What am I doing wrong (heparin SQ)

Nursing Students Student Assist

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Specializes in Hospice.

I've been noticing a trend when I inject heparin and want to make sure I'm not doing something wrong. When I inject, I'm seeing the almost immediate formation of a nodule at the injection site. It's usually hard and literally grows before my eyes. I asked the nursing professor about it and she had no clue (that was during one of my first injections). Since then, I've given heparin maybe 3 other times, and I've seen the nodule each time. I asked the patient if it felt different from his other injections and he said no. He said the lump just feels tender.I documented it and assumed it was an allergic reaction. But now that is seen it with other patients, I'm wondering if I'm injecting too deep? Not deep enough? None of my professors or the nurses seem to know. But if I'm doing something wrong, I want to nip it in the bud!

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Sounds to me like you are not inserting the needle far enough. Like when giving the tb test, this is exactly what you should see since it is a transdermal injection.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Your instructor should watch you and see if you are too shallow. You are forming a wheal which is associated with trans-dermal injections. This needs to be corrected for the patient will not adequately be anti-coagulated.

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Specializes in Hospice.

Thanks. My instructor has definitely watched me--I don't know if she's a bad instructor or what but she's not acting like it's something that I should be concerned about. She actually just sort of rubbed at it until it looked a little better and made me feel bad for wanting to document it/investigate it. That's why I came here, because I want to make sure that I'm not learning a bad habit, but I don't want to get on my professor's bad side!

I will see about going a little bit deeper. I've been dealing with very fragile patients with poor turgor and little body fat, so SQs have been tricky for everyone.

Thank you so much.

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If i am injecting someone with minimal body fat, i always try to pinch a section of fat up. This ensures it is a SQ injection.

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Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.

Your instructor watched it happen, doesn't know what caused it and is rubbing the insertion site???????!!!!!!!!! I'm sorry but your instructor is an idiot. This is not high level nursing. You're not injecting it deep enough. Simple as that. A very common and easily fixed error on the part of youngling nurses. Most new nurses and students are afraid of being aggressive (for lack of a better term) when inserting needles of any kind so they go really slow and often not deep enough. It's out of concern for not wanting to hurt patients and totally understandable. Just pinch up the skin, do the stick and never, never rub an insertion site from an anticoagulant injection. It causes bruising.

BTW, I admire your willingness to go the extra mile to figure this out. When your spidey sense is tingling then there's usually something wrong. :up:

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thanks. My instructor has definitely watched me--I don't know if she's a bad instructor or what but she's not acting like it's something that I should be concerned about. She actually just sort of rubbed at it until it looked a little better and made me feel bad for wanting to document it/investigate it. That's why I came here, because I want to make sure that I'm not learning a bad habit, but I don't want to get on my professor's bad side!

I will see about going a little bit deeper. I've been dealing with very fragile patients with poor turgor and little body fat, so SQs have been tricky for everyone.

Thank you so much.

She's lazy......shame on her. Rubbed until it was gone, did she really.....:sarcastic:. Well.....the patient is not getting the med correctly and therefore not getting the proper therapeutic effect. Even if there is little subQ fat you won't hit any "vital" organs.....you just nee to go a little deeper.

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Specializes in Infusion Nursing, Home Health Infusion.

Yes change the angle in which you enter the skin..make is sharper so you get deeper. The above posters are correct. you are administering it as if you were giving a PPD skin test which is intradermal and you are making a wheal which is not what you want to do in this case

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Specializes in cardiac CVRU/ICU/cardiac rehab/case management.

tips to a good shot in the real world. (that pt will say "wow! I didn't feel that" )

1 stretch the skin taut.

2 make it quick,get in and out fast. Fire it like a dart (it's less painful for pt )

3 ask the pt to take a deep big breathe .Just as they start taking the big breathe in. Go for it.presto! in and out .done!

(the pt is so busy concentrating on the breathe in while you are already in and out .Then pt will say "are you done? I didn't feel it "

FIRE FAST !!. slow push in = Pain! REMEMBER different races have different skin thickness.

Pt respond to your approach,if you appear confident they will already expect you to be good. If you draw it out,appear fearful the pt will already assume "this injection is going to be painful"

If a pt ask you have you done this before,you respond "oh sure,dozens of time" (you need not admit it was to an orange! )

My first injection was to an end stage demented pt. I stood crying at the bedside fearing I would hurt her. She didn't flinch but then again she was so out of it I probably could have harpooned her and got the same response

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Yes you need to make sure you are in the SQ tissue because heparin is very irritating to the skin. The needle should be going in all the way to the hub of the syringe, inject, hold for 5-10 seconds, then withdraw and activate the safety device on the needle. You should not be rubbing the site afterwards at all. Perhaps you should go to your lab in school and practice your technique more just to be safe.

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P.S. 90 degree angle for heparin and insulin.

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Specializes in ER trauma, ICU - trauma, neuro surgical.

One thing I learned was "pinch an inch." If there is enough tissue, grab with your fingers an area 1-2 inches wide and pull up. Check out a picture of an athletic trainer using calipers to measure body fat percentage...they really grab a portion and pull outward, almost away from the body. That's where you get a nice SQ injection. Or, check out a plastic surgeon when they are skin mapping a pt for tummy tucks in pre-op. I usually use my whole hand and squeeze slightly up. Then inject at almost a 90 degree as posted before if there is enough room. If you can gently squeeze and pull enough SQ tissue up, you will never hit muscle b/c the needle is shorter than the tissue you're squeezing.

If the pt is very thin, one of the best places is right above the iliac crest on the hip, slightly medial. If you see the skin bubbling up, then it is too shallow. And, if you get it deep enough (to where it needs to be), bruising will be minimal.

If all else fails, I think you can inject in the arm, behind the tricep (like with insulin).

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