Clinical Skills: Injection Technique

Qualified Adult Nurse, Claire Carmichael, takes us through different Injection Techniques, when to use them and tips on how to get the best results.

Introduction

Hi, everyone, my name is Claire Carmichael, and I'm a registered Nurse, and in today's video, we're gonna be talking all about injection technique.

And just a little disclaimer, as always, this isn't a training video, this is just more of an information, educational sort of video to show you things that we do out there in practice.

So firstly, there are a few different routes of administration of injections.

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Subcutaneous Injections

So the first one is Subcutaneous Injections, or subcut, for short, and this type of Injection, as you can see from this photo here, it sits just below the skin's surface.

You don't wanna be going into muscle with these types of Injections, and with the subcutaneous tissues, there's no blood supply there, so it does take it a lot longer to absorb into the body, so this is more for a slower-release medication type of injection.

So an example of this could be insulin. So any diabetic patient who is administered insulin, they will be doing its subcut, because it's just a slower-working, slower-acting, and slower rate of absorption for what they need for their condition.

Common Issues

Some common complications with subcut Injections are things like abscesses under the skin, a lot of bruising, and something called lipohypertrophy, and this is where you get a painful, fatty layer under the skin, and this is commonly caused by repeatedly injecting yourself in the same site.

So again, insulin users are injecting themselves in the same sites, over and over again, it develops this buildup, this toughening of the skin, this fatty layer, and just changes the skin, just from that repeatedly injecting in the site.

So that's why we always get people to inject in different places if they're self-administering injections, like insulin, people on testosterone, for example, they might inject in different sites on the thighs, arms, stomach, that sort of thing, so we do that just to prevent those side effects from happening.

And the most common that I've seen, anyway, out there in practice, for the site of Injections, when it's subcut Injection, is normally the abdomen, alongside the belly button, along that area.

I'm gonna put a picture here of different sites in different locations. You can also have it in your arm. Some people do it in their thighs.

So arm, thighs, and stomach, or abdomen, lower abdomen is the most common places that we give it, but you can give it in places like the back, or lower loin regions, as well, which I personally have never given it in those areas.

Mine is normally the top of the arm, stomach, or thighs.

The most common needle I use is the blue needle, or this one, which this one's actually a 23 gauge, which that is just the length and thickness of the needle.

The higher up the number, the smaller the needle, if that makes sense, smaller, thinner the needle is.

So this one that I have, for example, is a 21, and this is a very long and thicker needle than this one.

Let me get it the right way round, if you can see that. So that's what the difference is in needle sizes and colour.

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Different Size Needles And What To Use Them For

The green one's more for... I use more for drawing up with the green needle, and if it's something that's intermuscular, so if I'm giving an Injection into the buttocks, it will be a green needle, just 'cause it's thicker, normally it's a thicker liquid, a bigger muscle area that you're injecting into, so it needs to be a longer needle to get into that area.

Yeah, so subcut Injection is always a smaller needle 'cause you're just going under the skin.

And the way you wanna do it is, so you've got the arm here, and you just wanna pinch the skin a little bit, not the whole thing like that, 'cause you don't wanna be going into the muscle.

Just literally like the very tip, the top layer of the skin just lift slightly so that you can get the needle in.

You're gonna be putting the needle in a 45-degree angle. It's not gonna be straight in, 'cause you're not going into the muscle.

You want it at an angle, 45 degrees, that just goes under, into that subcut area that we were talking about.

And that's the way you would give a subcut Injection.

And just a slow, easy pace as it goes into the body.

And yeah, most people say these Injections are okay, they're not too bad for pain levels, but again, it very much depends on the person, the person's pain levels, to how people react to injections, I suppose.

And just going back to, as I was saying, with the green needle, I draw up with the green needle.

So always draw up with a different needle, and then give with a different needle, if that makes sense.

So you draw up, and it's just again, infection control, safety, that sort of thing.

So we always draw up the liquid with a green needle or a red blunt fill needle, which is normally a red-coloured needle, and it's a blunt needle, and that stops the glass particles from going back up into the syringe if you've got a glass bottle, so they're really, really good to use as well.

But I always draw up with green, and then normally give with blue.

If it's a baby, baby, baby injection, I give with an orange needle, which is a really tiny, tiny needle.

So yeah, so needle lengths, it depends on the patient.

Like I said, if you've got someone quite thin, like for me, I've got quite skinny arms, so I would always go a smaller needle for a slim person.

If someone's quite large, you would go, maybe, a bigger size needle, just to make sure that you're getting that product into the body where it should be.

