subcutaneous injection

Question 1

What equipment do you need to take?

Answer 1

7. Gather 5 equipment from bottom of trolley and put it on the top of trolley:
   j. Medicine order form (already in folder on top of trolley)
   k. Kidney dish with:
   l. Insulin medication vial
   m. Orange insulin needle
   n. 2 alcohol swabs – 1 for cleaning the medication vial and 1 for cleaning the patient’s skin
8. “After gathering my equipment, I will check the expiry date of each equipment.” Look for the expiry date on the equipment packaging OR the boxes for some equipment (eg. for alcohol swabs, the expiry date is on the packaging itself). Some equipment may not have expiry dates, but just show that you are looking for the expiry date on both the equipment and their boxes, even if there turns out to be no expiry date in the end. You will have a lot of time anyway! 

Question 2

How do you prepare the medication?

Answer 2

10. Remove white plunger cover on the top of insulin needle.
11. Remove orange needle cover on the bottom of insulin needle, into the kidney dish, using the one-hand-drop-down method. (You can use 2 hands to loosen needle cover initially, but when you drop the cover down, it must be using 1 hand only.) DO NOT THROW THIS NEEDLE COVER AWAY AS YOU MUST RECAP THE NEEDLE BECAUSE YOU ARE IN THE MEDICINE PREPARATION ROOM.
12. Withdraw 10 units of air into the insulin needle.
13. Set the insulin vial on a flat surface.
14. Poke the needle vertically through the top of the insulin vial and inject 10 units of air into the vial using the index finger of your dominant hand.
15. Hold insulin vial between the index and middle fingers of your non-dominant hand and hold syringe+needle with dominant hand. (Non-dominant hand is in a bunny-ear position!)
16. Invert the vial.
17. Ensure that the tip of the needle is below the liquid line to avoid withdrawing air bubbles.
18. Hold this system to eye-level to ensure correct dosage of medication.
19. Withdraw 10 units of insulin using dominant thumb and 3rd/4th finger to pull back on the plunger, while non-dominant hand stabilizes the vial plus body of the insulin needle.
20. Use non-dominant hand to continue stabilizing this system while flicking the needle with dominant hand to allow air bubbles to float to the top. Note that if there are too many air bubbles you can expel the medication back into the vial and withdraw again.
21. Turn the vial back upright and set it on a flat surface. NOTE: Remove the insulin needle from the vial only when it is upright, or else medicine will leak out.
22. Recap the needle in kidney dish using ONE HAND ONLY (to avoid poking other hand).

Question 3

How do you approach the patient? What else do you double check?

Answer 3

23. 3rd hand rub (from bottle on trolley) – show 7 steps. Do this 3rd hand rub as you are approaching the patient’s room with bare hands.
24. Place the kidney dish next to the dummy on the opposite side of your non-dominant hand. Place the medicine order form next to the dummy on the opposite side of your non-dominant hand too.
25. “I will approach the patient and:
    m. Introduce myself
    n. Explain the procedure to the patient, and inform them that it might be a little painful during the injection
    o. Obtain patient consent
    p. Ask the patient which is their non-dominant hand
    q. Double-check the patient’s full name and NRIC against 4 things: The patient’s verbal identifiers, the medicine order form (read out the full name and NRIC on the form), the patient’s wrist tag on the dummy (read out the full name and NRIC on the wrist tag).”
26. “I will also double-check the following 7 things:
    a. Check if the medicine vial has the correct drug name
    b. Check for the clarity of the drug
    c. Check for the expiry date of the drug (already done earlier but just say it again)
    d. Check if the dose of the drug to be given is correct against the medicine order form
    e. Check if the time that the drug is to be administered is correct against the medicine order form
    f. Check if the route of administration is correct, against the medicine order form (in this case it would be subcutaneous route)
    g. Check if the patient has ANY DRUG ALLERGIES.”

Question 4

How do you give the injection?

Answer 4

27. “If everything is in order, I will proceed with the procedure.”
28. Tear open second alcohol swab and leave packaging in kidney dish. Place 2 fingers laterally next to the belly button on the dummy. Must show examiner that you are measuring! Use the alcohol swab to clean this location on the patient’s skin in a circular motion, from inside to outside. Verbalize: “Alcohol dry.”
29. “I will inform patient that we are about to perform the injection and that it will hurt a little.”
30. Using non-dominant hand, pinch the fold of skin at the location you alcohol-swabbed previously AND CONTINUE PINCHING SKIN THROUGHOUT THE ENTIRE DURATION OF THE PROCEDURE.
31. Using dominant hand, pick up the insulin needle and let the needle cover slide off. Hold the insulin needle in a dart-like fashion.
32. Dart the needle into the skin quickly at a 90o angle to the skin surface. Ensure the full-length of needle is inside the skin. You do not need pull back on the plunger for subcutaneous injections as you do not need to check if you are in an artery or vein.
33. Using dominant hand, push down the plunger slowly while counting to ten.
34. Leave the needle in the skin (while still pinching it) and count to ten AGAIN to allow the last drops of medicine in the insulin vial to diffuse into the skin.
35. Use dominant hand to swiftly withdraw the needle and use your non-dominant hand to release your pinch on the skin. Discard the insulin needle in the sharps bin immediately, do not need to recap as recapping increases needlestick injury risk.
36. “I will thank the patient and tell them to inform the nearest medical staff if they experience any reaction to the medication, such as swelling, itchiness, or burning sensation around the needle puncture site.”
37. Throw entire kidney dish with all the rubbish into the rubbish bin (there will be a small plastic bag at the side of the trolley that acts as a rubbish bin, and a big rubbish bin with a foot pedal, you can choose from either one).
38. Hand rub (from bottle on trolley) – show 7 steps.
39. Record the name of drug administered, dosage, and time in the medication order form, and sign your name in the corresponding box (there will be a pen on the trolley).
40. “After completing the medication administration procedure, I will monitor for the therapeutic effect of the drug as time passes.”
41. Medical hand wash – show 7 steps.