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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 your hands

Confirm the patient’s details (name and date of birth)

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 if the patient has any allergies

Check if the patient has a preferred injection site (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 wristband against the name on the prescription. Where possible aim to use two identifiers (e.g. from the patient and the wristband).

2. Right drug: Check the labelled drug against the prescription and ensure the 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 for further details.

6. Right to refuse: Ensure the patient has consented to the injection.

7. Right documentation of the prescription and allergies: Does the patient have any allergies?

Once these 7 points have been covered, prepare the medication.

Always use a separate drawing up needle and injection needle.


Injection steps

1. Wash your 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 the 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 administering low molecular weight heparin injections
  • Upper outer aspect of the arm
  • Outer aspect of the upper thigh
  • Upper buttock
  • 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 routine use of alcohol-based cleansing wipes prior to administration of subcutaneous medication as this can predispose an individual to develop 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 usually required prior to subcutaneous injection.
  • In older patients and those who are immunocompromised, skin preparation using an alcohol-impregnated swab (70% isopropyl alcohol) may be recommended.The patient’s condition should be individually assessed and local policies should be followed.

 

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 upwards.

11. Inject the contents of the syringe whilst holding the barrel firmly. Aspiration is not recommended for subcutaneous injections, as there are no major blood vessels in the subcutaneous tissue and the risk of inadvertent intravenous administration is minimal. 5 You should, however, always follow your local guidelines.

12. Remove the needle and immediately dispose of it into a sharps container.

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

14. Replace the cotton swab or gauze with a plaster.


To complete the procedure

Wash your hands

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

Thank the patient

Discuss post-injection care:

  • Warn the patient that the injection site may be sore for one or two days, but this is normal.
  • Other potential complications include haematoma, infection, persistent nodules, local irritation and rarely anaphylaxis.
  • Advise the patient to seek medical review if they have any concerns.

REVIEWED BY

Graham Bone

Senior Clinical Lecturer in Medical Education


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]

4. Dougherty L, Lister S (2015) The Royal Marsden Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell.

5. Public Health England (2013) Immunisation Procedures: The Green Book, Chapter 4. Retrieved from: [LINK]


 

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