What am I doing wrong (heparin SQ)

[anashenwrath]

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!

[anashenwrath, ASN, RN]

Thank you so much everyone! I am really glad to hear that I'm not crazy for thinking my professor was making an error. Luckily, I had a great clinical experience last year, so I kind of know when something doesn't seem right. I'm just frustrated because I literally asked her if maybe I wasn't injecting deep enough, and she said, "This is heparin, you don't want to go too deep!" She makes me feel like an idiot!

Two more questions:

1) someone up there said to push fast, but I always thought you went slow with heparin because the medication burns?

2) It IS 90 degrees, isn't it??? Everyone and there mother at the hospital is saying 45 degrees, but when I look online it says 90!

PS: Thank you so much for the tips as well. A lot of these patients have very poor skin turgor; some of them have about as much body fat in their whole bodies as I have in one arm. It's immensely intimidating to be administering medication, and I'll be damned if I'm going to jeopardize their health by doing something wrong. I have clinicals tonight, so hopefully I'll have an opportunity to administer heparin!

[hodgieRN]

I inject it at a medium, steady rate. Some people may push it fast. I think it's b/c the pt stare at the needle and they may cringe or pray to heaven and earth the whole time until you get the needle out, so some nurses ilike getting it over with. Heparin and Lovenox can burn, so there are pt's who prefer being injected slowly. In general, for every pt who doesn't mind needles, there are those who are working on Oscar nominations. The whole process is only a few seconds, so go at a pace where you don't feel rushed b/c if you do, you will be visiting employee health for sticking yourself.

As for the degree of needle...If you grab enough fat, you can go at a 90 degree angle. The politically correct angle is 45 degrees if you are pinching a small area with two fingers. But let me be blunt...Smush it together with all five fingers like you are holding a hamburger and gently pull outward. That will ensure you aren't going to hit muscle. That can go at a 90 degree angle. Plus it will be a nice, deep SQ injection. On thin pt's, we usually have to manipulate, squeeze, pull, or find something to get it done. That might be more of a 45 degree scenario b/c the portion you have is less than the length of the needle. So, the angle of entry mainly depends on how much fat you can grab.

[Stoogesfan]

I was taught 45 degree angle for subQ and 90 for IM. If its a bigger patient then use 90 degree for subQ. The instructors have said that and so did every text I've read.

[rubato, ASN, RN]

Yeah, if they have no body fat, I might go closer to 45 degrees, but the issue is making sure it is deep enough to work effectively. If you're too shallow, it's taking a lot longer to get into the blood stream than it was intended. I think the person who wrote push fast meant the needle, not the medication.

[LM14]

My textbook says either 45 degrees or 90 degrees. I think you have to make that judgement depending on the amount of subcutaneous tissue your patient has. The book also says to lightly pinch the tissue. If you can pinch 2 inches, go in at 90 degrees. If you can only get about an inch, go in at 45 degrees. I have only given shots to mannequins so far lol, but this logic makes sense to me.

[blt99]

I agree with the above and sum up: SubQ is pinch an inch 45, pinch 2 inches 90 - is the general rule of thumb. Heparin/Lovenox is ALWAYS 90 degrees. And for cryin out loud, rubbing the injection site? Don't do it. SMH.

[rubato, ASN, RN]

I agree with the above and sum up: SubQ is pinch an inch 45, pinch 2 inches 90 - is the general rule of thumb. Heparin/Lovenox is ALWAYS 90 degrees. And for cryin out loud, rubbing the injection site? Don't do it. SMH.

You know, I keep forgetting that heparin is an anticoagulant, so yes, 90 degrees for sure. I remember our first injection week, one of the students said his patient got a horrible bruise at the injection site, so that may be part of it.

[hodgieRN]

Exactly! And, I'm not injecting heparin at a 45 degree angle on pt's that weigh 650lbs.