Intramuscular Injections

So next, we have Intramuscular Injections, or IM Injections, and this is just literally, as it says on the tin, it's into the muscle.

So with this one, when you draw up your stuff with the green needle, depending how big or small the arm is, like, me, I would use, again, I would use a blue needle.

That would get into the muscle quite fine, because look how size that needle, that is gonna go into my muscle easy.

So, yeah, so depending on the size of the person, choose your needle size, and then draw up, change your needle over, put the blue one on, and this time, you're going directly, 90-degree angle, straight into the muscle.

So, sorry, I took it out of the wrapper so I can show you properly.

So let's just pretend I've drawn up my stuff, I've put my needle on, I've got the right needle for the person, and then literally, so in a muscular one, you want the person to relax their arm, and this is going straight in, at a 90-degree angle, straight into the muscle.

And blue will be good on me, like I said, 'cause I'm a slim person.

You might want a green needle, depending on the size of the patient, just making sure that that's gonna get into the muscle for them.

But yeah, it's just straight in.

Don't worry, it's got the lid on, I'm not injecting myself on camera.

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Choosing A Method Sometimes Depends On The Medication

And again, like I said, it just depends on the medication, the route of the medication, and where it's best placed, whether it's subcut or whether it's IM, but on the prescription that's prescribed for the patient, it should tell you where they want this injection to go.

You can also look at the BNF, (British National Formulary) as well, because there are some medications, actually, that say either subcut or IM, you can actually have one or the other, it doesn't really matter which one.

So it's just about looking up what the medication route is and things like that, to how you're gonna give it, and looking at body shapes and sizes, and if the needle's gonna actually get into where you need to be.

Another thing to be mindful of when you are giving injections is hitting someone's bone. I have done this myself. It's easily, easily done.

You just misjudge something, you go in that little bit too far, and you actually feel it.

Very, very fortunately the patient has never felt it. I know I've gone wrong, but the patient has never felt it, and they've never made a comment about it or anything, and I've just apologized, and they're like, "Oh, I didn't even feel it."

So I've been very fortunate like that.

And the intermuscular area is, well, you can see mine actually quite well, I think, on here, that little shape there, that is my muscle, so as long as you're going in there, but normally you put your arm out, you see where the dent is, and they say about four fingers down, which is about two and a half centimeters, roughly, they say, two and a half centimeters from the top is where you should be injecting.

But just again, different arm shapes, different sizes will really affect where you're putting it, so just make sure you've got the right place, you're getting into that muscle like you should be, not hitting any nerves, or bones, or anything like that, and you'll be just fine.

And the next tip for Intermuscular Injections is make sure the patient, if you can't see the top of their arm, make sure they roll it up like this so you actually got a good visual aspect of their arm. If not, get them to take their arm out, 'cause you need to be sure that you're going into the right place, into the muscle.

So just make sure they get their arm out, you've got a clear visualisation where you're gonna go so that you don't make any mistakes.

And not just with the arm, with the buttocks, as well, you want a good view if you're going into the buttocks.

Depo Injections

So a common one for me is giving depo Injections.

So depo Injections are a contraceptive for people, and that goes into the buttocks, left or right.

Sometimes it does go into the arm, if someone... For example, we've got a lady that just prefers it in the arm, and it's been okayed, and it's been consulted and everything that she has it in her arm now, but most people with Depo, it will go into their buttocks.

And again, for me, the way I work it out is I go by, I look for the hip, see where the hip line is, and then you're gonna go, there's like a triangle shape from hip, middle, and you should have that triangle going like that. It's really hard to explain to someone that, actually, 'cause visually, in my head, I can see it, but to explain that's quite hard.

But I'm gonna put a picture here.

That's the kind of triangle area that I'm thinking.

Again, I will always use a green needle for that, 'cause it's quite a large muscle mass area that you're going into.

And certain different medications, as well.

Luckily with the Depo-Provera, it's already got the needle on the syringe, and it's already pre-loaded and everything.

You're literally just taking the lid off, giving the injection, away you go.

And again, it's a 90-degree angle, so straight in when you're giving that injection.

But other things, so things like, again, testosterone, things like that, like really thick hormone treatments I've given before, are more of a slow release.

The Five R’s of Medication

Like there's one that I gave, I can't remember the name of it specifically, but it's a really thick syrup, and it has to be given over two minutes.

So I was there, watching the clock, like, slowly pushing the syringe in.

Oh, it was horrific!

So just be mindful of that as well.

