needle:

• If blood appears, remove the syringe and prepare a new injection (explaining the reason for this to the patient)
• It is not necessary to aspirate when administering insulin or heparin. ¹
• There is variation in the guidelines with some suggesting aspiration is never required, you should follow your local guidelines

12. If no blood appears on aspiration inject the contents of the syringe while holding the barrel firmly. 

13. Remove the needle and immediately dispose of it appropriately (into a sharps container).

14. Apply gentle pressure over the injection site with a cotton swab or gauze.  Do NOT rub the site.

15. Replace cotton swab or gauze with plaster 

To complete the procedure

Thank the patient

Discuss post injection care:

• Warn them that the injection site may be sore for one or two days, but this is normal.
• Other potential complications include: haematoma, persistent nodules, local irritation (and rarely anaphylaxis).
• Advise the patient to watch for a developing rash, breathing difficulty or other relevant concerning symptoms. They should discuss this with a doctor if concerned.

Wash hands

Document that the medication has been given on the medication chart and in the patient’s notes.

References

1. BD. Subcutaneous Injection Guidelines for Needle Length and Gauge Selection. Published 2012. Retrieved from: [ [LINK]

2. World Health Organisation – WHO Best Practices for Injections and Related Procedures Toolkit. Retrieved from: [LINK]

3. Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. Yvan Hutin et al. 2003. Retrieved from: [LINK]