Always make sure that you are checking your prescriptions, checking the packet, making sure you've got the correct dose, the right patient, the five Rs of medication, which I'm gonna put here as a reminder, make sure you've got all of that right so that you can give the correct thing to your patient in the correct way.

And intermuscular medications, so things like that, you've got a good blood supply to the muscles, it's faster-absorbing, faster-acting.

Things like vaccines are always into the deltoid muscle up here, just because it's quicker-absorbing, faster-acting.

And studies show that the process, actually, in the body, it works better from that muscle, so that's why we use a lot of vaccines and things like that in the arms, because the process in the cells and everything in that particular muscle just works really, really well in the body for the vaccine.

So that's why, if you wanna know a little bit of background, that's why they put them in the arms.

So next, we have the intradermal Injection.

Intradermal Injection

So this sits just under the epidermis, into the dermal section of the skin, so it's literally just below the skin's surface.

So things like implants.

So if anyone has ever seen or had a contraceptive implant, that is the type of injection.

It literally just sits, it slides just under the skin, and just sits under the skin.

And this type of injection or implant that sits just under the skin has the longest absorption route.

I think that's why the contraceptive implant gets put just under the skin, because it lasts for three years, and that hormone's released over three years.

It's quite a long process, so it takes a lot longer to absorb into the body to be any sort of benefits, if that makes sense.

But again, it very much depends on the medication, what's in there, the structure of the medication, because injections can be given this way as well.

For example, I give one Injection that's like a little implant that goes in the stomach, but this is very much just under the skin.

It's a hormone Injection.

It's not contraceptive, but it was a hormone type of Injection, and this was given every three months, so it's a slow-release one.

But again, like I say, and it's just that slower absorption over three months is how long it takes for that to absorb into the body, and that's why they give it that way.

And again, it just depends on the medication, what it's used for, what conditions it's used for, to how they give you these things.

And with the Zoladex implant that I was talking about, this just completely dissolves into the body.

It's like a little, like, rod type of thing, but it's completely dissolvable, so that dissolves over the three months, and that's how that works, whereas something like the contraceptive implant which sits just under the arm is a rod that needs to be removed after three years, it doesn't dissolve into the body.

And common reactions from that are more localized reactions, because it's just under the skin surface.

They can get redness, they can get a little abscess, they can get a lot of bleeding, bruising, as well, is quite common for that type of injection.

For the one that we gave, the Zoladex, we had to alternate, as well, different sites, so I'd go left to right, left to right, every time they came to try and avoid those other side effects that we were speaking about in the subcut.

It's the same unwanted side effects, unfortunately.

A Recap On The Subcutaneous, Intermuscular and Intradermal

So just a quick summary before I go.

Subcutaneous injection is one that sits in the subcutaneous tissue.

It's given at a 45-degree angle, something like, it's really hard to view on this, something like that, a 45-degree angle, just into the subcutaneous tissue for that type of injection.

Next type of injection, intermuscular Injection, is a 90-degree angle, straight in, straight into the muscle, no messing about with that one.

And lastly, intradermal Injection, which literally just sits under the skin, just slightly under the skin, and the angle you want that one, it's literally 10 to 15 degrees, straight under the skin, and Bob's your uncle.

I suppose you could visualize it like a little clock, if you like a visual thing.

So this is intradermal, subcut, intramuscular, literally like that. If you think, lowest, halfway point, get it in there.

Something like that might help you remember, I don't know.

That's how I remember it. I sort of go, that stage, that stage, and then like a half. Yeah, you know what I'm trying to say.

Summary

So I hope that video just gives you a little bit of a visualization, demonstration, of how we do injection techniques, and things like that.

Things to be mindful of is, like I said, right patient, right medication, prescriptions, all that jazz.

Make sure you're injecting the right way for the prescription, making sure the patient's comfortable, make sure you're getting the right area that it needs to go into, and just being mindful, as well, of bleeding can happen afterwards.

People sometimes get shocked when they see it's bleeding after, like, "Ooh, gosh, it's bleeding."

But that can happen.

You know, we've got so many different little tiny capillaries and things under the skin that you can't see, sometimes you do just nip one, and it does bleed a little bit, so just put that continuous pressure onto it if that happens, for a couple of minutes.

Also check if your patient is on blood thinning tablets, like warfarin, aspirin, that sort of thing, because they might bleed a lot afterwards, and you need to put that firm, continuous pressure onto the site, for two minutes, straight after you remove that Injection, just to reduce the bleeding output, reduce any risk of bruising, and reduce any unwanted side effects, basically.

So thank you so much for tuning in. 

I hope that's been helpful for you, and I shall see you next time.